Esophagogastric Devascularization Periprocedural Care

Updated: Sep 19, 2016
  • Author: Nicholas Sikalas, MD; Chief Editor: Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS  more...
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Periprocedural Care

Preprocedural Planning

Most patients who undergo an esophagogastric devascularization procedure have cirrhosis and underlying coagulopathy, so significant intraoperative blood loss can be expected.

Regardless of whether the procedure is performed in the elective or the urgent setting, adequate intravenous access is necessary. This should include large-bore central venous access. In the elective setting, placement of a Swan-Ganz catheter for intraoperative monitoring can be considered.

A complete set of preoperative laboratory studies, including complete blood count count, comprehensive metabolic panel, coagulation studies, and type and crossmatch, should be performed.

Multiple units of packed red blood cells and fresh frozen plasma must be readily accessible.

A nasogastric tube should be placed. Great care should be taken for nasogastric tube placement because this by itself could cause esophageal varices to bleed.

If an endoscopic procedure was performed before surgery, a nasogastric sump tube should be left at that time.

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Equipment

Special equipment includes the following:

  • End-to-end anastomosis (EEA) circular stapler (25-29 mm) (modified Sugiura)
  • Tissue sealant device (optional)
  • Argon beam (optional)
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Patient Preparation

Anesthesia

General anesthesia is necessary for the procedure. A transplant anesthesiologist, if available, should be involved in intraoperative care. When a thoracic approach is used, selective ventilation of the right lung using a double-lumen endotracheal tube is prudent.

Positioning

When a traditional Sugiura procedure is performed, the patient is positioned in a standard right lateral decubitus position. An axillary role should be placed under the chest in order to avoid a brachial plexus injury.

When a modified Sugiura procedure is performed, the patient is positioned supine, and a gel pad or blankets can be used to expose the lateral aspect of the left subcostal region. The patient may also be air-planed to the right on the surgical table.

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Monitoring & Follow-up

The patient should be monitored in a surgical intensive care unit (SICU) setting immediately following the operation. Total parenteral nutrition (TPN) should be started if it was not already begun in the preoperative period.

On postoperative day 5-7, contrast esophagography should be performed to evaluate for leak, fistula, or narrowing at the transection line. If the test results are satisfactory, clear liquids may be started and the diet advanced slowly. A feeding jejunostomy or an intraoperatively placed postpyloric feeding tube may be of value in achieving early nutritional support in the postoperative period.

Esophagogastroduodenoscopy (EGD) should be performed 1 month postoperatively to evaluate the transection site for stricture formation. Any strictures should be dilated.

The patient should meet regularly with his/her surgeon or hepatologist for serial endoscopies.

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