Anesthesia for Esophageal Surgery

Abstract

Surgical procedures involving the esophagus are performed for a wide array of elective and emergent indications. Esophageal surgeries may be performed for malignant or nonmalignant lesions or abnormalities and may involve various combinations of open or minimally invasive procedures via the neck, abdomen, and thorax and most recently via endoscopic approaches. Patients with severe esophageal disease may be at elevated risk of aspiration and anesthetic management should reflect an appreciation of this risk. For larger incisional approaches, particularly transthoracic procedures, pain control is of paramount importance; thoracic epidural analgesia remains the gold standard for such patients and procedures although alternative approaches such as paravertebral blockade may provide equivalent analgesia for some procedures. Patients undergoing major transthoracic esophageal surgeries, particularly esophagectomy, are at elevated risk for major morbidity, especially pulmonary complications and anastomotic failure and leak. Preoperative optimization of such patients should be a priority for the perioperative physician and may include programs designed to treat underlying comorbidities, optimize nutrition, improve inspiratory muscle function, and prevent and treat anemia. Additional perioperative efforts should be made to optimize pain control, avoid iatrogenic fluid overload, employ lung-protective ventilation, and facilitate early extubation and mobilization. Early removal of gastric tubes and oral enteral feeding remain controversial and require more study.

Esophageal Surgery Clinical Case Discussion

Case: A 61-year-old male presents with a 14-month history of episodic dysphagia to solids that is progressively worsening. He notes no pain or weight loss. His evaluation included an EGD and biopsy showing high-grade dysplasia with features highly suspicious for invasive esophageal adenocarcinoma. Further evaluation in preparation for surgery included a whole-body PET-CT scan following injection of 14.014 mCi of F-18-FDG intravenously. Figure 38.10 shows the distal esophageal lesion illuminated by the marker. His past medical history is significant for CAD (MI 12 years prior treated with angioplasty). He has not had a recent cardiac catheterization. He also has intermittent supraventricular tachycardia (PSVT) controlled with diltiazem. He denies ever having a electrophysiologic study performed. He also suffers from HTN (enalapril), hypercholesterolemia (simvastatin), and asthma (albuterol as needed and Claritin). His only prior surgeries are a C4–7 discectomy and fusion and a L4–S1 laminectomy. He is scheduled for an Ivor Lewis esophagectomy.

Fig. 38.10

PET scan reveals focal soft tissue thickening with increased uptake of FDG in the distal esophagus at the gastroesophageal junction consistent with esophageal carcinoma

Questions

• What further preoperative evaluation might be considered reasonable?

• What are the anesthetic considerations for this esophageal surgery?

• What specific intraoperative preparation of this patient might be prudent?

• What are postoperative considerations for this patient?

Focused preoperative history, physical, and investigations:

• Patient reports a daily requirement for his MDI and has recovered recently from a viral pharyngitis (physical exam, preoperative MDI use; see Chap. 8).

• Cardiac evaluation: baseline ECG to evaluate impulse initiation site, AV node conduction, and QTc in the context of PSVT history and diltiazem use. Stress echocardiogram to evaluate audible murmur and function (see Chap. 2).

• Careful airway evaluation with particular attention to cervical extension after cervical fusion.

• Focused neurologic exam to identify any preoperative deficits given the risk of position-related neurologic injury in left lateral decubitus position (see Chap. 19).

What intraoperative management considerations will optimize the patient’s surgery?

• Thoracic epidural to provide postoperative analgesia for a right thoracotomy and upper midline laparotomy (see Chaps. 38 and 59).

• Avoidance of beta-blockade because of a significant history of reactive airway disease and chronic calcium channel blockade use. Intraoperative application of external electrodes for emergency cardioversion, pacing, or defibrillation. Calcium channel blockers indicated for treating hemodynamically stable PSVT (see Chap. 8).

• Fluid management strategy which seeks to optimize overall oxygen delivery, with particular attention to the high-risk esophageal anastomosis. A variety of methods can be used to guide fluid therapy (base deficit, serum lactate, mixed venous O₂ saturation). Optimal fluid management will seek to optimize cardiac output and oxygen delivery while avoiding excessive fluid administration (see Chaps. 21 and 38).

• High postoperative risk of atrial arrhythmias, in particular, atrial fibrillation. Treatment usually includes rate control with a beta-blocker especially in the patient with CAD, but preoperative use of a calcium channel blocker and history of asthma may preclude its use. Amiodarone can be used if atrial fibrillation is sustained and resistant to rate control with calcium channel blockers (see Chaps. 53 and 56).