Surgery - Oesophagectomy





Surgery

  • High risk surgical procedure
  • Rx for non-metastatic oesophageal cancer

Approaches

Open

  • Ivor-Lewis:

    • Laparotomy, then right thoracotomy
    • For more proximal oesophageal lesions

  • Thoracoabdominal:

    • Left thoracotomy crossing costal margin and diaphragm
    • For lower / distal oesophageal lesions

  • McKewan:

    • 3 stages:
      • Laparotomy
      • Right thoracotomy
      • Cervical anastomosis

Laparoscopic

i.e. Minimally invasive oesophagectomy (MIO)

3 stages:

  • Thoracoscopic oesophageal mobilisation
  • Laparoscopic gastric mobilisation
  • Cervical anastomosis

Common steps:

All approaches involve:

  • Resection of oesophagus and upper stomach
  • Removal of lymph nodes
  • Restoration of GIT continuity and function

➤ Replacement of oesophagus

  • Usually a portion of the stomach is used to replace the oesophagus
  • Colon (right or left) can be used too
  • Two step approach may be used sometimes
    1. Resection with feeding via jejunostomy tube
    2. Reconstruction of oesophagus at a later date

Original 3 stage MIO

?As described originally.

Stage 1: Thoracoscopy

  • Oesophageal mobilisation
  • Mediastinal lymph node dissection
  • Intercostal chest drain inserted
  • ± Paravertebral catheter placed
  • Right thoracotomy in left decubitus position

Stage 2: Laparoscopy

  • Laparoscopic gastric mobilisation
  • Abdominal lymph node dissection
  • Gastric tube formation i.e. oesophageal conduit
  • Supine with head up tilt

Stage 3: Cervical anastomosis

  • Diseased oesophagus pulled up
  • Oesophagus transected
  • Cervical anastomosis performed
  • Insertion of:
    • NG drainage
    • Feeding tube inserted
      • nasojejunal or jejunostomy
  • Close of abdominal and neck wound

Subsequent modifications

Subsequent modifications include:

  • Thoracosopic dissection performed ... in prone position
    • Better surgical acess
      • Due to structures falling forward
  • Mini-laparotomy after laparoscopy
    • Gastric conduit created outside abdo ... to ensure correct length
  • Anastomosis performed in chest
  • Ivor-Lewis
    • Two stages
      • Laparotomy
        • Transverse cut along the subcostal margin (3 to 4 cm away from the margin)
      • Right thoracotomy

Prognosis

Open oesophagectomy

  • High morbidity and mortality
    • In-hospital mortality = up to 5 to 10%
      • Less than 1% at 30 days at major specialist centres (e.g. PAH)
      • 2/3 of death are systemic sepsis (e.g. respiratory complication, anastomosis breakdown)
    • Major morbidity = 25 to 30%
  • Up to 6 month to recover from surgery
  • 5 year survival rate = 20 to 25%



AMx

Issues

➤ !! High periop M&M

  • Anatomotic leak
  • Wound infection
  • Atrial arrhythmia
  • Major pulmonary events

➤ Patient:

  • GORD common
  • Pre-op malnutrition
  • Pre-op chemo
    • Possible immunosuppression
  • Pre-op radiation
    • Inflammation leading to increased bleeding

➤ Surgical:

  • Prolonged surgery
    • May take over 8 hours
  • Hypothermia
    • Difficult to apply air warmer due to surgical exposure required
  • Positioning
    • Lateral or prone position
    • Change of positioning intraop
  • Mediastinum operation
    • Risk of catastophic haemorrhage
      • General surgeon (i.e. non-thoracic) operating in mediastinum
    • Hypotension due to compression of LA or major vessels
    • Arrhythmia

➤ Anaesthetic:

  • One lung ventilation for prolonged periods
  • Complications of extra-peritoneal CO2
    • Including
      • Capnothorax
      • Capnomediastinum
      • Surgical emphysema
    • Resulting in:
      • Cardiorespiratory compromise
      • Rapid increase in EtCO2
  • Postoperative analgesia
    • Thoracic epidural
    • Paravertebral catheter
  • Fluid management difficult
    • Too liberal
      • Pulmonary complications
    • Too restrictive
      • Compromised tissue perfusion
      • Increased risk of anastomotic failure

Plan

  • M
    • IBP and CVP
  • A
    • Thoracic epidural
      • Insert around T7 (T6/7 or T7/8)
      • Need to cover up to T5
    • DLT (+/- fibreoptic bronchoscope)
    • Arterial line
    • CVL
      • Avoid the side required for cervical anastomosis
    • Large bore peripheral line
    • NGT
      • Will need to be re-positioned intraop (Withdrawn and re-advanced)
      • Consider stitching NGT in
    • IDC
  • D
    • Remifentanil and NMBD infusion
  • E
    • Warmers (both fluid and air warmer)

➤ Induction:

  • Consider RSI
  • Consider inserting NGT prior to intubation

➤ Postop:

  • ICU or HDU according to local protocol
  • CXR to confirm chest drain and CVL (and NGT)
  • PCA as backup analgesia
  • Feeding through