Esophagectomy

last updated: April 14, 2017

Orlando Debesa

Esophagectomy

  • Partial (Ivor Lewis)

    • abdominal and right chest incisions​

    • intrathoracic anastomosis

      • stage 1: laparoscopy​

      • stage 2: thoracoscopy

  • Total (Blunt transhiatal)

    • abdominal and cervical incision​

    • cervical anastomosis

Kocher maneuver

  • dissection of the lateral peritoneal attachments of the duodenum to allow inspection of the duodenum, pancreas, and other retroperitoneal structures over to the great vessels

  • some only find it useful in removing adhesions

 

Cattel maneuver

  • mobilization of the ascending colon to the midline

 

Mattox maneuver

  • mobilization of the descending colon to the midline to expose the abdominal aorta

Esophagectomy

 

Esophageal Cancer

  • 12,000 cases/year

  • M>F

  • squamous cell and adenocarcinoma are 2 most common

  • S/Sx: dysphagia, odynophagia (pain with swallowing), weight loss, malnutrition, weakness

  • survival rate depends on stage when diagnosed

  • Tx: chemotherapy, radiation, surgical resection

 

Esophagectomy

  • reasons: esophageal cancer, Barretts, trauma

  • Approach

    • Transhiatal

      • midline abdominal and left cervical incision (gain access to upper esophagus)

      • done with patients with poor respiratory function

    • Transthoracic (Ivor-Lewis)

      • 5-6 hour total time

      • midline and right thoracotomy

      • 3 of 4 gastric arteries clipped (vasopressors not well tolerated)

    • 3 hole Approach (McKeown)

      • allows for increased exposure and removal of tumor

    • Left sided approach

      • for tumors at esophagogastric junction

      • difficult because it involves working around aorta

      • indicated when patient has had a right thoracotomy

 

Management

Cardiac

  • watch for atrial fibrillation as patient will not tolerate (part of the reason why beta blockers are started)

Pulmonary

  • Never BiPAP esophagectomy patients

  • Never NT suction

  • BiPAP okay with esophageal stents that were placed for cancer or stricture.

  • If stent was placed for perforation or leak of any type, do not place on BiPAP - the pressure may cause stent migration resulting in exposure of compromised area

  • Never NT suction

  • Albuterol/Atrovent q 6hrs

  • Mucomist for patients with increased secretions

  • Pulmonary toilet extremely important

  • All patients will have SQ air in their chest and abdomen from the injected air during laparoscopy

  • Chest tube are removed after confirmation of negative air leak

Gastrointestinal

  • Tubes

    • Nasogastric tube (NG tube)

      • low wall suction for decompression of the stomach to reduce tension on suture lines

      • maintain on medium wall suction

      • flush every 6 hours with 30mL water

      • usually removed by the surgeon on POD #2

      • do not put any caps, filters or clamps on the end of the blue sump port. These may become clogged or otherwise stop the flow of air which will impede the function of the NGT. If bile is leaking out of the blue sump port, push 30mLs of air through the sump port with the 60mL syringe to help circulate the bile out of the NGT

    • G tube

      • if present, place to gravity

    • J tube

      • used for feeding and medications

      • flush every 6hrs or after med administration with 30mLs of water

      • meds can go down the J tube with the exception of flomax and certain potassium supplements

      • patient will go home on J tube feeds

      • usually left if going to get post-op chemo

    • Chest tubes

      • make sure chest tube + JP tube output not greater that 100ml/hr x 2 hours

      • usually removed after confirmation of negative air leak​

    • JP tubes

      • patients usually go home with these (usually until follow up visit in 2 weeks)

    • Penrose drain

      • for neck incision

 

  • keep NPO

    • feeding usually POD#2 via J tube and only feed if NO leak is present

    • patients with esophageal stump will NOT be fed at all

    • presence of leak and aspiration risk determined by swallowing studies

    • if leak present or suspected, TPN started

    • PO intake usually POD 3 or 4 after barium study shows no leak

    • 1/2 cup of ice chips every 3 hours once a strong cough is present is okay if the patient is insistent

    • reflux treated aggressively 

GU/Renal

  • lasix usually never given within the first 24 hours

  • sudden decrease in urine output may be a reflection of bleeding into the stomach

  • foley catheter removed POD #2

Complications

  • pulmonary present in 5-30%

  • pneumonia most common

  • ARDS particularly in transhiatal approach

  • Tracheal Injury (rare)

  • Anastomosis leak

    • present in 1-30%

    • usually seen POD #5 or later

    • most common surgical complication

    • bile appears in chest tube or saliva in cervical neck incision

    • 37% mortality rate

    • cervical anastomosis has the highest rate of leak

    • when a leak occurs an esophagostomy may be surgically created (spit fistuma)

    • Dx: contrast swallowing study

  • Chyle leak

    • milky fluid in chest tube from thoracic duct injury

    • noted when fed via tube or orally

    • Dx: triglyceride >1.2 mmol/L

    • difficult to surgically repair

      • low output usually resolves without surgery

      • high output needs surgery and has high risk of sepsis

  • Gastric conduit necrosis

    • fever, tachycardia, hypotension, acidosis, oliguria

    • caused by poor blood flow or poor surgical technique

    • necrotic graft must be removed

  • Dumping syndrome

    • diarrhea, diaphoresis, pain, nausea, sudden weakness

    • avoid sweets and liquids

  • Dilated neoesophagus / bowels with air

    • make sure NG tube properly functioning/suctioning​

    • can cause stretching of the anastomosis

... but I would more especially commend the clinician who, in acute diseases, by which the bulk of mankind are cutoff, conducts the treatment better than others.
 
Hippocrates, 400 BC