Esophagogastrectomy/transhiatal and transthoracic

What the Anesthesiologist Should Know before the Operative Procedure

Esophagogastrectomy is a high-risk surgical procedure most commonly performed in patients with esophageal cancer for treatment or palliation. Anesthesiologists caring for such patients should have a thorough understanding of the patients’ disease state for which the surgical procedure is indicated, relevant aspects of the planned surgical approach and comorbid conditions these patients commonly present with. Comprehension of the disease state includes knowledge of the epidemiology and pathophysiology of esophageal cancer and relevant surgical anatomy. Other factors that can influence perioperative outcome and warrant careful consideration include surgical expertise and surgical volume at the treatment facility; multimodal anesthetic management protocols aimed towards fluid restriction, judicious use of vasopressors, early extubation and regional anesthesia. Anesthesiologists should make themselves familiar with these aspects to optimally care for such patients.

Epidemiology – incidence and mortality

With an annual incidence 4.3 cases per 100,000 men and women, there are an estimated 36,857 people living in the United States with esophageal cancer. According to data from the National Cancer Institute the overall survival in patients diagnosed with esophageal cancer is close to 18% and this has remained more or less stable since the early 2000s. Esophageal cancer accounts for 1% of all cancers but accounts for 2.6% of all cancer-related deaths. The median age of diagnosis is 69 years. (Additional statistics and charts are available at http://seer.cancer.gov/).

Tumor type and location

There are two primary types of esophageal cancer: squamous cell carcinoma (SCC) and adenocarcinoma (AC). As the entire esophagus is lined with squamous cell tissue, SCC can occur along the entire length of the esophagus and accounts for most esophageal cancers worldwide. Alcohol and smoking are recognized risk factors for SCC. In the western world including the United States the majority of new cases are adenocarcinoma. Adenocarcinoma originates in glandular tissue and usually occurs in the lower one-third part of the esophagus, near the stomach. Risk factors for adenocarcinoma include gastro-esophageal reflux disease (GERD), Barrett’s Esophagus, obesity, smoking and diet low in fruits.

Table I.

Table II.

Surgical anatomy

The esophagus is a muscular tube that connects the oropharynx to the stomach. It is approximately 25 cm long and extends from the lower border of the cricoid cartilage to the cardiac orifice of the stomach. It has three sections: the cervical, thoracic, and abdominal. The cervical segment extends from the cricopharyngeus to the suprasternal notch. The thoracic segment extends from the suprasternal notch to the diaphragm and the abdominal segment extends from the diaphragm to the stomach.

Anatomically the cervical esophagus is located slightly to the left of the midline and the thoracic duct lies to its left. As it passes through the thoracic inlet it lies posterior to the trachea. Within the mediastinum the esophagus is in close proximity to the aortic arch, descending thoracic aorta, thoracic duct, azygous vein, inferior pulmonary veins, left recurrent laryngeal nerve and left mediastinal pleura. Thus, there is a significant potential for injury to any of these structures during dissection and mobilization of the esophagus. The esophagus enters the abdominal cavity as it passes through the right crus of the diaphragm and joins the stomach at the gastric cardia.

Arterial blood supply

• The cervical portion is supplied by the inferior thyroid artery.

• The thoracic portion is supplied by esophageal and bronchial branches of the descending thoracic aorta.

• The abdominal portion is supplied by branches of the left gastric and left phrenic artery.

Venous and lymphatic drainage

Venous drainage follows the arterial supply. There is also a submucosal network of lymphatic channels, which drain to cervical nodes, tracheobronchial, mediastinal nodes, gastric and celiac nodes.

Table III.

Treatment options and surgical approach

Treatment options

Surgical resection remains the only curative option for esophageal cancer, but is associated with high morbidity and mortality, 3.2% and 29.7% respectively. Neoadjuvant chemotherapy and chemo radiation are other available therapeutic options often combined with surgical resection but will not be discussed further in this chapter. Pertinent to this chapter are the surgical options: esophagectomy or esophagogastrectomy via an open or minimally invasive approach. Over the past few decades the two main open surgical approaches to esophagectomy that have evolved include the transhiatal esophagectomy (THE) and transthoracic esophagectomy (TTE). THE approach is the “so-called” limited approach and tends to avoid a formal thoracotomy along with its gamut of perioperative concerns and complications. TTE along with mediastinal and upper abdomen lymphadenectomy is the more extensive approach widely agreed to provide better loco regional tumor control but on the other hand is the more extensive surgical procedure. Due to lack of high quality evidence the surgical approach generally narrows down to institutional and surgeon preference.

Table IV.

Alongside the two open surgical techniques of esophagectomy, various minimally invasive esophagectomy (MIE) techniques including thoracosopy with laparotomy, laparoscopy with thoracotomy, have been developed over the last few decades. These minimally invasive approaches help limit the surgical trauma of the operation and at the same time help achieve radical tumour resection with lymphadenectomy. Randomized trials comparing conventional open surgical techniques to MIE are lacking and more studies are needed to see if MIE helps decrease patient morbidity and mortality. Robotics is a tool that has come to be used with increasing frequency for thoracic surgical procedures including esophageal surgery. Use of the robot usually mandates a minimally invasive approach to the procedure – utilizing both laporascopic and thoracoscopic approaches to esophageal resection and reconstruction.

Once the esophagus is resected via the THE approach a cervical anastomosis is performed between the proximal esophagus and replacement conduit at the cervical level. Via a TTE approach this can be done either at the cervical or thoracic level. A thoracic anastomosis may have a lower risk of stricture, lower anastomotic leak rate and less risk of injury to the recurrent laryngeal nerve but a cervical anastomosis is still favoured by some surgeons as there is a longer proximal tumor free segment and a potential for reduced morbidity in cases of an anastomotic leak (will not occur in the mediastinum or pleural cavity). In general, it has been noted that stricture formation may be influenced by the technique (open possibly better than minimally invasive). An anastomotic leak in itself is associated with decreased survival.

Of note, the occurrence of anastomotic leaks can be explained by the surgical approach. With creation of a gastric conduit to be the new esophagus, three of the five major blood vessels to the stomach are divided: the left gastric, short gastric and left gastroepiploic vessels, leaving only the right gastric artery and the right gastroepiploic as the remaining blood supply. Thus, the apex of the gastric conduit, often the site of the anastomosis, has a decreased blood supply. Therefore, some have advocated a pre-surgical procedure to either embolize or ligate the left gastric artery to encourage collateralization of blood flow to reduce the risk of dehiscence.

Available expertise and surgical volume

Numerous studies and database analysis have demonstrated a link between low volume centres, with a low level of available expertise to be associated with increased morbidity and mortality in esophageal cancer surgery. The relationship between hospital volume (total number of procedures per year) and mortality (in-hospital or within 30 days) shows that esophagectomy carries a 20.3% risk of death if performed in a low-volume hospital. In a one analysis, based on 64,047 patients in a Medicare data set, esophageal cancer surgery risk did not converge over time with large variations in survival dependent on whether a hospital’s volume for a particular cancer surgery is a high, medium, or low.

Finally, critical to the effect on mortality is the individual surgeon’s volume – an effect that is magnified by the hospital volume. In a recent meta-analysis of long-term survival after esophageal cancer surgery an 18–25% and 9–13% improvement in survival was demonstrated in high-volume hospitals and high-volume surgeons, compared with low-volume hospitals and surgeons, respectively. Although there was huge heterogeneity in the number of annually performed esophagectomies in these studies, no high volume center performed less than 10 esophagectomies per year.

Enhanced recovery after surgery (ERAS)

Enhanced recovery after surgery is a process that has gained widespread acceptance as a means to improve perioperative outcomes by advocating evidence based practices in all aspects of perioperative care. ERAS has been shown to decrease complications and shorten length of stay (LOS) in colorectal surgery and recently published data suggests that implementation of ERAS protocols for esophagectomies has the potential to decrease LOS to a median of eight days, pulmonary morbidity and reduce mortality. ERAS focuses on preoperative optimization of the patient and targets key intraoperative milestones such as fluid management, perioperative pain control with a thoracic epidural aimed at the upper level of incision and lung protected ventilation strategy. Optimized postoperative care is another essential component of any ERAS protocol.

1. What is the urgency of the surgery?

The urgency of the surgery is determined by the stage and aggressiveness of the cancer being treated. Rarely, however, is an esophageal cancer procedure a surgical emergency. Patients are worked up over weeks and months; further adjuvant chemo or radiation therapy usually occurs before the surgical procedure. For example, an obstructing esophageal mass would usually be treated with enteral feeding via a gastrostomy tube and chemo or radiation therapy to decrease the mass size. The only true emergency would be an esophageal perforation leading to spillage of gastric contents into the lungs – this usually occurs as the result of an endoscopy procedure intended to biopsy a suspicious mass.

What is the risk of delay in order to obtain additional preoperative information?

There is little risk of delay to a surgical procedure to obtain preoperative information, especially if that information may aid in risk stratification and risk factor modification.

Emergent: An emergent procedure would primarily be related to an esophageal perforation, secondary to tumor complications or a perforation from a biopsy.

Urgent: An urgent surgery would be primarily related to the lack of ability to manage one’s secretions or inability to swallow. However, a feeding tube, palliative chemotherapy or radiation therapy and or an esophageal stent are usually performed prior to surgery in this situation.

Elective: Surgery is undertaken when the patient is deemed in optimal condition – both the medical treatment of the tumor and any co-morbid conditions.

2. Preoperative evaluation

a. Risk assessment and prediction of postoperative complications

One of the most important problems to confront in patients undergoing esophagectomies, is determination of the overall risk of adverse outcomes, not only major adverse cardiac events but importantly so, in this patient population the risk of major respiratory complications including atelectasis, pneumonia and respiratory failure. Esophagectomy is a high-risk surgical procedure that should only be undertaken in patients with the physiological reserve to survive the perioperative stress. Risk factors for morbidity and mortality after esophagectomy include:

• Poor cardiopulmonary status and reserve

• Advanced age

• Tumor stage

• Significant comorbidities

  a

  Pulmonary Dysfunction

  b

  Cardiac dysfunction

  c

  Diabetes mellitus

  d

  Hepatic dysfunction

Surgeons commonly use a risk assessment tool such as POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) or P-POSSUM to estimate postoperative mortality in surgical patients. For esophagectomy a dedicated model for patients undergoing esophagectomy surgery (O-POSSUM) has also been developed but appears to over predict mortality risk. These scoring systems can aid surgeons in patient selection and patients making treatment choices. Frailty scores have also been used to predict outcomes in patients presenting for esophageal surgery.

Preoperative work-up

In addition to the usual workup for a major surgical procedure, routine laboratory examination: hemoglobin, PT (prothrombin time), PTT (partial thromboplastin time), platelet count, and BUN/Cr (blood urea nitrogen/creatinine ratio) and an ECG should be performed. Based on patients history and physical exam further workup should be performed if information obtained from such testing will effect patient management in the perioperative setting.

As these patients are at increased risk of post-operative pulmonary complication, pulmonary function assessment including chest radiography, room air arterial blood gas analysis, spirometry with and without bronchodilators, should be undertaken. No absolute level of pulmonary dysfunction mandates cancellation of the surgical procedure. Instead, pulmonary function testing is used to determine the degree or risk for perioperative morbidity and mortality. The ARISCAT score, which was developed as a predictive model for postoperative pulmonary complications (PPC’s) is a useful tool in the assessment of these patients. A weighted point score is calculated based on the patients age, preoperative oxygen saturation, respiratory infection within the past month, anemia, upper abdominal or thoracic surgery, surgery lasting more than two hours and emergency surgery. This objective scoring system can assist in patient selection and guide pre-operative optimization.

Neoadjuvant chemotherapy and radiotherapy regimens should be reviewed as this will help one to assess the potential for difficulty in intubating the trachea, surgical dissection as well as the need to limit inspired oxygen concentration. The anesthesiologist should make himself/herself familiar with the extent of the tumor and the exact surgical procedure along with potential for changing the surgical plan.

Given the need for one-lung ventilation, the potential for difficulty in placing a dual lumen endotracheal tube should be assessed. Further, the landmarks for epidural catheter placement should be ascertained. The likelihood of difficult arterial (for an indwelling arterial line) and venous access should be determined. Placement of central venous catheters should be discussed with the surgical team to determine appropriateness in relation to the surgical field.

Medically unstable conditions warranting further evaluation include active cardiac condition as defined by the ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Non-cardiac Surgery and include acute coronary syndromes, symptomatic heart failure, symptomatic valvular heart disease and symptomatic arrhythmias. Pulmonary unstable conditions include preoperative pneumonia, uncontrolled asthma or COPD (chronic obstructive pulmonary disease); other active and uncontrolled medical conditions that warrant preoperative optimization include new renal dysfunction, abnormal coagulation profile severe malnutrition, and uncontrolled diabetes.

Delaying surgery is indicated for optimization of any of the above cardiac and pulmonary conditions and for new diagnoses of neurological impairment, liver dysfunction, and renal failure.

b. Cardiovascular system

Patients presenting for esophageal surgery should be evaluated for adequate cardiovascular function and reserve. It is not uncommon that an esophageal surgery patient present with a coexisting cardiovascular condition such as hypertension, dysrhythmia, coronary artery disease (CAD), valvular heart disease, or peripheral vascular disease (PVD).

Hypertension

One in three Americans have hypertension and only half of them have satisfactory control of their blood pressure. Patients with controlled hypertension are known to experience less hemodynamic fluctuations in the perioperative setting. At the same time there is a paucity of compelling data indicating that patients with uncontrolled high blood pressures are at increased risk of adverse perioperative events.

It is important that the patients’ blood pressure be accurately measured in the perioperative period and a suitable target range for blood pressure be determined on an individual basis. Any signs or symptoms of acute end organ compromise due to uncontrolled hypertension (hypertensive urgency or emergency, e.g., myocardial ischemia) should prompt a delay in elective surgery.

Systemic complications of hypertension should be sought, including evidence for left ventricular hypertrophy, renal dysfunction, and neurological disease. Antihypertensive medications should be reviewed and most of them should be continued preoperatively including on the day of surgery. Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II receptor blockers (ARB) have been associated with hypotension on induction of anesthesia and intraoperatively. Although strong evidence supporting or refuting the administration of these drugs preoperatively is lacking, most providers prefer holding ACEI and ARB preoperatively.

Risk reduction

Preoperative hypertension is a known predictor of perioperative morbidity. Uncontrolled hypertension results in more frequent hemodynamic fluctuations in the perioperative setting, which has an association with increased morbidity perioperatively. Having said that, current guidelines from the AHA/ACCF suggest that risks and benefits of delaying surgery to optimize antihypertensive treatment should be carefully considered as data on the benefit of treating asymptomatic chronic hypertension preoperatively is lacking. All antihypertensive medications except for ACE inhibitors and ARBs should be continued perioperatively. A goal to attempt to keep the patient’s blood pressure within 20% of their baseline pressure is reasonable for which fluids and vasoactive medications may be needed and titrated appropriately.

Coronary artery disease

Presence of coronary artery disease is a well-known risk factor for increased perioperative morbidity and mortality. Patients with CAD can either present with medically managed CAD or re-vascularized (percutaneously – PCI with or without stenting or surgically – CABG). A thorough history and physical exam to assess risk factors, symptom control and exercise tolerance should be performed. Presence of unstable angina should prompt a delay in surgery and further testing and treatment if indicated. For stable patients risk stratification (using either the revised cardiac risk index or NSQUIP database) should be performed and treatment optimization ensured before proceeding with surgery. Of note, if a coronary stent is placed, the timing of surgery must be carefully considered due to the need for antiplatelet therapy.

Risk reduction

Based on the patient’s preoperative evaluation and risk factor assessment a decision should be made to perform further cardiovascular testing if treatment decisions based on these tests will effect patient management and help improve outcomes. All medications for coronary artery disease should be continued perioperatively. Exceptions are ACEI and ARB, which are usually discontinued prior to the day of surgery to avoid intra and postoperative hypotension.

During an esophageal procedure, one can anticipate fluctuations in hemodynamic variables such as heart rate and blood pressure. To the extent possible, monitoring the 5 lead EKG, control of the heart rate and maintenance of a mean arterial pressure within in 20% of the patient’s baseline are ideal (use of an indwelling arterial line is helpful). Invasive pulmonary arterial catheter monitoring is not usually indicated to guide intraoperative management. Unfortunately, intraoperative transesophageal echocardiography is contraindicated.

Valvular disease

The incidence and prevalence of valvular heart disease increases as patient’s age, and may present as a co-existing condition in the esophageal surgery patients. In particular, aortic and mitral valve conditions should be sought and, if present, the adequacy of their treatment determined. This will likely start with a targeted history and physical exam and may require anatomic and/or functional evaluation (e.g., transthoracic echocardiography with or without stress testing, cardiac MRI [magnetic resonance imaging]). Valvular disease must be optimized and treated prior to any esophageal procedure. All medications for valvular heart disease should be continued perioperatively.

Risk reduction

Since transesophageal echocardiography is contraindicated during surgery, one must rely on hemodynamic parameters to optimally manage valvular heart disease (which should be well controlled prior to surgery). One must precisely pay attention to preload and blood pressure targeted to the goals of a particular valvular disorder (e.g., with aortic stenosis, it is important to keep the diastolic blood pressure relatively higher to improve coronary artery perfusion).

Thoracic epidural analgesia used during the procedure may be either beneficial (reduced preload for mitral regurgitation), or detrimental (reduced afterload for aortic stenosis). Careful titration of local anesthetic agents in the thoracic epidural space is advised. Additionally, one must assess the need for endocarditis prophylaxis dependent on the severity of the valvular lesion and any prior interventions.

Cardiac conduction abnormalities and Dysrhythmias

The most common dysrhythmias that patients undergoing esophageal surgery present with include atrial fibrillation and premature atrial or ventricular contractions. Chronic atrial fibrillation should be well controlled in rate. Based on the stroke risk assessment these patients may be on long-term anticoagulation. Their stroke risk in the perioperative period should be determined and discontinuation and bridging of anticoagulation should be assessed on a case-to-case basis. Premature atrial or ventricular contractions must be evaluated carefully as they may be a marker of poor cardiovascular reserve.

Risk reduction

One must remember that in both chronic atrial fibrillation and in premature contractions, the atrial kick is lost, leading to a decrease in stroke volume with a potential decrease in cardiac output. For both conditions, one must be careful not to precipitate an increase in heart rate with injudicious use of vasoactive agents. Titration of hemodynamic agents and cautious maintenance of adequate intravascular volume (not excessive to avoid pulmonary edema) will assist in the maintenance of a rhythm consistent with adequate cardiac output. The timing of anticoagulant discontinuation is crucial as neuroaxial anesthesia may be contraindicated for surgery, leaving patients at a disadvantage for pain management. In such case an alternative pain management treatment plan must be formulated.

Peripheral vascular disease

Peripheral arterial disease (PAD) may be managed medically or surgically. The adequacy of peripheral blood supply must be ensured, especially since patients are at risk for reduction in blood flow due to hemodynamic compromise during the procedure. Unstable PAD should be treated (e.g., surgery, stent, medical management) before surgery to avoid complications. Medications for PAD should be continued perioperatively except for anticoagulants, which should be held at an appropriate time preoperatively to avoid intraoperative bleeding and safe insertion of neuroaxial catheters.

Patients with cancers are known to be at high risk of deep venous thrombosis and pulmonary embolism (DVT/PE). Even if on treatment, cancer patients are at higher risk for recurrent venous thromboembolic events and have higher risk anticoagulation-associated major bleeding. One should seek signs and symptoms of a DVT preoperatively and be suspicious for these events intraoperatively and postoperatively.

Risk reduction

Antiplatelet or anticoagulant therapy for PVD may complicate the surgical procedure with an increased propensity for bleeding. Risk versus benefits of continuing aspirin in the perioperative period should be determined on a case-to-case basis. Similarly the appropriateness of bridging anticoagulation in patients with venous thromboembolism should be determined based on the pts risk of stroke versus increased risk of major bleeding perioperatively. Mechanical prevention of DVT should take place during surgery with compression stocking or compression inflation devices and preoperative subcutaneous heparin as determined by local protocols.

c. Pulmonary

COPD

Pulmonary complications after surgical procedures requiring anesthesia have a significant impact on morbidity, mortality, need for postoperative intensive care, hospital stay and health care cost. Chronic disease of the lungs such as asthma and COPD are frequent comorbid conditions in patients presenting for esophageal surgery. Preoperative assessment helps stratify the patient’s perioperative risk of pulmonary complications, ascertain baseline functional status and tailor strategies for optimization. Additional testing could include spirometry, diffusing capacity of the lungs for carbon monoxide (DLCO), and a functional test of exercise capacity. One can also consider a room air arterial blood gas to establish baseline oxygenation and ventilation.

Risk reduction for COPD

Preoperative smoking cessation and physical activity can decrease the risk of postoperative pulmonary complications. Other interventions that have been studied and frequently employed include preoperative bronchodilator therapy, antibiotic therapy for purulent sputum and chest physiotherapy, but data supporting these interventions is lacking. Intra and postoperatively the use of neuroaxial anesthesia or analgesia are associated with fewer PPC’s.

Bronchodilators, systemic or inhaled corticosteroids and leukotriene antagonists should be continued preoperatively. Non- histamine releasing drugs should be preferred for induction and maintenance of anesthesia. Ventilation strategies that help prevent accumulation and air trapping in the overly compliant lung known by various names such as “auto PEEP”, breath-stacking, and dynamic pulmonary hyperinflation should be employed. At the extreme, this problem can result in hemodynamic compromise and even cardiopulmonary arrest. Similarly, with one-lung ventilation, a conservative ventilation approach should be taken using low tidal volumes, long expiratory periods and acceptance of mild hypercapnia intraoperatively to decrease the risk of mechanical injury to the dependent ventilated lung with COPD or reactive airway disease.

d. Renal-GI:

Renal disease

Baseline renal dysfunction is not a contraindication to this procedure; at the same time renal function should be preserved in the perioperative period. Thoracic surgery is a known risk factor for postoperative acute kidney injury. Other risk factors include pre-existing renal insufficiency, age older than 60 years, left ventricular dysfunction. One should assess not only the creatinine and the BUN, but also the creatinine clearance as scaled to body weight and age. A patient who presents for esophageal surgery with chronic renal failure on dialysis must be assessed individually with the surgical team, the oncologist and the anesthesia team as this high-risk patient may not be an appropriate candidate for this surgical procedure.

Risk reduction

Measures that can reduce the incidence of perioperative renal dysfunction include maintenance of normal hemodynamic parameters, attention to intravascular fluid status (as determined by urine output or arterial blood pressure waveform analysis). Nephrotoxic drugs (certain antibiotics, NSAIDs) and intraoperative hypotension should be avoided.

Gastrointestinal disease

Patients who present for esophageal surgery usually present with gastrointestinal (GI) disease. In fact, gastroesophageal reflux disease (GERD) has been implicated as a cause of Barrett’s esophagus, known to lead to esophageal cancer. Patients may suffer esophageal obstruction as the result of tumor growth in the esophagus. Patients may also have concurrent hiatal hernia, gastric ulcer disease and diverticular disease. Clearly, an acute change in GI function usually led the patient to the cancer diagnosis, but an acute occurrence of gastritis or diverticulitis may lead to postponement of the surgical procedure to optimize GI function. There is little additional work-up needed for GI disease as it is usually well-defined, based on the preoperative work-up for esophageal surgery, including upper GI endoscopy and imaging studies. All medications that the patient has been taking can be continued until the surgical procedure.

Risk reduction

In patients presenting with GERD and/or hiatal hernia or obstructive esophageal cancer, a rapid sequence induction and intubation should be considered. One can consider preoperative sodium citrate and/or prokinetics (e.g., metoclopramide, assuming no gastric outlet obstruction) to reduce the likelihood and severity of aspiration pneumonitis but evidence supporting its use is lacking.

e. Neurologic:

It would be uncommon for a patient with significant concurrent neurological disease to present for esophageal cancer surgery, but it can occur.

Stroke and transient ischemic attacks (TIAs)

A patient with a distant history of stroke or transient ischemic attack (TIA) should be able to have esophageal surgery without neurological compromise. Baseline neurological function and deficits should be evaluated and documented. Current treatment and preventive measures should be reviewed and continued in the perioperative period. It is prudent to determine any previous need for postoperative ventilation or other perioperative complications. Clearly, acute disease or any change in neurological status needs to be investigated and treated prior to esophageal surgery.

Risk reduction

As discussed in the section of CAD, after a risk benefit analysis perioperative antiplatelet therapy may be continued. Other drugs for risk factor treatment and modification including antihypertensive and statins should be continued perioperatively. The concurrence of cerebrovascular disease and hypertension may lead the clinician to manage and maintain mean arterial pressure closer to the patient’s baseline than otherwise indicated.

Chronic neurological diseases

Other chronic neurological diseases with which these patients can present with include but are not limited to:

Parkinson’s disease

Dementia and Alzheimer’s disease

Peripheral neuropathy and myopathies

Chronic back pain.

f. Endocrine:

Endocrine disorders such as diabetes and thyroid disease are prevalent in our society and can be anticipated in the esophageal surgical patient. Chronic endocrine conditions should be well-documented and recent changes investigated. Acute changes in an endocrine disease process will usually lead to postponement of the surgical procedure to allow for treatment and optimization of the chronic condition. Severe perturbations of blood glucose may impair wound healing and increase risk of surgical site infections. Severe perturbations in thyroid function may impair both hemodynamic stability and the ability of the patient to participate in postoperative rehabilitation (especially if hypothyroid).

Diabetes

Diabetes should be well-controlled with a normal Hb-A1C level on a stable blood glucose management regimen.

Risk reduction

As usual for a surgical procedure, oral hypoglycaemic should be held and blood sugar managed via intermittent insulin blouses or an insulin intravenous infusion. Intraoperatively, frequent sampling of blood glucose can be done at the same time as arterial blood gas analysis; intravenous insulin can be titrated to achieve normoglycemia. It is also essential to control blood glucose in the postoperative period.

Thyroid

Hyper- or hypothyroid disease may be detrimental to the stability and recovery of the patient who undergoes esophageal surgery. Hyperthyroidism results in an accelerated metabolic state, which can complicate hemodynamic management and provision of adequate nutrition. Furthermore, a hypermetabolic state may result in hypoxemia in a patient with marginal oxygen exchange in the postoperative period. Hypothyroidism can equally complicate the perioperative management of the esophageal surgery patient. Not only must patients be able to mount an appropriate hemodynamic response (e.g., tachycardia in the face of hypovolemia or sepsis), but also patients must be motivated and able to exert themselves physically after surgery to regain strength and prevent postoperative complications. Thyroid function studies should be performed if there is any suspicion of thyroid disease; abnormal studies should prompt an endocrinology consult.

Risk reduction

Once a euthyroid state is assured, it is usually safe to proceed with surgery. Thyroid supplementation can be safely continued in the perioperative period.

g. Additional systems/conditions, which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Hematologic status

The patient presenting for esophageal surgery may have undergone chemotherapy and/or radiation therapy. It is imperative to inspect the patient for signs of immunocompromise prior to surgery including an assessment of the white blood cell count and an absolute neutrophil count. Furthermore, the patient may present with anemia, thrombocytopenia and/or pancytopenia. Clearly, any of these conditions may compromise the patient’s ability to mount an appropriate immune response, result in perioperative bleeding or lead to the need for transfusion. Severe hematologic perturbations should delay surgery to allow for bone marrow recovery. Additional treatment with agents such as erythropoietin may be necessary.

Nutritional status

The nutritional status of the patient should not be ignored as a lack of healing or inappropriate healing may lead to two of the most common perioperative complications: anastomotic leak and stricture formation. Furthermore, due to malnutrition, many of these patients suffer from electrolyte abnormalities, which may need to supplement perioperatively. For example, hypomagnesemia is very common and may need to be supplemented intra and postoperatively.

Significant nutrition compromise may delay surgery for insertion of a feeding tube. For example, jejunostomy tube to be able to give supplemental or total nutrition in the preoperative period. Similarly, the surgical team may elect to place a jejunostomy tube at the time of surgery for planned total or supplemental enteral nutrition in the postoperative period. A pharmacist or a dietician in the hospital, as needed, may guide the type and amount of enteral nutrition.

4. What are the patient's medications and how should they be managed in the perioperative period?

The patient for esophageal surgery will present on medications that fall into four categories:

1. Medications for the primary problem: These medications will be those related to the esophageal cancer and/or the underlying gastrointestinal pathology. Thus they may include medications to treat GERD or gastric ulcer. It is also important to consider medications that are being used to treat the consequences of chemotherapy and radiation therapy such as antiemetic’s, agents to reduce intragastric acidity (H₂ blockers and proton pump inhibitors) or hemopoetic growth factors (erythropoietin).

2. Medications for comorbid conditions: These medications will include those discussed above and should be carefully ascertained and documented.

3. Medications for anxiety and pain: Preoperative anxiety is commonly seen in surgical patients especially those presenting for cancer surgery. Anxiety has been studied to negatively impact hospital length of stay and postoperative pain control. Patients on anxiolytics and chronic pain medications should be encouraged to take their normal doses preoperatively. Depending on the duration and dose of these medications, the additive and synergistic effect they have on commonly used medications during anesthesia should be closely considered.

4. Non-prescription medications, over the counter medications and drug supplements: It is important to ask patients about over the counter, alternative medications, herbs, and nutritional supplement use to avoid potential adverse perioperative interactions. Herbal substances may contain biologically active agents. For example, valerian tea is sold as a nutritional supplement for insomnia, nervous tension, hysteria, excitability, stress, and intestinal colic or cramps. It acts similarly to benzodiazepines. It interacts with both benzodiazepines and opioids but is also associated with withdrawal symptoms in people who abruptly discontinue taking it after long-term use. Other supplements to be aware of are the “G” herbs. Ginger, garlic, and gingko biloba may result in perioperative bleeding as a mild anticoagulation state may occur; they can also enhance the action of warfarin. Conversely, ginseng can reduce the effectiveness of warfarin. Patients with a cancer diagnosis also frequently turn to homeopathic remedies in an attempt to cure their cancer. Homeopathic remedies may contain biologically active substances, which when taken in large doses can cause disease states. For example, zinc is present in many homeopathic remedies and may cause loss of smell.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

There are no specific medications for this procedure that are of greater concern than others. The clinician should determine what specific chemotherapy agents have been administered preoperatively and be wary of their effects on the cardiac and pulmonary systems.

i. What should be recommended with regard to continuation of medications taken chronically?

Cardiac: All should be continued perioperatively except for ACEI and ARB agents.

Pulmonary: All should be continued perioperatively.

Renal: All should be continued perioperatively.

Neurologic: An assessment of which medications to continue perioperatively should be made with a neurology consultant. In general, medications that interact acutely with anesthetic agents should be discontinued.

Antiplatelet: These drugs should be discontinued preoperatively at an appropriate time such that there is little residual effect on platelet function at the time of surgery.

Psychiatric: There is increased awareness of withdrawal phenomenal from psychotropic medications and these medications should preferably be continued in the perioperative period. Medications that interact acutely with anesthetic agents should be discontinued. MAO inhibitor use is now rare, but the clinician must be cognizant of the extreme adverse interactions MAO inhibitors may have with certain medications commonly used during anesthesia, for example, indirect sympathomimetic agents (ephedrine).

j. How to modify care for patients with known allergies

Known allergens should be avoided. There are no medications or agents used that are so unique as to need to administer them in the face of an allergy. Alternative medications with similar effects should be sought.

k. Latex allergy – If the patient has sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

All usual latex precautions should be undertaken in the patient with a latex sensitivity or allergy. Some commonly overlooked devices that may contain latex include PA catheters and trans venous pacing catheters. If placement of these devices is indicated, risk benefits in the setting of latex allergy should be considered or alternatives sought. Treatment of latex allergy includes use of antihistaminic, steroids, fluids and epinephrine.

l. Does the patient have any antibiotic allergies?

The goal of antibiotic prophylaxis for this surgical procedure is to primarily prevent infection from skin and gastrointestinal pathogens. In general, cefazolin is chosen. However, alternative combinations of antibiotics may be sought in the event of an allergy, as long as the primary goal of infection prevention is achieved. Consultation with an infectious disease specialist may be advised.

m. Does the patient have a history of allergy to anesthesia?

As per a usual preoperative assessment, one should question a patient for allergies or adverse reactions to common anesthetic agents, as well as seek a history of malignant hyperthermia (MH). Conditions related to MH should be questioned including a history of core myopathies and Kind-Denborough syndrome.

Malignant hyperthermia (MH)

If MH is documented in the patient or a primary relative, then all trigger agents such as succinylcholine and inhalational agents should be avoided. An anesthetic plan must include a clean anesthesia machine flushed according to the manufacturers recommendations (may take anywhere from 10 to more than 90 minutes), placement of a MH cart in the operating room with a protocol for MH written out and readily available. Dantrolene prophylaxis is not recommended for most MH-susceptible patients; as long as non-MH triggering anesthetics are used and a sufficient supply of dantrolene is readily available (The MH Hotline may be consulted as well. https://www.mhaus.org, 1+800-644-9737.)

Local anesthetics/muscle relaxants

“True” allergies to local anesthetics and muscle relaxants are very rare. Esters group local anesthetics produce allergic type reactions more often than amide group local anesthetics. Preservative in local anesthetic solution or latex contamination have been attributed to be the culprit allergen in some of these reactions and should be considered when evaluating the patient’s previous allergy events. Neuroaxial anesthesia or analgesia may have to be avoided if a true allergy to both classes of local anesthesia is confirmed. Similarly, allergic reactions to muscle relaxants are very rare. Most common culprit agents include succinylcholine and rocuronium. Alternative muscle relaxants should be sought in such situations.

5. What laboratory tests should be obtained and has everything been reviewed?

Common laboratory test will be same for other major surgical procedures. May vary by the patient’s age and gender. The specific hospital norms should be used.

• a

  Complete blood count: It is recommended that a CBC be obtained. There is no absolute cut off value for theses measures.

• b

  Electrolytes: Electrolytes should be normal.

• c

  Coagulation panel: PT, aPTT, fibrinogen levels should be normal.

• d

  Imaging: A chest radiograph will determine baseline airspace disease and lung markings. A CT and/or MRI should have been performed to assess the location of the tumor.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

Planning the anesthetic is a complex interplay of determining the best approach that takes into account the patient’s primary disease process (and its extent), the comorbid conditions that the patient presents with, the planes surgical procedure, and the surgeons and OR team level of experience and expertise. For example, a mildly obese patient with COPD presenting for a minimally invasive esophagogastrectomy with a planned three hole approach must take into account the appropriate bed, the need for a bean bag, and positioning assistance for the staff, the need for one-lung ventilation in a patient that may not tolerate the procedure for the anesthesia team, and the probability of a difficult dissection with a surgeon who may or may not be experienced in minimally invasive techniques.

a. Regional anesthesia

Neuraxial anesthesia

Thoracic epidural analgesia is specifically indicated for this procedure as an adjunct to general anesthesia. In a landmark meta-analysis, Rodgers et al. calculated that the use of neuraxial blockade had an odds ratio that suggested improved 30-day mortality. Furthermore, this was specifically shown for thoracic epidural analgesia. Similarly, the odd ratio for 30-day complications was improved with neuraxial blockade. Another group examined 910 high-risk patients (one or more adverse preoperative conditions), undergoing abdominal or esophageal surgery. They compared patients with or without epidural anesthesia and analgesia for multiple endpoints including death, sepsis, cardiovascular event, renal failure, gastrointestinal failure, and respiratory failure. Respiratory failure was found to be significantly less in the epidural group than those without epidural therapy (p < 0.02).

Benefits: The benefits include non-opioid based analgesia assisting with postoperative pulmonary hygiene, decreased postoperative pulmonary complications, prevention of excessive sympathetic tone and coronary artery dilation.

Drawbacks: Hypotension, especially in relatively hypovolemic patients. Chest tube pain is not adequately treated and multimodal analgesia is indicated.

Issues: Many patients will present who are on preoperative anticoagulation – the risk of epidural placement relative to the duration of anticoagulation discontinuation must be weighed relative to the benefits of epidural analgesia.

Peripheral nerve block

Benefits: Paravertebral nerve block is an alternative to provide analgesia when epidural analgesia is contraindicated. It provides intense analgesia that is localized to the incision.

Drawbacks: Unlike epidural analgesia, no sympathectomy or coronary artery dilatation is achieved. Further, paravertebral blockade is short lived (6-8 hours) unless a catheter is placed, which has a lower success rate than epidural catheter placement for analgesic effect. However, administration of the paravertebral blocks may be perceived more uncomfortable for the awake patient than placement of a thoracic epidural.

Issues: Maintenance of a paravertebral catheter for local anesthetic infusion is challenging with patient movements.

b. General anesthesia

General anesthesia with or without one-lung ventilation is indicated for this procedure.

Benefits: The benefits are airway control, ability to administer muscle relaxants to help optimize surgical exposure and improved hemodynamic control during the procedure.

Drawbacks: Lung isolation can be challenging in some patients. The induction of anesthesia may result in hypotension with concurrent use of epidural anesthesia. The emergence from anesthesia can be challenging if the patient has inadequate analgesia.

Other issues: One must pay careful attention to the mode of ventilation, especially with one-lung ventilation. A strategy that prevents intraoperative acute lung injury should be adopted including low tidal volume, PEEP and acceptance of mild hypercapnia. One should consider the use of ventilation strategies to prevent dynamic pulmonary hyperinflation, especially during one-lung ventilation, for example, high I: E ratio, decreased respiratory rate. Although not specifically studied for esophageal surgery, data from studies in other settings, including the original ICU ARDS study, can be extrapolated suggesting that the application of lung protective ventilation in such patients is useful to prevent iatrogenic lung injury. If the patient is undergoing a procedure that involves laparoscopic surgery, then one must be aware of the potential for increased arterial carbon dioxide accumulation due to carbon dioxide insufflation. Adjustment of the respiratory rate may be necessary. Management of intraoperative fluid balance is also exceedingly important. One group examined esophageal surgical patients in two different time periods, which featured high and low fluid management strategies. After analysis for multiple variables, it was determined that high fluid administration during esophageal surgery was associated with unsuccessful extubation on postoperative day one.

Airway concerns: Precise airway control is required with attention to the placement of the endotracheal tube. One should be especially careful not to injure the vocal cords as esophageal surgery patients are at risk for aspiration in the perioperative period. For the patient at risk of aspiration preoperatively, a rapid sequence induction should be performed.

c. Monitored anesthesia care

This is not appropriate for esophageal resection surgery.

Intraoperative complications of esophageal surgery:

• Aspiration: One or both of esophageal sphincters may be dysfunctional or absent after surgery increasing the risk of regurgitation and aspiration

• Hypoxia

• Intraoperative tracheal or bronchial injury

• Intraoperative great vessel injury and Hemorrhage

• Other adjacent organ/structure damage – pneumothorax or capnothorax, thoracic duct injury

• Nerve injury – recurrent laryngeal nerve, vagus nerve

• Arrhythmias most commonly atrial fibrillation

• Hypothermia

6. What is the author's preferred method of anesthesia technique and why?

The author’s preferred anesthetic technique is general anesthesia with thoracic epidural analgesia. This author believes that an arterial line and two large bore intravenous lines are always required; a central line should be placed as indicated by patient comorbid conditions or lack of appropriate peripheral intravenous access. A multimodal analgesic regimen should be used with epidural analgesia, intravenous acetaminophen and/or intravenous nonsteroidal anti-inflammatory agents. A thoracic epidural should be placed and used during the procedure with short acting local anesthetics. Based on the patient’s comorbidities a cardio stable induction and intubation should be performed keeping in mind that these patients can be safely extubated in the OR at the completion of the procedure.

Preoperatively, the author assesses the patient for (1) the stage, location and prior treatment of the esophageal cancer chemo and radiation therapy, (2) the planned surgical procedure, and (3) the patient’s comorbidities:

1. The stage, location, and prior treatment of the esophageal cancer all contribute to the anesthetic plan, as they determine the actual planned procedure, the likelihood of intraoperative complications such as significant adhesions and/or bleeding, the condition of the patient with respect to nutrition, and hematological status.

2. Understanding the planned surgical procedure is paramount as it determines the need for one-lung ventilation, estimates the duration and difficulty of the procedure, and influences line placement. The usual procedures are listed below and have been discussed earlier:

a. Transthoracic esophagectomy (Ivor Lewis)

• In the Ivor Lewis esphagectomy, the esophageal tumor is removed through an abdominal incision and a right thoracotomy; the esophagogastric anastomosis is located in the upper chest.

• Needs one-lung ventilation.

• Central line, if needed, is placed on right.

• Remember that you will be turning from supine to lateral – watch lines and endotracheal tube.

• CO2 insufflation for laparoscopy and/or thoracoscopy may increase ETCO₂ even more than expected with a lung protective strategy.

b. Three-hole/incision esophagectomy

• In the three-hole esophagectomy, the tumor is removed via an abdominal incision, right thoracotomy, and left neck incision. The esophagogastric anastomosis is located in the neck.

• Needs one-lung ventilation.

• Central line, if needed, is placed on right.

• Remember that you will be turning from supine to lateral – watch lines and endotracheal tube.

• CO2 insufflation for laparoscopy and/or thoracoscopy may increase ETCO2 even more than expected with a lung protective strategy.

c. Transhiatal esophagectomy

• In the transhiatal esophagectomy, the esophageal tumor is removed via an abdominal incision, and a left neck incision. A thoracotomy is not performed. The esophagogastric anastomosis is located on the left side of the neck.

• Does not need one-lung ventilation.

• Central line, if needed, is placed on right; PROTECT the left neck, as an anastomosis will be done there.

• Does not require turning the patient.

• CO2 insufflation for laparoscopy may increase ETCO2 even more than expected with a lung protective strategy.

d. Left thoracoabdominal

• Needs one-lung ventilation.

• Central line, if needed, is placed on left.

• Remember that you will be turning from supine to lateral – watch lines.

• Large incision with high risk of blood loss and pulmonary dysfunction due to splinting.

3. The patient’s comorbidities determine all of the extra medications and/or monitors that may be required. For example, a central line can be considered, both for intravenous access in patients with limited peripheral access due to prior chemotherapy or perioperative administration of vasoactive drugs in the patient with pre-existing cardiopulmonary disease.

What prophylactic antibiotics should be administered?

Based on the degree of expected microbial contamination, surgical incisions during esophagectomies are classified as clean-contaminated (the viscus is entered under controlled conditions and without unusual contamination). Targeted organisms include enteric gram-negative bacilli and gram-positive cocci.

Based on the 2013 Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery, Cefazolin 2 gm for patients under 120 kg and 3 gm for patients above 120 kg is the first line recommended antimicrobial agent. For patients allergic to penicillin’s and cephalosporin’s, clindamycin (900 mg) or vancomycin (15 mg/kg IV; not to exceed 2 g) with gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or aztreonam (2 g IV) can be used. Metronidazole (500 mg IV) plus an aminoglycoside or fluoroquinolone are also acceptable alternative regimens. The surgical care improvement project (SCIP) recommends that all antibiotics be administered within an hour of surgical incision; if vancomycin or a fluoroquinolone is used, the infusion should be started within 1 to 2 hours before the initial surgical skin incision to have adequate tissue levels at the time of incision and to minimize the possibility of an adverse reaction manifesting close to induction of anesthesia.

What can I do intraoperatively to assist the surgeon and optimize patient care?

The intraoperative management revolves around (1) creating good operating conditions, (2) anticipating complications, and (3) optimizing pulmonary function perioperatively.

• Creation of optimal operating conditions for this procedure primarily rests on ensuring that the patient has good neuromuscular relaxation (especially for the abdominal portions of the surgery) and that good lung isolation (if indicated) be achieved through either a dual lumen endotracheal tube or through the use of a bronchial blocker.

• One should anticipate complications. The most common complication (and the most urgent) is cardiovascular compromise, which can occur due to:

  a

  Direct organ manipulation and compression by the surgeon.

  b

  Operative blood loss due to major vessel entry (especially in patients with prior radiation therapy). One should be prepared with good intravenous access and blood products available.

  c

  Thoracic epidural analgesia. Adequate volume status should be ensured by judicious use of intravenous fluids.

  d

  Arrhythmias such as atrial fibrillation may occur. Continuing β blockers in the perioperative period and judicious fluid management are interventions that can help minimize the perioperative risk of this complication. Perioperative statin use has also been associated with a reduction in the risk of atrial fibrillation in thoracic and esophageal surgery patients. An arrhythmia that is unstable should be treated per ACLS protocol.

  Hypotension can also occur due to the use of a conservative fluid administration regimen, and/or the use of. However, conservative fluid management is important to avoid pulmonary edema.

Pulmonary compromise:

• a

  Hypoxemia. Difficulty with ventilation and hypoxemia is also commonly encountered in these patients. Usually this is the result of initial malposition of the endotracheal tube/bronchial blocker or intraoperative movement of the endotracheal tube/bronchial blocker. It is prudent to have quick access to a fiberoptic bronchoscope to diagnose and remedy these problems. All of the usual manoeuvres to improve oxygenation during one-lung ventilation may be considered, including the use of CPAP, PEEP, and intermittent nondependent lung insufflation.

• b

  Barotrauma and volutrauma: Use of a lung protective ventilation strategy with low tidal volumes, PEEP as tolerated, pressure controlled lung insufflation, and avoidance of over hydration. One can accept a degree of hypercapnia to avoid dependent lung injury from overzealous ventilator strategies.

• c

  Tracheal injury: Intraoperative tracheal injury has been reported after both transabdominal and transhiatal esophageal surgery. Direct visualization in the surgical field or on the other hand sudden loss of airway pressure and air leaking in the surgical field should alert the anesthesiologist to the possibility of a tracheal injury. If the injury is recognized primary repair is most commonly undertaken at the time of the operation.

• d

  Vocal cord injury: The tracheal should be carefully intubated to avoid any risk of vocal cord injury.

• e

  Postoperatively esophagectomy is often associated with dangerous, subclinical aspiration. Patients need a comprehensive swallowing evaluation to detect aspiration prior to initiation of oral feedings. The patient needs to have good glottic function to be able to protect his or her airway from gastric contents.

Nutritional:

• a

  Many esophageal surgery patients are malnourished; electrolytes should be carefully monitored and supplemented as indicated.

Neurologic:

There are no neurologic complications that are unique to the procedure.

If the patient is intubated, are there any special criteria for extubation?

The usual criteria for extubation are appropriate for the esophageal surgery patient. It is anticipated that extubation will be possible with excellent analgesia, a warm patient, and adequate hemodynamics.

Postoperative management

Good postoperative care requires advanced planning and active scrutiny for potential complications. The major considerations are listed below.

Postoperative care location

Esophageal surgery is amongst some of the highest risk procedures that are undertaken across the United States. Therefore, it is logical to have patients enter a high acuity postoperative setting where continual or very frequent assessment can be performed. One solution is to have all patients transferred to an ICU after surgery, with the anticipation that the most straightforward patients will be discharged by postoperative day one assuming excellent pain control, hemodynamic stability without bleeding, suitable respiratory function with operational chest tubes, appropriate lung expansion on chest radiograph, and adequate renal function. Even when a patient is deemed ready for transfer to the ward, that transfer should be to a step-down unit with telemetry and frequent personal monitoring as many postoperative complications manifest on day 1 to 3 days after surgery.

Analgesia

Postoperative analgesia strategies should be formulated and discussed with the patient preoperatively. Multimodal analgesic regimens should be utilized with focus on use of neuroaxial blocks, paravertebral blocks, and non-narcotic medication regimens. Thoracic epidural analgesia is specifically indicated for many high-risk surgeries (as discussed above) and specifically for esophageal surgery. It has been studied to reduce the risk of postoperative pulmonary complications in post thoracotomy patients.

In 2006, Cense et al. examined 182 esophageal surgical patients (transthoracic incision) with and without thoracic epidural analgesia; multivariate analysis revealed an association between no thoracic epidural analgesia and increased pneumonia postoperatively. As stated previously, postoperative pneumonia increases the overall 30-day mortality risk by 20% to 30%. If thoracic epidural analgesia is not possible or is contraindicated, then paravertebral nerve blocks and/or catheter placement, intercostal nerve blocks can be performed. These methods have been found to superior to on demand parenteral intravenous opioids. The least favoured method is intravenous opioids in isolation.

Common postoperative complications

Because the highest degree of preventable perioperative morbidity and mortality is related to pulmonary complications, it is most logical to focus on this problem. Patients should have good pulmonary toilet, excellent analgesia and early mobilization to preserve lung function. Aspiration, especially silent aspiration, is a continual risk; it may present with sudden hypoxemia, followed by radiographic evidence of aspiration. This may be due to ineffective vocal cord function, lack of protective sphincters, or other consequences of the surgical procedure, such as nerve injury or inflammation. Due to this unpredictable occurrence, patients should be NPO until passing a functional assessment of a patient’s ability to protect their airways.

There may be a low threshold for enteral tube feeding until the patient can demonstrate the return of glottic function and the ability to protect his or her airway. Furthermore, exquisite attention to secretion control and swallowing function is essential; speech pathology consult is most useful in these patients. Other immediate complications to be aware of include postoperative hemorrhage and inadequate preload due to the combined effects of a gastrointestinal surgery, epidural analgesia and a restrictive fluid administration protocol. This may manifest as a decline in renal function and hypotension. That being said, volume expansion must be judicious and targeted to a goal (mean arterial blood pressure and adequate urine output, arterial wave form analysis). Creating pulmonary edema with excessive fluid administration is a catastrophic complication in this patient population already at risk for pulmonary morbidity.

Infection (empyema, sepsis), stricture, leak and fistula formation are other perioperative complications.

Stricture is noted by the inability to swallow unrelated to the actual muscle function of the glottis. This usually develops gradually and is often managed conservatively with esophageal dilatations. In contrast, an anastomotic leak may present suddenly or over time. Presentation in the hospital may be associated with regional or widespread infection, empyema and/or aspiration. Rarely, a tracheoesophageal fistula may form; this complication has a poor outcome and may be treated medically or surgically.

Aspiration risk after esophageal surgery for further surgery

Patients who have esophageal surgery often present for related or unrelated surgical procedures after esophageal resection. It is of paramount importance to recognize that the post esophageal resection patient may not have a competent upper or lower esophageal sphincter to protect the airway from gastric contents. Also, the anastomosis may be to the side of the neck (transhiatal surgical procedure) and not behind the trachea, rendering compression of the cricoid cartilage against the esophagus (Sellick manoeuvre/cricoid pressure manoeuvre) ineffective to prevent aspiration. It is important to always practice a rapid sequence induction with a patient who is post esophageal resection and reconstruction.

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