Esophagectomy
Considerations
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High risk for postoperative morbidity & mortality
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Identify surgical approach & associated considerations
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Possible need for lung isolation
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Comorbid disease processes:
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Full stomach & high risk for aspiration
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Malnourishment, deconditioning, anemia, coagulopathy
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Smoker, chronic obstructive lung disease, coronary artery disease, hypertension, diabetes mellitus
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Cancer 4M's:
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Mass effects, medications, metastases, metabolic abnormalities
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Prolonged surgery with severe hemodynamic insults:
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Need for invasive monitors & access
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Lung protective ventilation
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Maintenance of anastamotic integrity:
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Thoracic epidural anesthesia
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Judicious fluid administration & vasopressor usage
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Optimize oxygen delivery
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Goals & Conflicts
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Preoperative:
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Assessment of 4M’s
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Optimization of comorbidities
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Planning for postoperative care
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Intraoperative:
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Aspiration prophylaxis
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RSI due to high risk of aspiration
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Thoracic epidural
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Arterial & central venous access, large bore IV access
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Lung isolation & lung protective ventilation
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Planning for repositioning
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Preparations for severe hemodynamic instability especially during blunt mediastinal dissection
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Restrictive fluid strategy with vasopressors PRN to treat epidural-related vasoplegia
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Surgical approach:
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Ivor Lewis: laparotomy, right thoracotomy
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Transhiatal: laparotomy, left neck
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Three hole
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Left thoracoabdominal
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Laparoscopic/thoracoscopic
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Surgical considerations:
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Prolonged surgery
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Need for one lung ventilation
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Intraoperative repositioning
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Hemodynamic instability: intrathoracic dissection, supraventricular arrhythmias
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No vascular access left neck
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Postoperative:
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Greatest mortality risk of all thoracic surgery
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Attempt postoperative extubation & plan for high acuity stay
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Monitor for: aspiration pneumonia, respiratory failure, anastamotic dehiscence with empyema, mediastinitis, septic shock, arrhythmias, CHF
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