An overview of the process
A two-stage operation in two body cavities under one anaesthetic. An abdominal stage, supine, to mobilise the stomach and form the gastric conduit; then a thoracic stage in the left lateral position, through a right thoracotomy or thoracoscopy, for oesophageal mobilisation and the intrathoracic anastomosis.
The gastric conduit is perfused by a single artery and its blood supply is marginal and pressure-dependent. Conduit viability determines anastomotic leak, and leak determines the postoperative course.
The operation may change intraoperatively; conversion to gastrectomy occurs.
Pre-op assessment
- Respiratory reserve is the pivotal assessment. The patient will undergo one-lung ventilation and a thoracotomy. Document smoking history, spirometry where available, and exercise tolerance.
- A recent respiratory tract infection requires assessment of symptom resolution and review of inflammatory markers before proceeding. This decision should be escalated.
- Establish the neoadjuvant chemoradiotherapy history. Consider cardiotoxicity, pulmonary toxicity, marrow suppression and deconditioning.
- Nutritional assessment. Dysphagia and weight loss are near-universal.
- Airway assessment with double-lumen tube placement specifically in mind.
- An obstructed oesophagus may retain residue despite fasting. Consider aspiration risk.
- Confirm a valid crossmatch and that blood is physically available before the list starts.
- Consent covers general anaesthesia, double-lumen tube, thoracic epidural, arterial line, central line, blood loss and transfusion, and critical care.
Induction and intra-operative management
- Volatile or TIVA.
- Left-sided double-lumen tube, with position confirmed by fibreoptic bronchoscopy.
- The tube position must be rechecked bronchoscopically after turning the patient into the lateral position.
- A range of double-lumen tube sizes, a videolaryngoscope and a bronchial blocker should be immediately available. Difficult placement is common and should prompt early senior assistance.
- An arterial line is required.
- Central venous access is required. Confirm line and tube position on a postoperative chest radiograph.
- Large-bore peripheral cannulae.
- Core temperature monitoring, neuromuscular monitoring, urinary catheter.
- Active warming with forced-air warming and a fluid warmer. Two body cavities are open and the case is long.
- Single-dose antibiotic prophylaxis within 60 minutes of incision, redosed if prolonged.
- Communicate deliberately at airway management, at turning, and at thoracotomy. All team members should know the airway status, the epidural and the invasive lines.
One-lung ventilation
- Avoid hyperoxia. Permit mild hypercapnia.
- Tidal volume 4–5 mL/kg predicted body weight. Calculate predicted, not actual, body weight.
- PEEP 5 cmH₂O to the ventilated lung.
- CPAP 5 cmH₂O to the non-ventilated lung.
- Provide 100% oxygen with recruitment immediately before initiating one-lung ventilation, then reduce to the lowest FiO₂ maintaining SpO₂ above 92%.
- If saturations fall during one-lung ventilation, recheck tube position bronchoscopically before adjusting anything else. Then consider FiO₂, recruitment, PEEP to the ventilated lung and CPAP to the non-ventilated lung. Intermittent two-lung ventilation may be requested from the surgeon.
The gastric conduit and haemodynamic management
- Maintain arterial pressure to perfuse the conduit. Hypotension threatens the anastomosis.
- Avoid fluid overload. Excess fluid produces conduit and bowel oedema and respiratory failure after one-lung ventilation.
- Goal-directed fluid therapy with cardiac output monitoring if the patient's condition requires.
- Treat epidural-related hypotension with a low-dose vasopressor rather than repeated fluid boluses, with a vasopressor infusion ready before the epidural is dosed.
- Discuss target arterial pressure during the thoracic stage with the teams.
Perioperative analgesia
- Thoracic epidural, sited and tested. Insertion in the lateral position after induction is an accepted approach.
- Paravertebral block, erector spinae plane catheter or intrathecal opioid are alternatives where epidural is contraindicated.
- Regular paracetamol.
- PONV prophylaxis with at least two agents.
- For prophylactic low molecular weight heparin, allow 12 hours from the last dose before siting or removing an epidural catheter and 4 hours afterwards; for treatment dose, 24 hours and 4 hours. Extend the interval if insertion was traumatic.
Post-operative care
- Patients go to critical care.
- Where the patient is to be extubated, plan double-lumen tube exchange or removal deliberately, taking account of the airway risk in a patient who was difficult to intubate.
- Handover should include the airway history and whether tube placement was difficult, the conduit and anastomosis site, the chest drains, the epidural settings, the dose of low molecular weight heparin and when the next is due, the blood loss, total fluid and vasopressor, the feeding jejunostomy if sited, and the last gas.
- New atrial fibrillation after oesophagectomy should be treated as an anastomotic leak until disproven. Leak commonly presents with tachycardia, arrhythmia, fever and respiratory deterioration before any radiological sign.
- Conduit ischaemia presents early and may present as sepsis.
- Respiratory failure is the commonest major complication — atelectasis, pneumonia, and oedema after one-lung ventilation.
- Chylothorax presents as high-volume milky chest drain output once feeding starts.
- Recurrent laryngeal nerve injury presents as hoarseness, a weak cough and aspiration.
References
- Low DE, Allum W, De Manzoni G, et al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World Journal of Surgery, 2019.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS). European Journal of Cardio-Thoracic Surgery, 2019.
- Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists' Association, Regional Anaesthesia UK. Regional anaesthesia and patients with abnormalities of coagulation.
- Kietaibl S, Ferrandis R, Godier A, et al. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. European Journal of Anaesthesiology, 2022;39:100–132.