E Esophageal resection

Esophagectomy is commonly performed for malignant disease of the middle and lower third of the esophagus. It may also be indicated for Barrett’s esophagus (peptic ulcer of the lower esophagus) and for peptic strictures that do not respond to dilation and end-stage achalasia. Whereas lesions in the lower third are usually approached through a left thoracoabdominal incision, middle-third lesions are best approached by the abdomen and thoracotomy. Resections of the esophagogastric junction for malignant disease are best performed through a left thoracoabdominal approach in which a portion of the proximal stomach is removed along with a celiac node dissection. In a transhiatal approach, the esophagus is exposed through abdominal and neck incisions.

Total esophagectomy may be done through an abdominal and right thoracotomy approach with colonic interposition and anastomosis in the neck. Either the right or the left side of the colon can be mobilized for interposition. Both depend on the middle colic artery and the marginal artery of the colon for their vascular supply.

2. Preoperative assessment

a) History and physical examination

(1) Cardiovascular: The patient may be hypovolemic and malnourished from dysphagia or anorexia. Chemotherapeutic drugs (daunorubicin, doxorubicin [Adriamycin]) may cause cardiomyopathy. Chronic alcohol abuse may also produce toxic cardiomyopathy.

(2) Respiratory: A history of gastric reflux suggests the possibility of recurrent aspiration pneumonia, decreased pulmonary reserve, and increased risk of regurgitation and aspiration during anesthetic induction. If a thoracic approach is planned, the patient should be evaluated to ensure that one-lung ventilation can be tolerated. Patients with upper esophageal tumors or mediastinal lymphadenopathy may need tracheal or bronchial compression. Difficult airway and respiratory compromise are possible. Many patients with esophageal cancer have a long history of smoking, with consequent respiratory impairment.

(a) Chemotherapeutic drugs (bleomycin) may cause pulmonary toxicity that can worsen with high concentrations of oxygen.

(b) Pulmonary function tests and arterial blood gases can be helpful in predicting the likelihood of perioperative pulmonary complications and whether the patient may require postoperative mechanical ventilation. Patients with baseline hypoxemia or hypercarbia on room air arterial blood gases have a higher likelihood of postoperative complications and a greater need for postoperative ventilatory support. Severe restrictive or obstructive lung disease will also increase the chance of pulmonary morbidity in the perioperative period.

b) Patient preparation

(1) Laboratory tests: Type and cross-match packed red blood cells, electrolytes, glucose, blood urea nitrogen, creatinine, liver function test, complete blood count, and platelet count. Prothrombin time, partial thromboplastin time, urinalysis, arterial blood gases, and other tests as indicated by the patient’s history and physical examination.

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