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Oesophagectomy

Introduction

• Epidemiology: Oesophageal cancer is the eighth most common malignancy worldwide with an increasing incidence. At initial presentation, 20-30% of patients have metastases.
• Surgical Procedure:
  • Involves excision of the oesophagus and relocation of the stomach in the mediastinum to form a gastric conduit connecting the pharynx to the remaining gastrointestinal (GI) tract, with the abdominal stage performed first.
  • The anastomosis is at the extreme end of the foregut’s blood supply, making it vulnerable to ischaemia without careful management of haemodynamic parameters and fluid to ensure its perfusion.
  • In revision oesophagectomy, a colonic interposition is performed using a section of the colon on a pedicle.
  • This is a high-risk procedure with multiple vulnerable anastomoses.

Considerations

• High Risk for Postoperative Morbidity & Mortality:
  • Identify surgical approach & associated considerations.
  • Possible need for lung isolation.
  • Comorbid Disease Processes:
    • Full stomach & high risk for aspiration.
    • Malnourishment, deconditioning, anemia, coagulopathy.
    • Smoker, chronic obstructive lung disease, coronary artery disease, hypertension, diabetes mellitus.
  • Cancer 4M’s:
    • Mass effects, medications, metastases, metabolic abnormalities.
  • Prolonged Surgery with Severe Hemodynamic Insults:
    • Need for invasive monitors & access.
    • Lung protective ventilation.
  • Maintenance of Anastomotic Integrity:
    • Thoracic epidural anesthesia.
    • Judicious fluid administration & vasopressor usage.
    • Optimize oxygen delivery.

Risk Factors for Perioperative Morbidity & Mortality

• Poor cardiac and/or pulmonary function.
• Advanced age.
• Tumour stage.
• Diabetes mellitus.
• Impaired general health.
• Hepatic dysfunction.
• Peripheral vascular disease.
• Smoker.
• Chronic use of steroids.

Goals & Conflict

Preoperative

• Assessment of 4M’s:
  • Optimization of comorbidities.
  • Planning for postoperative care.
• Optimization:
  • Smoking cessation.
  • Correct/optimise anemia.
  • Nutrition: Patients may be cachectic or obese, but even obese patients may be malnourished due to hypermetabolic state.
    • Patients taking <75% of caloric goals require supplementation.
    • Patients taking less than 50% of caloric goals require tube feeds.
  • Rehabilitation with physiotherapy is emerging.

Intraoperative

• Aspiration Prophylaxis:
  • Rapid sequence induction (RSI) due to high risk of aspiration.
  • Thoracic epidural.
  • Arterial & central venous access, large bore IV access.
  • Lung isolation & lung protective ventilation.
  • Planning for repositioning.
  • Preparations for severe hemodynamic instability, especially during blunt mediastinal dissection.
  • Restrictive fluid strategy with vasopressors as needed to treat epidural-related vasoplegia.

Evidence-based Strategies

1. Avoiding large volumes of fluid.
2. Extubation in theatre.
3. Regional analgesia (Thoracic Epidural Analgesia > Paravertebral Block).
4. Lung protective ventilation.

Surgical Approach

• Ivor Lewis: Laparotomy, right thoracotomy.
• Transhiatal: Laparotomy, left neck.
• Three-hole: Laparotomy, thoracotomy, and cervical incision.
• Left Thoracoabdominal: Combined thoracic and abdominal incision.
• Laparoscopic/Thoracoscopic: Minimally invasive techniques.

Surgical Considerations

• Prolonged surgery.
• Need for one lung ventilation.
• Intraoperative repositioning.
• Hemodynamic instability: Intrathoracic dissection, supraventricular arrhythmias.
• No vascular access in left neck.

Postoperative

• Greatest mortality risk of all thoracic surgery.
• Attempt postoperative extubation and plan for high care stay.
• Monitor for
  • Aspiration pneumonia.
  • Respiratory failure.
  • Anastomotic dehiscence with empyema.
  • Mediastinitis.
  • Septic shock.
  • Arrhythmias.
  • Congestive heart failure (CHF).

Evidence-based Strategies

1. Adequate analgesia.
2. Reversal of neuromuscular blocking agents (NDMR).
3. Normothermia.
4. Haemodynamic stability.

Conduct of Anaesthesia for Oesophagectomy

View or edit this diagram in Whimsical.

Oesophageal Injury

Introduction

• Causes:
  • Spontaneous perforations, trauma, or iatrogenic perforations (60%).
  • Most common sites: Level of the cricopharyngeus and proximal to the lower oesophageal sphincter due to angulation of the hiatus and increased pathology such as oesophageal webs, rings, and strictures.

Pathophysiology

• Oesophageal rupture allows food, gastric contents, secretions, and air to enter the mediastinum, leading to contamination, mediastinal emphysema, inflammation, and necrosis.
• Perforation of the overlying pleura allows oesophageal contents to enter the pleural space, causing pleural cavity contamination and pleural effusion, usually on the left.

Time to Treatment

• Time from injury to treatment initiation is crucial:
  • Mortality with treatment delayed >24 hours: 27%.
  • Mortality with treatment <24 hours: 14%.

Cause of Death

• Most common causes: Pneumothoraces, mediastinitis, and pleural effusions.

Management of Acute Oesophageal Perforation

1. Initial Assessment:

   • Clinical examination.
   • Fluid resuscitation.
   • Diagnostic imaging: CXR, CT, oesophagography, endoscopy.

2. Leak Type Determination:

   • Contained or Limited Leak:
     • Non-operative Management:
       • Medical management with monitoring.
       • Minimally invasive interventions if deterioration occurs.
     • Operative Management:
       • Primary repair if suitable.
       • Controlled fistula or resection if unsuitable for primary repair.

Anaesthetic Considerations

• Septic Shock: Possible due to mediastinal contamination.
• Aspiration Risk: High; minimize coughing and straining to avoid worsening injury.
• Cricoid Pressure: Controversial.
• Airway Management:
  • Secure airway and place nasogastric tube in proximal oesophagus above the injury.
  • Surgeon will position the NG tube beyond the repaired oesophagus during surgery to keep the stomach decompressed.
  • NG tube not used for enteral nutrition; use jejunostomy instead.
• Lung Isolation: Required.
• Normothermia: Maintain using a forced air device and warmed IV fluids (goal-directed).

Positioning

• Varies with pathology and surgical approach:
  • Lateral position for primary repair, thoracoscopy, or open thoracotomy.
  • Upper arm abducted for surgical access, avoid excessive stretch on brachial plexus.
  • Avoid corneal abrasions.
  • Frequent intraoperative repositioning may be needed, ensuring tube position is rechecked.

Analgesia

• Thoracic epidural analgesia.
• Multimodal analgesia (MMA).
• Paravertebral block.

Postoperative Management

• Includes broad-spectrum antibiotics and monitoring for sepsis.
• Evaluate for possible collections or leakage with ultrasound or CT.
• Gastrografin contrast study 2-3 weeks post-repair to check for ongoing leaks.
• If T-tube in place, perform contrast swallow to check for leaks before removal at 8-10 weeks post-operation.

Links

• Mediastinal masses
• Lower GIT surgery
• Tracheal surgery
• Thoracic pre-op assessment
• Head and neck surgery

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References:

1. FRCA Mind Maps. (2024). Retrieved June 5, 2024, from https://www.frcamindmaps.org/
2. Anesthesia Considerations. (2024). Retrieved June 5, 2024, from https://www.anesthesiaconsiderations.com/
3. King, W. and Dickinson, M. (2015). Oesophageal injury. BJA Education, 15(5), 265-270. https://doi.org/10.1093/bjaceaccp/mku039
4. Howells, P., Bieker, M., & Yeung, J. (2017). Oesophageal cancer and the anaesthetist. BJA Education, 17(2), 68-73. https://doi.org/10.1093/bjaed/mkw037

Summaries:
TOF

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© 2025 Francois Uys. All Rights Reserved.

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