Perioperative management - Esophageal resection

Esophageal malignancies:

• Carcinoma (squamous cell carcinoma, adenocarcinoma)
• Sarcoma (rare)

Benign long stenoses:

• Caustic burns (acid/ alkali)

• Cirrhosis
• Severe obstructive and restrictive lung disease (COPD, pulmonary fibrosis)
• Severe heart failure
• Severe coronary artery disease

Bioptic confirmation

The diagnosis is primarily confirmed by endoscopy with biopsy. In malignancies the biopsy should clarify whether the tumor is an adenocarcinoma or squamous cell carcinoma of the esophagus. Often, this differentiation has already been made during the initial endoscopic study. However, there remain cases where the differentiation has not been conclusive, thereby necessitating rebiopsy. In addition, the workup in adenocarcinoma must establish whether it is a Barrett's carcinoma or rather a carcinoma of the gastroesophageal junction.

This histological diagnosis will determine the subsequent steps:

• Squamous cell carcinoma

During preoperative staging in squamous cell carcinoma, which over the past few years has become less common, the following should be considered: In view of the longitudinal spread of squamous cell cancer, endoscopy should look for mucosal metastases proximal and distal to the tumor. In addition, endoscopy should rule out a possible second tumor, especially in the region of the hypopharynx. Furthermore, endoscopy should be complemented by endoscopic ultrasonography (EUS) to gain an understanding of the depth of any mural invasion and the relationship of the tumor to the adjacent tissues. Endosonographycannot visualize the tracheobronchial system or can only do so inadequately. If the tumor is related to the tracheobronchial systemor located superior to the tracheal bifurcation, the tracheobronchial system must be studied endoscopically to rule out tumor invasion into this system. In order to rule out distant metastases and to assess the tumor in relation to adjacent organs, diagnostic endoscopy must be supplemented by a CT study of the chest and abdomen.

• Adenocarcinoma

If it is adenocarcinoma, histological confirmation of the Barrett's mucosa adjacent to the tumor should also be attempted, to the extent that this is still possible next to the malignancy. Endoscopy should rule out the presence of adenocarcinoma of the gastroesophageal junction Sievert type II or III because this would have other therapeutic consequences (e.g., extended transhiatal total gastrectomy). If Barrett's carcinoma is present, staging should in principle be conducted in the same way, i.e., by endoscopy, EUS and CT, although assessment of the tracheobronchial system is secondary, since Barrett's carcinomas are usually located inferior to the tracheal bifurcation. However, since most tumors are located distad, involvement of the abdominal cavity is not uncommon; for this reason, diagnostic laparoscopy may be performed in locally advanced Barrett's carcinoma to detect possible peritoneal metastasis (in about 20% of cases). The subsequent therapeutic approach is primarily determined by R0 resectability and the differentiation between T1/T2 and T3/T4 tumors. Treatment is stratified in terms of primary surgery or neoadjuvant therapy protocols based on the T category and R0 resectability.

PET imaging

Recently, PET imaging, preferably as PET-CT, has become increasingly important in preoperative staging. Apart from the identification of distant metastases, PET-CT also allows assessment of the intensity of the tumor metabolism and therefore permits early response evaluation with corresponding therapeutic consequences, especially if decision making favors neoadjuvant therapy.

Routine diagnostic workup of the colon, e.g., by colonoscopy, regarding the possible transposition of the colon does not appear necessary.

Preoperative risk assessment 

Since patients suffering from squamous cell carcinoma of the esophagus or Barrett's carcinoma are distinctly different populations, the necessary studies assessing the preoperative risk of these two tumor entities also differ. With both groups, however, one must presume alcohol and nicotine abuse. This results in significantly impaired pulmonary and hepatic function (COPD, pulmonary fibrosis, fatty liver, liver cirrhosis). The appropriate preoperative studies, e.g., diagnostic pulmonary function testing and evaluation of liver function parameters in serum (albumin, cholinesterase, Quick, y-GT, AP, bilirubin, platelets, etc.) are mandatory. On the other hand, patients with Barrett’s carcinoma often have a long-standing history of reflux and are usually overweight. A body mass index of more than 25 is even debated as being a causative factor in the development of Barrett's carcinoma. The obesity and age of these patients are responsible for a high rate of concomitant cardiac disorders. In about 30% of these patients, coronary artery disease can be expected, which must be assessed (ergometry, echocardiography, possibly myocardial perfusion scintigraphy) and possibly treated (cardiac catheterization) before surgery. The overall surgical risk can be quantified with a score (so-called Bartels’ score), thus objectifying risk assessment.

After surgery has been indicated, the patient should be prepared for it as soon as possible. Particularly in dehydrated and cachectic patients, preoperative fluid and calorie replacement or a hypercaloric diet should first be initiated. At the same time an intensive physical preparation should be instituted, especially in terms of breathing exercises and a no smoking policy.

• Regarding nutrition see above.
• Special preoperative preparation, such as intensive laxative measures, is not required. As required by the anesthetists, the patient should have nothing by mouth (for at least 2 – 6 hours) before surgery.

Specific intraoperative complications

• For instance, possible spleen injury with subsequent splenectomy.

Specific postoperative complications

• Failure of the esophagogastrostomy or the lateral suture/staple line of the gastric tube
• Anastomotic stricture requiring dilatation
• Development of pleural empyema
• Development of mediastinitis
• Ischemia of the gastric tube
• Pulmonary fistula
• Atelectasis
• Pancreatic fistula
• Pancreatitis

General risks:

• Postoperative bleeding
• Thrombosis
• Embolism
• Pneumonia
• Infectious complications, i.e., wound abscess, intraabdominal abscess

In oncological surgery:

• Large tumors may prevent the R0 resection originally planned
• Catheter jejunostomy for postoperative enteral nutrition with associated complications (ileus, small bowel fistula).
• In the case of intraoperative complications during construction of the gastric tube or too short a gastric conduit, transposition of the colon may have to be employed as replacement organ.

With the patient awake and cooperative, an epidural catheter is placed before anesthesia is induced. This catheter is used for both intraoperative and postoperative analgesia. The patient is intubated with a double-lumen endotracheal tube that allows intraoperative left-sided one-lung ventilation during the thoracic part of the procedure, thus permitting compression of the right lung for better exploration of the mediastinum.

• General anesthesia
• Epidural nerve block
• Nasogastric tube
• CVL (Central Venous Line)
• IUC (indwelling urinary catheter, transurethral) or intraoperative suprapubic catheter

Since the surgical procedure of the transthoracic esophagectomy involves two body cavities, the abdomen and right chest, the patient must first be positioned supine and then left lateral decubitus.

There are two different types of positioning:

• The procedure starts with the normal supine position, with the left arm abducted.

Subsequently, the patient is placed into left lateral decubitus position, with the right arm placed on a leg holder padded with a Moltex pad and fixed with a bandage.

• From the beginning, the supine patient is placed in a so-called "torqued position" with the left arm abducted and the right arm positioned at right angle on a padded leg holder. The patient's left side of the body is supported with 2 padded brackets, the right chest is padded such that most of the lateral thoracic wall is exposed up to the spine. This way, by tilting the operating table as far to the left as possible, the patient can be placed into almost full left lateral decubitus position without repositioning. For rather proximal intrathoracic esophageal tumors this position has drawbacks.

• Most often the surgeon is standing on the right side of the patient, with the scrub nurse facing him/her, and the instrument table rolled under the operating table at the level of the patient's pelvis.
• With the 1st assistant also facing the surgeon, the 2nd assistant stands to the left of the surgeon.

Surgical instrument sets/retractor systems:

• GIA 75 for constructing the gastric tube (> 2 magazines)
• Circular stapler, if needed (25 mm or 28 mm diameter)
• Ulrich cable winch retractor + rods
• Thoracic retractor (2x)
• Abdominal instrument set, large; chest set
• Argon beamer, if necessary
• Suction; cell saver, if necessary
• Various sutures
• Needle catheter jejunostomy set

Additional material/instruments:

• Universal draping set 2: 1x
• Adhesive towel drape, medium: 2x
• Surgical gown, uncoated: 1x
• Circular wound edge protector, 28 cm: 1x
• Suction tubing with suction bag: 1 x
• Scalpel blade no. 21 2x
• Scalpel blade no. 10 1x
• Surgicleaner: 1x
• NaCl rinsing solution: 1x
• Chloramine: 1x
• Swab bowl: 1x
• Saline bowl with ring: 1x
• Suprapubic catheter: 1x
• Robinson drain 20 Fr: 2x
• Chest tube: (curved 28 Fr + straight 28/32 Fr): 1x
• Redon drain 12 Fr + Redon bottle: 2x
• Gloves for surgical team
• Skin stapler 35 W: 1x
• Adhesive bandage: 1x

Postoperative care:

• Early postoperative extubation and adequate analgesia (epidural nerve block!) are of vital importance.
• Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).
• This link will take you to the International Guideline Library.

Deep venous thrombosis prophylaxis:

• With low-molecular-weight heparin.
• This link will take you to the International Guideline Library.

Ambulation:

• After extubation mobilize the patient in the evening to the edge of the bed, and on day 2 and 3 out of bed.

Physical therapy:

• Physical therapist helps the patient in ambulation and with intensive breathing exercises.

Diet:

• In our own protocol, we let the patient sip tea on postoperative day 1, drink 3 cups of tea on day 2 and tea ad libitumon postoperative day 3. Traditionally, after 3 - 4 days the return to regular diet is started gradually with soup. On postoperative day 2 liquids may be initiated via the catheter jejunostomy with tea 30 mL/h; starting postoperative day 3 a 50:50 mixture of tea and enteral feeding solution is administered in increasing amounts.
• If the patient displays symptoms (fever, leukocytosis, atypical abdominal complaints) or the fluid of the chest drains becomes discolored, anastomotic failure must be considered, which in case of an anastomosis high in the chest is best diagnosed by endoscopy.

Bowel management:

• If the bowel movement does not start by itself after 3 - 4 days, a light laxative may be administered.

Work disability:

• Usually, patient will be unable to return to work for at least 4 weeks.