Perioperative management - Esophagectomy

Malignant Esophageal Tumors:

• Carcinomas (Squamous Cell Carcinomas, Adenocarcinomas)
• Sarcomas (rare)

Benign Long-Segment Stenoses:

• Corrosive Injuries (Acid/Alkali)

• Liver cirrhosis
• severe interstitial lung diseases (COPD, pulmonary fibrosis)
• severe heart failure
• severe coronary heart failure

Biopsy Confirmation
Primarily, the endoscopic clarification of the diagnosis with biopsy confirmation takes place. Here, a biopsy should provide clarity as to whether a malignant tumor is an adenocarcinoma or a squamous cell carcinoma of the esophagus. Often, this differentiation has already occurred during the initial endoscopy. However, there are always cases where the differentiation is not clearly successful, so that rebiopsies become necessary. In addition, for adenocarcinoma, it must be clarified whether it is a Barrett's carcinoma or rather a cardia carcinoma.

The further procedure is oriented to this histological diagnosis:

• Squamous Cell Carcinoma
  In squamous cell carcinoma, which has become increasingly rare in recent years, the following must be considered in preoperative staging: in view of the longitudinal extension of squamous cell carcinomas, endoscopy should search for mucosal metastases oral or aboral to the tumor. Furthermore, endoscopy should rule out a possible second carcinoma especially in the area of the hypopharynx. Moreover, the endoscopy should be supplemented by endoscopic ultrasound (EUS) to obtain an impression of the wall infiltration depth and the surrounding relationship of the tumor. The tracheobronchial system can only be inadequately or not at all visualized via endosonography. If the tumor has relation to the tracheobronchial system or is located oral to the tracheal bifurcation, endoscopic clarification of the tracheobronchial system must be performed to rule out tumor invasion into this system. To rule out distant metastases and to evaluate the positional relationship of the tumor to neighboring organs, the endoscopic diagnostics must be supplemented by a CT thorax and abdomen.

• Adenocarcinoma
  If it is an adenocarcinoma, additionally, the histological confirmation of Barrett's mucosa in the tumor environment should be aimed for, as far as this is still possible next to the tumor. Endoscopically, the presence of an adenocarcinoma of the esophagogastric junction Siewert type II or III should be ruled out, because this would result in different therapeutic consequences (e.g., transhiatal extended total gastrectomy). If a Barrett's carcinoma is present, the staging examination should in principle proceed similarly, i.e., through endoscopy, EUS and CT, although the clarification of the tracheobronchial system takes a back seat, as Barrett's carcinomas are usually located aboral to the tracheal bifurcation. In view of the mostly distal localization, involvement of the abdominal cavity is not uncommon, so that adiagnostic laparoscopy can be performed in locally advanced Barrett's carcinoma to detect possible peritoneal carcinomatosis (in approx. 20% of cases). Decisive for the further therapeutic procedure is primarily the R0 resectability and the differentiation into T1/T2 tumors or T3/T4 tumors. Based on the T category or the R0 resectability, stratification follows with regard to primary surgery or neoadjuvant therapy protocols.

PET Imaging
In recent times, PET imaginghas gained increasing importance in preoperative staging examinations, preferably in the form of PET-CT. In addition to identifying distant metastases, PET-CT also enables the assessment of the intensity of tumor metabolism and therefore allows, especially in the decision for neoadjuvant therapy, an early response evaluation with corresponding therapeutic consequences.
Routine colon diagnostics, e.g., by colonoscopy for the use of the colon as a possible replacement organ, does not appear necessary.

Preoperative Risk Assessment
Since patients who suffer from squamous cell carcinoma of the esophagus or those with Barrett's carcinoma represent quite different populations, the necessary examinations regarding preoperative risk assessment also differ between the two tumor entities. However, in both groups, alcohol and nicotine abuse must be assumed. This results in significant deteriorations of lung and liver function (COPD, pulmonary fibrosis, liver steatosis, liver cirrhosis). The corresponding preoperative examinations such as pulmonary function diagnostics as well as clarification of liver function parameters in serum (albumin, CHE, Quick, y-GT, AP, bilirubin, platelets, etc.) are required. Patients with Barrett's carcinoma, on the other hand, often have a long history of reflux and are usually overweight. A body mass index of over 25 is even discussed as causative for the development of Barrett's carcinoma. The overweight and the age of these patients are responsible for a high rate of cardiac comorbidities. In these patients, coronary heart disease can be expected in about 30% of cases, which must be clarified (ergometry, cardiac echo, possibly myocardial scintigraphy) and, if necessary, treated preoperatively (cardiac catheter examination). Overall, the surgical risk can be determined via a score (so-called Bartels Score), thereby making the risk assessment objective.
The surgical preparation should take place as soon as possible after the indication has been established. Especially in dehydrated and cachectic patients, preoperative fluid and calorie intake or hypercaloric nutrition should be carried out first. At the same time, intensive physical preparationshould take place, particularly in the sense of respiratory gymnastics as well as nicotine abstinence.

Regarding nutritional therapy, see above.
Special preoperative preparations, such as intensive laxative measures, are not required. The patient should only be kept fasting preoperatively in a standard manner, as required by anesthesiology (minimum 2 – 6 h).

Specific intraoperative complications:

• e.g. a possible spleen injury with splenectomy.

Specific postoperative complications:

• Insufficiency of the esophagogastrostomy or the lateral gastric tube suture,
• the anastomotic stenosis with bougienage requirement,
• the development of a pleural empyema,
• the development of mediastinitis,
• ischemia of the gastric tube,
• pulmonary fistula,
• atelectasis,
• pancreatic fistulas,
• pancreatitis.

General risks:

• postoperative secondary bleeding,
• thrombosis,
• embolism,
• pneumonia,
• infectious complications in the sense of wound abscess or intra-abdominal abscess.

For oncological operations:

• In case of unexpectedly large tumor, an R0 resection may not be achievable under certain circumstances.
• Placement of a catheter jejunostomy for postoperative enteral nutrition with the associated complications (ileus, small bowel fistula).
• In the event of intraoperative complications during the creation of the gastric tube or too short gastric interponate, a colon interponate may have to be used as a replacement organ if necessary.