Esophagectomy

 

 

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 anastamotic integrity:

    • Thoracic epidural anesthesia

    • Judicious fluid administration & vasopressor usage

    • Optimize oxygen delivery

 

 

Goals & Conflicts

 

  • Preoperative:

    • Assessment of 4M’s

    • Optimization of comorbidities

    • Planning for postoperative care

  • Intraoperative:

    • Aspiration prophylaxis

    • 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 PRN to treat epidural-related vasoplegia

    • Surgical approach:

      • Ivor Lewis: laparotomy, right thoracotomy

      • Transhiatal: laparotomy, left neck

      • Three hole

      • Left thoracoabdominal

      • Laparoscopic/thoracoscopic

    • Surgical considerations:

      • Prolonged surgery

      • Need for one lung ventilation

      • Intraoperative repositioning

      • Hemodynamic instability: intrathoracic dissection, supraventricular arrhythmias

      • No vascular access left neck

  • Postoperative:

    • Greatest mortality risk of all thoracic surgery

    • Attempt postoperative extubation & plan for high acuity stay

    • Monitor for: aspiration pneumonia, respiratory failure, anastamotic dehiscence with empyema, mediastinitis, septic shock, arrhythmias, CHF