Transhiatal Esophagectomy Periprocedural Care

Updated: Aug 25, 2018
  • Author: Pradeep Saxena, MBBS, MS; Chief Editor: Dale K Mueller, MD  more...
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Periprocedural Care

Patient Education and Consent

Patient Instructions

Patients are instructed to do breathing exercises with regular use of an incentive inspirometer.

Elements of Informed Consent

Informed consent for the procedure is obtained. The diagnosis, treatment options, operative procedure to be performed, possible complications, and risks are explained to the patient and attendants, in their own language. The list of risks includes the following:

  • Infection
  • Bleeding
  • Anastomotic leak
  • Chylothorax
  • Respiratory complications, with possible need for ventilator support
  • Cardiac arrest
  • Death
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Preprocedural Planning

Optimal results can be obtained by carefully assessing operative risk and operating on a fit patient. The assessment includes review of the following:

  • Nutritional status
  • Pulmonary function
  • Cardiac reserve
  • Hepatic function
  • Renal function
  • Other comorbidities

Patients with poor nutritional status who have difficulty swallowing may require esophageal dilatation or feeding jejunostomy to improve nutritional status before surgery. Nutritional status may be improved preoperatively by supplemental tube feedings at home.

Patients with esophageal cancer are frequently smokers or alcoholics. They should be evaluated for chronic obstructive or restrictive pulmonary diseases, liver dysfunction with hypoproteinemia, coagulopathy, portal hypertension, or cirrhosis.

Breathing exercises and regular preoperative use of an incentive inspirometer are helpful in training the patient for early postoperative ambulation. The patient should be advised to abstain from smoking. Epidural anesthesia is very useful for comfortable postoperative breathing and early extubation and ambulation.

Routine blood studies, coagulation profile, liver function tests, renal function tests, chest radiography, and electrocardiography are performed in all patients. Upper gastrointestinal endoscopy with biopsy and barium esophagography is used to confirm and assess disease. Standard staging for esophageal carcinoma is performed.

In cases of malignancy, the locoregional extent of disease and distant metastasis is assessed using CT scanning of the neck, chest, and upper abdomen. Endoscopic ultrasonography is useful in locoregional assessment of the disease, especially for documenting tumor infiltration to adjacent mediastinal structures, mainly the tracheobronchial tree and thoracic aorta. Bronchoscopy with biopsy is also useful in the evaluation of infiltration of the tracheobronchial tree. Positron-emission tomography (PET)–CT scanning and staging laparoscopy are performed in select cases. Preoperative chemotherapy is advised for T3 disease and if lymph node metastasis is suspected.

For advanced T3 or T4 tumors of the lower end of esophagus and esophagogastric junction, preoperative laparoscopy and peritoneal cytology are useful to detect radiologically occult metastatic disease.

Videoesophagography may be useful in the assessment of aspiration tendency, and the vocal cords should be evaluated via indirect laryngoscopy.

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Patient Preparation

The patient is kept nil by mouth 6 hours prior to surgery. Bowel preparation to prepare the colon is done if colonic interposition is anticipated.

Anesthesia

General anesthesia with endotracheal intubation is used.

Positioning

Because the cervical esophagus is best approached through a left-sided neck incision, the patient is positioned supine on the operating table with the left arm at the side and the right arm extended on an armrest or at the side. A long roll is placed between the shoulder blades vertically so as to extend the neck and let the shoulders fall down. The patient’s head is supported on a head ring and is turned to the right side.  Avoid hyperextension of the neck without head support, which can result in spinal cord injury.

A nasogastric tube and Foley catheter drainage are routinely used. A central venous line, if required, should be placed on the right side of the neck. Arterial blood pressure monitoring is useful.

The patient’s neck, chest, and abdomen are prepared and draped, exposing the operative field in the neck and upper abdomen.

Lastly, a table-mounted “upper hand” retractor is secured to the table with the cross bar at the nipple line. Two suction catheters are placed on the table, one at the head and one near the abdomen. [12]

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Monitoring & Follow-up

Postoperative care

Postoperatively, the patient is kept in intensive care under close monitoring.

Extubation may be done immediately postoperatively, or the patient may be electively ventilated overnight.

Breathing exercises, chest physiotherapy, and regular use of an incentive inspirometer are helpful in early postoperative ambulation.

Jejunal feeds through a feeding jejunostomy are initiated once bowel sounds appear and the patient passes flatus.

A water-soluble contrast study is performed on the seventh postoperative day; if no leak is detected, oral feeding is resumed. The closed suction drain in the patient’s neck should be left for a sufficient period, usually until the tenth postoperative day; oral feeding should be delayed if an anastomotic leak is suspected. [8]

The patient is usually discharged in the second postoperative week.

If the histology report indicates positive surgical margins, adjuvant chemoradiotherapy is offered.

Long-term monitoring

To assess long-term functional results after transhiatal esophageal resection, the patient is evaluated for the presence and degree of dysphagia, regurgitation, and postvagotomy diarrhea and dumping syndromes. Patients should be preoperatively counseled about the changes in eating habits and the need for dilatations. 

Patients with an esophagogastric anastomosis leak should be placed on an aggressive follow-up dilatation program in the first few months after transhiatal esophageal resection to prevent late stenosis and to provide comfortable swallowing. Esophageal bougienage is initiated from the second postoperative week onward, with passage of 36F, 40F, and 46F Maloney esophageal dilators. After discharge, patients undergo follow-ups with regular dilatation with a 46F or larger Maloney bougie if they experience any degree of cervical dysphagia.

Most patients do not experience regurgitation of gastric contents. Regurgitation, if it occurs, may be graded as mild if it occurs upon reclining or in the prone position shortly after eating. This is a minor problem and requires no treatment. Troublesome nocturnal regurgitation compels patients to sleep with their head elevated at night. Severe regurgitation with pulmonary complications is caused by aspiration and occurs in 1% of cases.

About 33% of patients who undergo truncal vagotomy and pyloromyotomy report varying degrees of diarrhea and dumping syndrome (postprandial nausea, cramping, diaphoresis, palpitations, flushing, weakness, dizziness, hypotension, syncope). For mild symptoms, no treatment is required, and most of these symptoms usually resolve over time. Minor dietary changes, such as eating frequent small meals, avoiding meals rich in carbohydrates, and separating liquids and solids, may be helpful in controlling symptoms. Antispasmodics may be required for cramping. Diarrhea can be treated with supplemental dietary fiber, diphenoxylate, or Imodium.

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