ANESTHETIC CONSIDERATIONS

IN ESOPHAGEAL SURGERIES
Dr. Nitya Reddy R
 INTRODUCTION
• Eighth most common malignancy worldwide
• 20-30% of patients have metastases at initial presentation
• Curative therapy involves surgery, often with preop chemotherapy
• Esophageal surgery is high risk procedure associated with substantial morbidity and
mortality.
• Challenges include increased risk of pulmonary aspiration, possible need for one lung
ventilation, and postoperative pain management.
 CHANGING PATHOLOGY OF
ESOPHAGEAL CANCER
• Western countries- adenocarcinomas are common
• In developing nations- squamous cell histology continues to predominate
• Outcomes are poor with survival rates of around 20-25% at 2 yr for advanced disease
• Most common anatomical location is GE junction and gastric cardia
• Dismal outcomes due
• Propensity for metastasis
• Patients to present late and already have invasive tumours and nodal or metastatic disease.
RISK FACTORS FOR
ESOPHAGEAL
MALIGNANCY
 NEOADJUVANT CHEMOTHERAPY
• Typically used in T3( tumour invading adventitia but not distant structures) or N1 (regional lymphnode disease) after
staging
• Drug combinations
• Cisplatin/5FU
• Paclitaxel/carboplatin FLOT and CAPEOX regimens
• Cisplatin/fluoropyrimidine
• Oxaliplatin/5FU
• Cisplatin- cardio, hepato and nephrotoxic
• 5FU is cardio and hepatotoxic
• Washout period of several weeks between chemotherapy and surgery allows normalization of hemopoiesis, leukopenia,
infection risk and thrombocytopenia
• In patients with complications from chemotherapy
• Delaying surgery to allow adequate recovery
• Or early cessation of chemotherapy
 PREANESTHETIC CONSULTATION
• Risk factors for perioperative mortality and morbidity are
• Poor cardiac and/or pulmonary function
• Advanced age
• Tumor staging
• DM
• Impaired general health
• Hepatic dysfunction
• Peripheral vascular disease
• Smoker
• Chronic use of steroids
 Assessing the airway
Minimising the risk of and preparing for
pulmonary aspiration difficult airway
management

Preanesthetic planning for

esophageal surgery
Determining whether Determining whether
one lung ventilation is severe comorbidities are
necessary present

Planning postoperative
pain control
 RISK ASSESSMENT
• Climbing 2 flights of stairs
• O-POSSUM (physiological and operative severity score for enumeration of mortality and
morbidity)
• APACHE II score
 PREOPERATIVE ASSESSMENT AND
PREHABILITATION
• Cardiopulmonary exercise testing
• Inability to deliver 800ml/min/m2 O2 and a lower AT (42% if AT < 9ml/kg/min and 20% if AT is
>11ml/min/kg) – increased perioperative risk
• Pre optimisation of comorbid diseases
• Smoking cessation and preoperative anemia management
• Nutrition
• Can be obese but still be malnourished and catabolic state
• Cancer cachexia and dysphagia contribute to poor nutritional state
Nutritional support:
• Fortified drinks
• Supplementation when patient fails to take 75% of their nutritional goals and tube feeding for patients
with deficiencies of 50% or more
 COPD AND ARDS
• PPC’s: predicted FEV1<65% and reduced peak expiratory flow rate
• Perioperative inhaled beta agonists along with steroids remain mainstay of treatment.
• Other lung related complication is ARDS:
excessive fluid administration

overdistension of capillaries

Endothelial glycocalyx damage

Increased vascular permeability

 PREHABILITATION
• Physiotherapy and exercise training before surgery to improve fitness
• Yet to be evaluated in patients undergoing esophagectomy
• This is an area of substantial interest and is likely to become important in future.
SURGICAL CONSIDERATIONS
SURGICAL INCISIONS. (A) IVOR LEWIS; (B) IVOR LEWIS WITH ROOF-TOP ABDOMINAL
INCISION; (C) TRI-INCISIONAL; (D) TRANSDIAPHRAGMATIC (E) TRANSHIATAL
 MINIMALLY INVASIVE
ESOPHAGECTOMY
• Thoracoscopic and laparoscopic surgical techniques
• Variation of ivor lewis with multiple ports for thorax and abdomen
• Robotic technique have also been described
 PLANNING POSTOPERATIVE
ANALGESIA
• Open thoracotomy or laparotomy : neuraxial techniques are preferred i.e, TEA or PVB
• Benefits:
• Lower incidence of post op pneumonia and anastomotic leak
• Shorter length of ICU stay
• Better post op analgesia
• Improved overall survival and decreased cancer recurrence

Epidural catheter is placed at T5-6 for a planned thoracotomy at T7-8 if both abdominal and thoracic
incisions are planned

Alternative analgesia techniques: ESP block, serratus anterior plane block, pectoral or intercostal
nerve block
• Thoracoscopy: TEA or PVB for larger thoracotomy incisions
• VATS: regional anesthesia with iv and/or NSAIDS And opiods
• Laparoscopy:
• degree of pain is usually low to moderate
• TAP blocks are an alternative
• Can be given preoperatively or post operatively
• Local infiltration combined with supplemental iv opioid and non opioid analgesics can also be
used.
• PCA and ketamine
• Adjunct analgesics such as gabapentin, pregbalin, or low dose TCA
 MONITORING
• Standard ASA monitors
• Additional monitoring for patients with comorbidities like IBP, foleys to measure urine output
• CVC for an anticipated need for vasoactive medications
• Is static marker and unreliable for assessing fluid responsiveness
• Microcirculatory perfusion monitoring: to detect compromised perfusion of anastomosis
• Sidestream dark field microscopy
• Laser Doppler flowmetry
• Near infrared spectroscopy
• Laser speckle imaging
• Fluoroscence imaging
• Optical coherence tomography
 ANESTHESIA TECHNIQUE
• General anesthesia with endotracheal intubation with or without supplemental epidural
Inhalational agents

anti inflammatory and anti oxidative effects in OLV

Lung protective effect

Improved post op outcomes

 CONSIDERATIONS FOR ONE LUNG
VENTILATION
• If open thoracotomy or thoracoscopy is planned
• A double-lumen endotracheal tube (DLT) and single-lumen endotracheal tube (ETT) may be
initially inserted with subsequent placement of a bronchial blocker
• Final positioning of these devices is accomplished with fiberoptic bronchoscopic guidance
• A protective ventilatory strategy is employed for both OLV and two lung ventilation
LUNG PROTECTIVE VENTILATION
• Low TV ventilation –TV of 4 to 5 mL/kg with OLV; or a TV of 6 to 8 mL/kg with two lung
ventilation
• Titrated respiratory rate – adjust respiratory rate to maintain ETCO2 and PaCO2 near the
patient's baseline.
• Individualized PEEP –titrate PEEP on the basis of respiratory system compliance and
airway driving pressure usually between 5 and 8cm H20
• Limited airway driving pressure –a driving pressure limit of 15 cm H2O. Although a safe
limit is not known, high airway driving pressure is associated with complications after OLV
• Minimum fraction of inspired oxygen (FiO2) – Minimize FiO2 to maintain SpO2 >90
percent.
 FLUID MANAGEMENT
• Restrictive fluid strategy
• Estimating fluid responsiveness
• Crystalloids vs colloids
• Fluid warming
• Use of vasopressors
 HEMODYNAMIC MANAGEMENT
• Hypotension: compression of inferior venacava
• Dysrhythmias : during manipulation of pulmonary vasculature and mediastinal dissection
• Hemorrhage: infrequent, blood transfusion is rare
• Prevent hypothermia
 VASOPRESSORS
• POST ESOPHAGECTOMY – LEAKS/STRICTURES SECONDARY TO CONDUIT
ISCHEMIA
• HYPOTENSION (G.A/E.A),BLOOD LOSS,V.C
• PHENYLEPHRINE VS NORADRENALINE
 EMERGENCE AND EXTUBATION
• Current practice: extubate the patient
• No evidence that post op mechanical ventilation is associated with reduced PPC’s
• A well planned perioperative care improves the overall outcome after esophageal surgeries.
 SUMMARY OF ANESTHETIC
TECHNIQUE FOR ESOPHAGECTOMY
• General ASA standard monitors
• Invasive monitoring- IBP, trends of CVP
• Minimising aspiration risk
• TEA
• OLV with lung protective strategies
• Goal directed fluid therapy
• Maintaining adequate perfusion to optimize the anastomotic blood flow
• Fast track extubation
 PERIOP PHARMACOLOGICAL
THERAPIES
• METHYLPREDNISOLONE

• SIVELESTAT – NEUTROPHIL ELASTASE INHIBITOR

 POST OPERATIVE COMPLICATIONS

Respiratory Surgical Cardiac

• Pneumonia is the most • Anastamotic leaks • Supraventricular
common arrhythmias particularly AF
• Atelectasis
• ARDS
• Recurrent laryngeal nerve
palsy
 SURGICAL
• Ng decompression
• Anastamotic leak 10-37%
• Distant site of anastamosis – ischemia,inadequate healing
• Avoid tissue edema,vasoconstriction.
• 5 days – 1 week
• Nbm,high protein enteral feeds,antibiotics
• Re-exploration
 CARDIAC
• SUPRAVENTRICULAR ARRHYTHMIAS – AF
• PERICARDIAL IRRITATION,SEPSIS,ANASTAMOTIC LEAK,OLV,AGE
 ENHANCED RECOVERY
PROTOCOLS:
• Preop carbohydrate loading – 2h liq,6h solid
• Pre emptive analgesia – TEA,NSAIDS,L.A
• Grade A recommendations for MIO – early postop feeding,thromboprophylaxis
• Components – preop optimisation of HB,NUTRITION,EARLY MOBILIZATION,DAILY
EVALUATION OF DRAIN,CATHETER AND TUBE REMOVAL.
 MIE
• Modified ivor lewis – left lateral position
• Improved ln retrieval,shorter stay,less ileus,wound infection,transfusion
• Prolonged operating times and inc risk of re-operation
 PALLIATION IN ESOPHAGEAL
MALIGNANCY
• 75 to 85% of patients are never treated with curative intent
• Multidisciplinary management is cornerstone in providing good care
• Specific complications pertinent to esophageal malignancy include
• Dysphagia management
• External beam RT and Brachytherapy
• Chemotherapy
• Nutritional support
• Analgesia
• Prevention of GI bleeding
 DYSPHAGIA
• Endoscopic stenting is the treatment of choice
• Other options: Chemo or radiotherapy, endoscopic laser therapy, endoscopic chemical
injections, dynamic phototherapy, cryoablation and dilatations
• Performed under sedation or general anesthesia
• Bypass surgery is used less frequently and is performed when curative surgery is abandoned
intraoperatively
 ANALGESIA
• Limited access to oral route so other routes may need to be utiised
• Stenting to regain access to GI tract is the key to allow easier analgesia and nutrition
• Chronic pain therapy with gabapentinoids may be valuable adjuncts.
 NUTRITIONAL SUPPORT ACCESS
(GASTROSTOMY OR JEJUNOSTOMY)
• General anesthesia is required
• Concerns
• Frequently cachectic
• Anaemia
• Functionally immunosuppressed
• Suffering from ongoing GI reflux
• Obstructed esophagus with food residue

Requires careful tailoring of anesthesia technique

 KEY POINTS
• Esophageal carcinoma is becoming more common
• Pathology and patient characteristics are changing
• Careful preoperative assessment and optimization is needed
• Exquisite attention to analgesia, fluids and ventilation intraoperatively
• Esophagectomy surgery can be associated with a number of post op complications including
organ failure and critical illness
• Anesthetists may also be involved in palliative therapy
THANK YOU