Transhiatal Esophagectomy Periprocedural Care

Updated: Aug 24, 2015
  • Author: Pradeep Saxena, MBBS, MS; Chief Editor: Dale K Mueller, MD  more...
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Periprocedural Care

Patient Education & Consent

Patient Instructions

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

Elements of Informed Consent

An informed consent for the procedure is taken. The diagnosis, treatment options, operative procedure to be performed, possible complications, and risks are explained to the patient. The patient and attendants are explained in their own language about the risks of infection, bleeding, anastomotic leak, chylothorax, respiratory complications, need for ventilator support, cardiac arrest, and possible death.

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Pre-Procedure Planning

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

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Equipment

Table-mounted upper-hand retractors with deep liver-retracting blades, long right-angle clamps, and long electrocautery extensions are useful for transhiatal resection of thoracic esophagus.

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Patient Preparation

Anesthesia

General anesthesia with endotracheal intubation is used.

Positioning

The patient is positioned supine on the operating table with his left arm by his side and right arm extended on an arm rest or each on 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.

A nasogastric tube and Foley catheter drainage are routinely used. Central venous line, if required, should be placed on right side of 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, table mounted upper hand retractors are attached to the operating table.

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Monitoring & Follow-up

Postoperative care

Postoperatively, the patient is kept in intensive care under closed 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. [5]

The patient is usually discharged in the second postoperative week.

If the patient’s margins are positive based on a histology report, adjuvant chemoradiotherapy is offered.

A recent meta-analysis showed a survival advantage for neoadjuvant therapy for esophageal cancer. Neoadjuvant chemoradiation is advised for stage II, III, and IVa esophageal carcinomas with good performance status. With frequent use of neoadjuvant chemotherapy, there is a significant decrease in advanced postsurgical pathologic TNM stages over time (P < 0.0001).

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 regurgitation 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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