Minimally Invasive Esophagectomy Periprocedural Care

Updated: Aug 08, 2017
  • Author: Michael Scott Halbreiner, MD; Chief Editor: Kurt E Roberts, MD  more...
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Periprocedural Care

Patient Preparation

Anesthesia

The implications involving anesthesia when performing minimally invasive esophagectomy (MIE) include longer operating times, possible prone positioning, and longer duration of single-lung ventilation (SLV) with thoracoscopic approaches. The use of protective ventilation is often implemented with SLV, whereby smaller tidal volumes (5 mL/kg) and a positive end-expiratory pressure (PEEP) of 5 cm H2O are used.

Although no evidence exists regarding the benefit of protective ventilation during MIE, it seems appropriate to use given the increased time on ventilation and the benefits in decreasing the inflammatory response and improving lung function postoperatively that have been demonstrated in the open transthoracic approach. [29]

The risk of tracheal aspiration is increased in patients undergoing a thoracotomy. It is particularly influenced by the presence of esophageal cancer, which affects normal lower esophageal sphincter function. For this reason, prophylactic gastroesophageal reflux management, rapid-sequence intubation, and securing the airway with a cuffed endotracheal tube, which have been shown to reduce pulmonary aspiration, are standard procedures in this patient population. [30]  Repeated low-grade nasogastric and oropharynx suctioning before and after extubation further minimizes the risk of aspiration.

Early extubation, provided it can be done safely, has been shown to decrease length of stay in both the intensive care unit (ICU) and the hospital. It contributes to improved outcomes and had no significant difference compared to late extubation in terms of in-hospital mortality. [31, 32]

Thoracic epidural anesthesia (TEA) has clear benefits in perioperative pain relief, facilitating faster extubation and earlier mobilization, thereby reducing respiratory complications and length of stay. TEA for more than 48 hours was shown to reduce the incidence of reintubation and pneumonia as well as ICU and hospital stay compared to no epidural or a TEA for less than 48 hours. [33]

Positioning

The minimally invasive approaches to esophageal resection are the laparoscopic and thoracoscopic Ivor Lewis (transthoracic) esophagectomy, the laparoscopic transhiatal esophagectomy, and thoracoscopic esophageal mobilization with then laparoscopic transhiatal resection. All procedures typically begin with the patient in a supine position so that esophagogastroscopy can be performed to assess precise location and extension of the tumor. Suitability of the stomach as a conduit may also be assessed. [7, 34]

Thoracoscopic mobilization is performed either in the left lateral decubitus or prone position; the patient is then turned supine for gastric pull through and cervical anastomosis. For an Ivor Lewis procedure, the laparoscopic mobilization is performed first, and then the patient is turned and the procedure is completed in the chest with the anastomosis. The standard transhiatal resection can be performed with only laparoscopy and a cervical incision. [35]

See the video below for a discussion of room setup and port placement.

Minimally invasive esophagectomy. Room setup and port placement. Video courtesy of Memorial Sloan-Kettering Cancer Center, featuring Inderpal S Sarkaria, MD.