Oesophagectomy

The curriculum asks us to know 'the principles of the peri-operative management of the commoner complex cases including... oesophagectomy'.

Resources

Oesophageal cancer is the 8th commonest malignancy globally, and increasing in incidence
20 - 30% of patients have metastases at presentation
Curative therapy frequently involves neoadjuvant chemotherapy then surgery; it remains a high risk surgery with substantial morbidity and mortality

Factor	Adenocarcinoma (80%)	Squamous Cell Carcinoma (20%)
Age / Gender	↑ age M > F	M > F
Ethnicity	Caucasian	Sub-Saharan Africa (3x risk) Far East Asian
Economic	Developed world	Lower socioeconomic status Developing world
Lifestyle	Smoking	Alcohol Smoking Poor oral hygiene
Dietary	Low fruit/veg intake	Salted or preserved food
Associated disease	GORD Barrett's oesophagus Obesity Family history	Mutations in EtOH metabolic pathway Achalasia Caustic injury Nutritional deficiencies
Iatrogenic	Thoracic radiation Drugs relaxing LOS	Thoracic radiation

Respiratory

Patients often have a smoking history so smoking-related lung disease such as COPD may coalesce
Previous thoracic radiation as the aetiological factor can cause restrictive lung disease

Cardiovascular

Patient may have existing cardiovascular disease owing to shared risk factors such as smoking, alcohol use or obesity
There is a high incidence of both hypertension and ischaemic heart disease in oesophageal cancer patients
Cardiotoxicity is a known adverse effect of the commonly used chemotherapeutic agents for oesophageal cancer

Renal

Patient may have a degree of renal impairment from advancing age, secondary to co-existing comorbidities such as hypertension, due to poor fluid intake secondary to oesophageal obstruction or as an adverse effect of chemotherapy

Gastrointestinal and nutritional

Dysphagia ± oesophageal obstruction predisposes to:

Poor nutritional intake and the sequelae of malnutrition
Pulmonary aspiration due to incomplete upper GI tract emptying

Patients may have existing GORD, increasing their aspiration risk

Haematological

Anaemia may exist due to chronic disease ± poor nutrition
Equally, coagulopathy can occur due to poor nutrition or hepatotoxicity from typically used chemotherapeutic agents

Immune

Patients may be immunosuppressed from chemotherapy, increasing their risk of opportunistic or other infections

Neo-adjuvant chemotherapy

Received by most patients, typically for those with T3 and/or N1 disease
Drug combinations include a platinum-based agent and either fluorouracil or paclitaxel
There is typically a washout period post-chemotherapy to allow recovery of haemopoiesis and immunosuppression
This creates a surgical 'window' where optimum outcomes can be achieved

Surgical resection

In general, surgery involves:

Excision of the oesophagus
Relocation of the stomach into the mediastinum
Formation of the gastric conduit by connecting the pharynx to the remaining GI tract

The anastomosis is formed at the extreme end of the foregut blood supply, rendering it vulnerable to ischaemia

There are a number of surgical approaches and variations on conventional descriptions

Ivor-Lewis: laparotomy followed by right-sided thoracotomy (or a modified technique using laparoscopy + VATS)
McKeown tri-incisional approach for upper oesophageal tumours
Transdiaphragmatic (transhiatal) approach, which avoids thoracotomy

Perioperative management of the patient undergoing oesophagectomy

An MDT approach to decide optimum treatment plan, with thorough pre-assessment by surgical and anaesthetic teams

Investigations

Bloods: FBC | Clotting | G&XM | U&E | LFT
ECG
CXR
± TTE

Risk assessment

CPET

Oxygen consumption increases 50% in the immediate post-op period, so need to establish ability to increase cardiac output and oxygen delivery after surgery
Lung function tests to include FEV₁, FVC, FEV₁/FVC ratio and TL_CO

± More invasive cardac investigations such as stress echocardiography or angiography to quantify cardiovascular risk

Optimisation

Prehabilitation including smoking cessation
Diseases associated with poorer outcomes include cardiopulmonary disease and diabetes mellitus; these should be optimised
Anaemia should be managed appropriately
Nutritional status should be optimised; patients may be obese rather than cachectic but still be malnourished

Monitoring and access

AAGBI as standard
Arterial line
Central line
Temperature probe (not oesophageal!)

Fluid management

Excess fluid administration risks pulmonary oedema and venous congestion of the anastomosis
Inadequate fluid administration may lead to excess vasoconstrictor use, myocardial strain and anastomotic ischaemia
Overall, avoiding excessive fluid therapy is crucial for good outcomes
Goal-directed or restricted fluid strategies should be used

Anaesthetic technique

Typically a left-sided DLT and one-lung ventilation during the thoracotomy/thoracoscopy

Analgesia

Analgesia for oesophagectomy is challenging owing to multiple incisions, which are widely distributed across thorax and abdomen
Good pain relief is vital for optimal post-operative respiratory function, mobilisation and reduction in complications

Pre-emptive thoracic epidural analgesia is considered the gold standard

Reduces chronic post-operative pain
Lower risk of anastomotic leak
Lower opioid requirement
Shorter duration of ICU stay

Paravertebral blocks/catheters may be used where epidurals are contra-indicated or technically difficult to place, and may be as efficacious

Care bundle

Meticulous positioning, especially in cachectic patients as at risk of pressure sore
Surgeons may request glucagon 1mg IV for lower esophageal sphincter relaxation
Temperature control
VTE prophylaxis
Glucose control if diabetic

Disposition

Extubation at the end of surgery and HDU care (lower risk of pulmonary complications)
If brought to ICU as a level 3, early extubation reduces ICU length of stay

Strategies to reduce morbidity from leak

Avoid CPAP
Avoid hypotension
Gastric decompression by NG tube
IV PPI
Early nutrition
Vigilant monitoring for early detection of leak

Other

Multi-modal anagelsia, including opioid PCA in addition to existing regional anaesthesia, reduces risk of post-operative pneumonia
Early enteral use of β-blockers (but not amiodarone) is evidence-based in the prevention of AF
Early mobilisation
Early swallowing assessment to facilitate return to oral intake

Respiratory complications

Respiratory complications (17 - 51%) are the most common cause of post-operative morbidity and substantially increase risk of mortality
They include:

Pneumonia - associated with higher peri-operative and 5yr mortality
ARDS - should prompt investigation for occult cause e.g. anastomotic leak sepsis
Recurrent laryngeal nerve palsy (4 - 67%); the risk is higher with the tri-incisional approach
Pneumothorax | atelectasis | pleural effusions | HAP
Surgical-associated respiratory complications such as tracheobronchial tree injury and thoracic duct injury (1 - 5%)

Factors reducing post-operative respiratory complications

Adequate analgesia

Reversal of neuromuscular blockade

Maintenance of normothermia

Extubation at the end of surgery

Chest physiotherapy

Early mobilisation

Anastamotic leak

Anastomotic leak (10 - 37%) is the most serious surgical complication, and accounts for as much as 35% of peri-operative mortality

Major leaks present in the first 5 days post-operatively, typically with sepsis and pleural effusions
Smaller leaks may manifest 7 days post-operatively, sometimes with more subtle signs

Epidural analgesia and avoiding excessive fluid administration are associated with lower risk of anastomotic leak
Management includes:

Conservative therapy e.g. NBM, TPN, antibiotics, chest physiotherapy
Radiological e.g. serial contrast studies, IR-guided drainage of collections
Surgical e.g. re-exploration and revision surgery

Cardiac arrhythmia

Supra-ventricular arrhythmias, particularly AF (40%), are common and associated with increased mortality
Atrial arrhythmia may be from:

Direct contact e.g. during thoracic dissection or pericardial irritation
Indirect sources e.g. sepsis, anastomotic leak, pre-existing cardiac disease, raised RA pressure post-one-lung ventilation

Gastrointestinal complications

Early	Late
Ileus	Gastric reflux (expected)
Delayed gastric empytying	Oesophageal stricture
Gastric outlet obstruction from vagotomy	↓ peristalsis from vagotomy
	'Dumping syndrome'

In dumping syndrome, hyperosmolar gastric contents are propelled into the small bowel, leading to:

Insulin release
Diarrhoea and nausea
Tachycardia and hypotension