Anesthesia for esophageal surgery
- Jennifer Macpherson, MD
Jennifer Macpherson, MD
- Assistant Professor of Anesthesiology
- University of Rochester, Rochester, New York
This topic will discuss anesthetic management of elective and urgent esophageal surgery, both open and endoscopic. Challenges include increased risks for pulmonary aspiration, possible need for one lung ventilation, and postoperative pain management.
Anesthetic techniques for esophagoscopy are reviewed separately. (See "Anesthesia for gastrointestinal endoscopy in adults".)
Preanesthetic planning for esophageal surgery includes:
●Minimizing risk of pulmonary aspiration. Many patients with esophageal disease have a high risk of pulmonary aspiration due to esophageal mass, stricture, or achalasia. Precautions for a full stomach are always employed since esophageal contents are unknown and retained ingested food may be present even after an appropriate fasting period. If general anesthesia is planned, these precautions include a rapid sequence induction and intubation (RSII) technique or awake endotracheal intubation. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Airway management'.).
●Assessing the airway. If necessary, prepare to manage a difficult airway. (See "Management of the difficult airway for general anesthesia".)
- Hurford WE, Dutton RP, Alfille PH, et al. Comparison of thoracic and lumbar epidural infusions of bupivacaine and fentanyl for post-thoracotomy analgesia. J Cardiothorac Vasc Anesth 1993; 7:521.
- Yeung JH, Gates S, Naidu BV, et al. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016; 2:CD009121.
- Zhang W, Fang C, Li J, et al. Single-dose, bilateral paravertebral block plus intravenous sufentanil analgesia in patients with esophageal cancer undergoing combined thoracoscopic-laparoscopic esophagectomy: a safe and effective alternative. J Cardiothorac Vasc Anesth 2014; 28:966.
- Chen WK, Miao CH. The effect of anesthetic technique on survival in human cancers: a meta-analysis of retrospective and prospective studies. PLoS One 2013; 8:e56540.
- Kim R. Anesthetic technique and cancer recurrence in oncologic surgery: unraveling the puzzle. Cancer Metastasis Rev 2016.
- Wigmore TJ, Mohammed K, Jhanji S. Long-term Survival for Patients Undergoing Volatile versus IV Anesthesia for Cancer Surgery: A Retrospective Analysis. Anesthesiology 2016; 124:69.
- Joshi GP, Bonnet F, Shah R, et al. A systematic review of randomized trials evaluating regional techniques for postthoracotomy analgesia. Anesth Analg 2008; 107:1026.
- Pöpping DM, Elia N, Marret E, et al. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a meta-analysis. Arch Surg 2008; 143:990.
- Davies RG, Myles PS, Graham JM. A comparison of the analgesic efficacy and side-effects of paravertebral vs epidural blockade for thoracotomy--a systematic review and meta-analysis of randomized trials. Br J Anaesth 2006; 96:418.
- Ding X, Jin S, Niu X, et al. A comparison of the analgesia efficacy and side effects of paravertebral compared with epidural blockade for thoracotomy: an updated meta-analysis. PLoS One 2014; 9:e96233.
- Werawatganon T, Charuluxanun S. Patient controlled intravenous opioid analgesia versus continuous epidural analgesia for pain after intra-abdominal surgery. Cochrane Database Syst Rev 2005; :CD004088.
- Guay J, Kopp S. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev 2016; :CD005059.
- Li W, Li Y, Huang Q, et al. Short and Long-Term Outcomes of Epidural or Intravenous Analgesia after Esophagectomy: A Propensity-Matched Cohort Study. PLoS One 2016; 11:e0154380.
- Fares KM, Mohamed SA, Hamza HM, et al. Effect of thoracic epidural analgesia on pro-inflammatory cytokines in patients subjected to protective lung ventilation during Ivor Lewis esophagectomy. Pain Physician 2014; 17:305.
- Heinrich S, Janitz K, Merkel S, et al. Short- and long term effects of epidural analgesia on morbidity and mortality of esophageal cancer surgery. Langenbecks Arch Surg 2015; 400:19.
- Romero A, Garcia JE, Joshi GP. The state of the art in preventing postthoracotomy pain. Semin Thorac Cardiovasc Surg 2013; 25:116.
- White PF, Kehlet H. Improving postoperative pain management: what are the unresolved issues? Anesthesiology 2010; 112:220.
- Kehlet H, Wilkinson RC, Fischer HB, et al. PROSPECT: evidence-based, procedure-specific postoperative pain management. Best Pract Res Clin Anaesthesiol 2007; 21:149.
- Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol 2009; 22:588.
- Steinthorsdottir KJ, Wildgaard L, Hansen HJ, et al. Regional analgesia for video-assisted thoracic surgery: a systematic review. Eur J Cardiothorac Surg 2014; 45:959.
- Carney A, Dickinson M. Anesthesia for esophagectomy. Anesthesiol Clin 2015; 33:143.
- Durkin C, Schisler T, Lohser J. Current trends in anesthesia for esophagectomy. Curr Opin Anaesthesiol 2017; 30:30.
- Bartels K, Fiegel M, Stevens Q, et al. Approaches to perioperative care for esophagectomy. J Cardiothorac Vasc Anesth 2015; 29:472.
- London MJ, Hollenberg M, Wong MG, et al. Intraoperative myocardial ischemia: localization by continuous 12-lead electrocardiography. Anesthesiology 1988; 69:232.
- Hahm TS, Lee JJ, Yang MK, Kim JA. Risk factors for an intraoperative arrhythmia during esophagectomy. Yonsei Med J 2007; 48:474.
- Porteous GH, Neal JM, Slee A, et al. A standardized anesthetic and surgical clinical pathway for esophageal resection: impact on length of stay and major outcomes. Reg Anesth Pain Med 2015; 40:139.
- Fumagalli U, Melis A, Balazova J, et al. Intra-operative hypotensive episodes may be associated with post-operative esophageal anastomotic leak. Updates Surg 2016; 68:185.
- Chau EH, Slinger P. Perioperative fluid management for pulmonary resection surgery and esophagectomy. Semin Cardiothorac Vasc Anesth 2014; 18:36.
- Xing X, Gao Y, Wang H, et al. Correlation of fluid balance and postoperative pulmonary complications in patients after esophagectomy for cancer. J Thorac Dis 2015; 7:1986.
- Magder S. Fluid status and fluid responsiveness. Curr Opin Crit Care 2010; 16:289.
- Renner J, Scholz J, Bein B. Monitoring fluid therapy. Best Pract Res Clin Anaesthesiol 2009; 23:159.
- Funk DJ, Moretti EW, Gan TJ. Minimally invasive cardiac output monitoring in the perioperative setting. Anesth Analg 2009; 108:887.
- Desebbe O, Cannesson M. Using ventilation-induced plethysmographic variations to optimize patient fluid status. Curr Opin Anaesthesiol 2008; 21:772.
- Cecconi M, Parsons AK, Rhodes A. What is a fluid challenge? Curr Opin Crit Care 2011; 17:290.
- Ansari BM, Zochios V, Falter F, Klein AA. Physiological controversies and methods used to determine fluid responsiveness: a qualitative systematic review. Anaesthesia 2016; 71:94.
- Thiele RH, Bartels K, Gan TJ. Inter-device differences in monitoring for goal-directed fluid therapy. Can J Anaesth 2015; 62:169.
- Al-Rawi OY, Pennefather SH, Page RD, et al. The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy. Anesth Analg 2008; 106:884.
- Mets B. Should Norepinephrine, Rather than Phenylephrine, Be Considered the Primary Vasopressor in Anesthetic Practice? Anesth Analg 2016; 122:1707.
- Theodorou D, Drimousis PG, Larentzakis A, et al. The effects of vasopressors on perfusion of gastric graft after esophagectomy. An experimental study. J Gastrointest Surg 2008; 12:1497.
- Gemmill EH, Humes DJ, Catton JA. Systematic review of enhanced recovery after gastro-oesophageal cancer surgery. Ann R Coll Surg Engl 2015; 97:173.
- Underwood TJ, Noble F, Madhusudan N, et al. The Development, Application and Analysis of an Enhanced Recovery Programme for Major Oesophagogastric Resection. J Gastrointest Surg 2017; 21:614.
- Kucuk C, Arda K, Ata N, et al. Tracheomegaly and tracheosephagial fistula following mechanical ventilation: A case report and review of the literature. Respir Med Case Rep 2016; 17:86.
- Sethi P, Bhatia PK, Biyani G, et al. Acquired Tracheo-oesophageal Fistula: A Challenging Complication of Tracheostomy. J Coll Physicians Surg Pak 2015; 25 Suppl 2:S76.
- Patti MG, Fisichella PM. Controversies in management of achalasia. J Gastrointest Surg 2014; 18:1705.
- Smith CD. Esophageal strictures and diverticula. Surg Clin North Am 2015; 95:669.
- Fowler MA, Spiess BD. Postanesthesia Recovery. In: Clinical Anesthesia, 7th ed, Barash PG, Cullen BF, Stoelting RK, et al. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2013.
- Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 2014; 208:536.
- PREANESTHETIC PLANNING
- ANESTHETIC TECHNIQUES
- General anesthesia
- - Premedication
- - Planned neuraxial analgesia
- - Induction
- Rapid sequence induction and intubation
- Considerations for one lung ventilation
- - Maintenance
- Inhalation and intravenous agents
- Neuraxial agents
- - Emergence
- Postoperative pain management
- - Open thoracotomy or laparotomy
- Epidural or paravertebral block
- Alternative analgesic strategies
- - Thoracoscopy or laparoscopy
- ANESTHETIC MANAGEMENT FOR SPECIFIC PROCEDURES
- - Monitoring
- - Anesthetic and pain management
- - Airway and ventilation management
- - Fluid and hemodynamic management
- - Extubation
- - Enhanced recovery protocols
- Emergency repair of esophageal perforation or rupture
- Repair of tracheoesophageal fistulae
- Repair of gastroesophageal reflux disease
- Repair of achalasia
- Repair of esophageal diverticuli
- PERIOPERATIVE COMPLICATIONS
- Intraoperative complications
- Early postoperative complications
- SUMMARY AND RECOMMENDATIONS