Esophagectomy (Ivor Lewis or McKeown)
Patient phenotype
Esophageal cancer, age 55-75, often smoker, GERD/Barrett's, possibly post-chemoradiation (deconditioned, malnourished). High-risk operation with 5-10% perioperative mortality.
Procedure
Ivor Lewis: laparotomy + right thoracotomy, gastric conduit pulled into chest. McKeown: laparotomy + right thoracotomy + neck anastomosis. Long (4-8h), one-lung ventilation phase.
Anesthetic plan
GETA + thoracic epidural T6-T8 ESSENTIAL for postop analgesia + recovery. DLT for OLV. Massive transfusion ready. Restrictive fluids (anastomotic leak risk with overhydration). ICU postop.
Setup
- ·Standard ASA + temp + Foley + UOP
- ·Two A-lines or one + femoral
- ·CVC (multilumen, MAC)
- ·Two large-bore PIVs
- ·Type & cross 4 units PRBC + FFP/platelets available
- ·Thoracic epidural T6-T8 (placed pre-induction)
- ·Left-sided DLT 37-39 Fr + fiberoptic verification
- ·Forced air warmer + fluid warmer
Biggest concerns by phase
Nutrition + ERAS optimization
Many esophagectomy patients malnourished from dysphagia + chemo. Pre-op nutrition optimization (oral supplement or J-tube) + smoking cessation reduce complications. Albumin + prealbumin trend. Pre-rehab if time.
Thoracic epidural placement awake
T6-T8 epidural before induction (positioning easier with cooperative patient + neuro exam intact). 0.0625-0.125% bupivacaine + fentanyl 2 mcg/mL infusion intraop + postop. Reduces opioid 50-75%.
Restrictive fluid strategy — anastomotic leak risk
Aim < 1.5-2 L total intraop. Excess fluid → anastomotic edema → leak → mediastinitis (mortality 50%). Use vasopressor for hypotension (NE), not fluid bolus. Monitor UOP > 0.5 mL/kg/hr.
OLV phase + DLT migration in repositioning
Lateral decub for thoracic phase. Verify DLT after positioning (10-25% migration). Standard OLV concerns: hypoxia stepwise approach, HPV preservation with TIVA option.
Conduit perfusion — surgeon pulls stomach into chest
Gastric conduit relies on right gastroepiploic artery. Hypotension → ischemia → leak. Maintain MAP > 65, avoid vasopressor extremes. Surgeon may use ICG fluorescence to verify conduit perfusion.
ICU intubated — pneumonia + leak watch
Stay intubated to ICU. Postop concerns: anastomotic leak (POD 5-10, sudden chest pain + sepsis), pneumonia (very common), AF, chyle leak, RLN injury. Epidural maintained × 4-7 days for early ambulation.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
Esophagectomy patient, 4 hours in, OLV phase. SpO₂ 92% on FiO₂ 0.6 + PEEP 8. EBL 800 mL so far. Anesthesia tech says you have 2 units PRBC remaining. Surgeon needs another 2-3 hours. What's your plan?
What an examiner probes for
- ▹Order more blood pre-emptively (don't wait for emergency)
- ▹Activate type-specific cross
- ▹Optimize OLV: position check, suction, recruitment
- ▹Restrictive fluid still — vasopressor for BP, judicious blood
- ▹Plan for ICU transport intubated
Sources
- Miller's Ch 64
- Slinger Anesthesia for Thoracic Surgery
- ERAS Esophagectomy
Anatomy reference
Sourced reference images. 4 matches for "esophagus stomach digestive thorax".
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