ESOPHAGECTOMY ANESTHESIA
From the American Society of Anesthesiologists’ Annual Meeting, October 13-17, 2007, San Francisco, CA
John E. Ellis, MD, Professor, Department of Anesthesia and Critical Care, University of Chicago Pritzker School of
Medicine, Chicago, IL (Moderator); David Amar, MD, Professor of Anesthesiology, Weill Medical College of Cornell
University, and Director of Thoracic Anesthesia, Memorial Sloan-Kettering Cancer Center, New York, NY; Eric Jacobsohn,
MBChB, MHPE, Professor and Chair, Department of Anesthesia, University of Manitoba Faculty of Medicine, and Medical
Director, Winnipeg Regional Health Authority Anesthesia Program, Winnipeg, MB
| Case: 52-yr-old man presents with 2-mo history of worsening dyspnea, productive cough of green sputum, and weight loss
(60 lb); underwent several months of neoadjuvant chemoirradiation for esophageal adenocarcinoma; scheduled for Ivor
Lewis esophagectomy; electrocardiography (ECG) showing sinus rhythm but many premature atrial complexes (PACs);
has 60-packs/yr smoking history and mild chronic obstructive pulmonary disease (COPD); institution or surgeon has
adopted clinical pathway that includes thoracic epidural analgesia (tends to decrease blood pressure [BP]), fluid restriction,
extubation immediately after surgery, and early mobilization
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| Thoracic epidural anesthesia and analgesia: epidural essential; stop clopidogrel (Plavix) before epidural if patient
taking drug >6 mo (Amar); guidelines now state 1 yr (Ellis); evidence-based medicine and outcomes with epidural anesthesia
indicate no difference; however, when caring for patient in intensive care unit (ICU), well-functioning epidural
clearly makes patient more comfortable (able to breathe deeply and cough); epidural may also decrease incidence of
postoperative atelectasis and “soft” respiratory parameters for outcome; no change in mortality shown
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 | Epidural placement in patient on clopidogrel: “tough call”; many feel discontinuation for 7 days probably not enough; experts
in regional anesthesia divided; speaker does not place epidural if clopidogrel discontinued ≤7 days (Jacobsohn);
wait 2 wk to be sure (Ellis)
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| If epidural cannot be placed: patient receives intravenous (IV) patient-controlled analgesia (PCA) postoperatively (typically
with either fentanyl or morphine) [Amar]; ketamine useful for visceral pain; utilize multimodal approach with epidural ketorolac
and IV morphine or IV fentanyl to “top off” if epidural insufficient (Ellis); give ketorolac for other areas of pain (eg,
cervical anastomosis) when epidural analgesia cannot be used; also PCA in combination with thoracic epidural; indwelling
catheter placed at surgical site for local analgesia also useful; be careful using local analgesia in neck (concern about getting
too deep); patient already at risk for surgically induced problems with diaphragm and recurrent laryngeal nerve; place local
anesthetic judiciously; catheter should be superficial (Jacobsohn); some evidence in literature of better perfusion of upper
gut with thoracic epidural; dehiscence of esophageal anastomosis extremely lethal; study by Liu found insufficient evidence
of effects of postoperative analgesia on major postoperative complications; high prevalence of complications with esophagectomy;
speaker looked at length of stay after colectomy surgery and found (for failed epidural) length of stay longer than
for PCA; speaker places epidural at T6-7 (Ellis); balance thoracic vs abdominal placement (Jacobsohn); lumbar epidural
causes more vasodilatation and less analgesia; no randomized trials comparing placement of epidural in esophagectomy
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| Preemptive analgesia: popularity has waxed and waned over years; speaker doses early 1) to ensure block functioning
correctly and 2) because of belief in usefulness of preemptive analgesia; however, associated challenges with fluid and
BP; use local anesthetics, opiates, combination of both, or α2 agonists (Ellis); issue of fluid balance complicates matters;
most surgeons have concerns related to vasopressor use in these cases (Jacobsohn); epidural improves esophageal
blood flow (Ellis); speaker starts analgesia early, using low concentration of bupivacaine (0.05%) and hydromorphone
(eg, Dilaudid) [Amar]; speaker doubtful that above concentration reduces hypotension (Ellis); fairly uncommon; consider
bolus with higher concentration of local anesthetic to complement analgesic agents; in speaker’s institution, epidural
placed in pain service early on day of surgery, then tested; “overall, they work pretty well” (Amar)
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| Fluid therapy: advantages include well-perfused esophagus, good kidney function, preservation of gut perfusion, avoidance
of dehiscence of esophageal anastomosis, and possible avoidance of endotoxemia; disadvantages include possibility
of flooding lungs, airway edema, wound-healing complications, and cardiac complications (Ellis)
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| Studies: review of pulmonary complications after esophagectomy found mortality related to initial degree of pulmonary
complications; avoiding complications important issue in short-term morbidity and mortality, but also affects long-term
mortality; study of 4000 patients showed those with pulmonary artery (PA) catheter received greater amount of fluid,
and cardiorespiratory complications significantly increased; studies looking at fluid management in adult respiratory
distress syndrome (ARDS) suggest fluid restriction may improve survival; other studies suggest patients with acute
lung injuries may benefit from albumin and furosemide (Lasix) therapy, although albumin and saline study (Saline versus
Albumin Fluid Evaluation [SAFE] study) did not show benefit; Fluids and Catheters Treatment Trial (FACTT),
comparing conservative to liberal fluid strategy in patients with acute lung injury, showed restrictive fluid strategy resulted
in improved outcome; only 2 retrospective studies on esophagectomy, but other studies suggest fluid restriction
decreases cardiorespiratory complications; acceptable end points for fluid management must be determined, as opposed
to “going with the old formulas pouring fluid into these patients” (Jacobsohn)
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| Shift to fluid restriction: began 15 to 20 yr ago; goals include urine output and hemodynamics; do not insert central
venous pressure catheter in every patient (Amar); study comparing large and small fluid volumes in major abdominal
surgery indicates that those receiving large amounts of fluid have dramatic decrease in wound PO2 , compared to those
receiving restricted fluid (decreasing wound PO2 important risk factor for developing wound complications) [Jacobsohn]
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| Postoperative respiratory management: speaker (Amar) uses protective lung ventilation for one-lung anesthesia;
accustomed to ventilating with lower tidal volumes (VT ); most surgeons prefer double-lumen tube, but speaker prefers
single-lumen tube with blocker; speaker does not routinely extubate patient at end of surgery; trend now to extubate as
early as possible; speaker’s typical procedure for one lung—6-mL/kg VT , positive end-expiratory pressure (PEEP) at 5
cm H2 O, and increase in respiratory rate to avoid hypercapnia; with adequate positioning of double-lumen tube and no
other issues, procedure works well; speaker typically begins with volume mode and switches to pressure mode if any
issues develop (Amar); “everybody deserves PEEP”; no physiologic rationale for avoiding PEEP if placing patient on
side and ventilating one lung; down lung at risk for atelectasis (Jacobsohn); tolerate peak VT pressures <30 cm H2 O
(Amar); peak VT pressure of 40 cm H2 O concerning; “something unusual” if pressure >25 cm H2 O at 6-mL/kg VT ;
overinflation issues with pressure >30 cm H2 O (Jacobsohn); speaker uses fiberoptic bronchoscope to place double-lumen
tube; if unavailable, learn to auscultate (Amar)
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| Many patients potentially susceptible to lung injury, due to chemotherapy and radiation therapy; recent study found volume
of unirradiated lung protective; setup of irradiation, chemotherapy, high airway pressures, and high fraction of inspired
O2 (Fio 2 ) may conspire to increase prevalence of acute lung injury; prevent complications by avoiding
pulmonary complications; N-acetylcysteine may be protective by being free-radical scavenger and preventing lung injury
(Ellis); pulmonary complications multifactorial; early medialization of nonfunctioning vocal cord may decrease
incidence of peri-operative microaspirations and respiratory complications in patient with asymptomatic recurrent laryngeal
nerve injury (Jacobsohn); fairly high prevalence of cardiac toxicity in patients with history of chemotherapy
and radiation therapy (Ellis)
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| Clinical pathways: few minimally invasive esophagectomy surgeries done at speaker’s institution (Amar); transhiatal
esophagectomy less debilitating surgery but not as curative (Ellis); data for pulmonary complications in transhiatal vs
thoracotomy-based procedures show few differences (Jacobsohn); recent case series compared minimally invasive surgery
to open procedures and “found it safe and comparable in the short term,” with 25% reduction in estimated blood
loss, 25% reduction in hours in ICU, and 1- to 2-day reduction in length of hospital stay (Ellis)
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| Transfusion: not typically done; if patient has had chemotherapy and comes to operating room (OR) with hematocrit of
28%, speaker may get patient through surgery, but patient might receive transfusion in postanesthesia care unit (PACU)
[Amar]; study in Canada found 1% absolute decrease in mortality after introduction of universal leukoreduction;
Transfusion Requirements in Critical Care (TRICC) study suggests restrictive transfusion strategy may be beneficial in
some patients (largely irrelevant; blood not leukoreduced); adverse effects on outcome variable
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| Developing body of evidence: patients with coronary artery disease (CAD) at risk for ischemia (hemoglobin <9 g/dL)
[Jacobsohn]; almost all patients arrive with stress test; intense cardiology evaluation useful; perioperative β-blockade
prevalent issue (Amar); new American College of Cardiology/American Heart Association (ACC/AHA) guidelines for
perioperative work-up in CAD indicate β-blockers useful before major surgery in patients with predictors of minor
clinical risk (eg, diabetes, renal insufficiency, previous CAD); proceed with major surgery if <3 predictors of minor
clinical risk (but not with major clinical risk predictors, unstable angina, recent chest pain, valvular heart disease, or
significant new arrhythmias) [Jacobsohn]; in patient with COPD, use β1 -selective blockers (eg, metoprolol, atenolol,
esmolol) [Ellis]; studies in cardiology and internal medicine indicate effectiveness of selective β-blockade in patients
with COPD (Jacobsohn); β-blockade overdone in medium-to-low-risk patients (Amar)
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| Extubation: speaker now less likely to extubate in OR if ICU bed available (obtain chest x-ray; make sure lung reexpanded,
down lung not atelectatic, no pneumothoraces, and patient warm and not agitated); goal to extubate within
hours of surgery (Jacobsohn); 70% to 80% of patients extubated in OR; surgeon worried about intentional sedation
leading to greater fluid administration (Amar); presence of well-working epidural may lead to quicker extubation (Ellis)
; speaker recommends caution in extubating patient with severe sleep apnea or obesity; “there’s no rush unless you
have an ideal candidate” (Amar); following clinical pathways fine, but also consider individual characteristics of patient
(eg, alveolar-arterial [AA] O2 gradient, airway, leak around tube, double-lumen vs single-lumen tube, sleep apnea,
effectiveness of epidural); in less ideal patient, no point in immediate extubation (Jacobsohn)
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| Managing respiratory failure: determine likelihood that respiratory failure acutely remediable issue (unlikely); most patients
require intubation; surgeons concerned about distention of conduit and stomach vs reintubation; after reintubation,
if extubation unlikely, consider early tracheostomy (Jacobsohn); quickly reintubate, if necessary; avoid bilevel
positive airway pressure (BiPAP); issue of tracheostomy occurs 1 wk after intubation (Amar); data indicate those with
earlier tracheostomy, with prolonged course of ventilation in ICU, may have fewer complications and lower mortality
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| Management of postoperative atrial fibrillation (AF)
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| Risk for postoperative supraventricular tachycardia (SVT): in general population, AF increases at ≈55 yr of age, with
slight male predominance; over next 4 decades, incidence of AF expected to increase from 2 million to 6 million patients;
in general population, risk mimics risk after thoracic surgery or coronary artery bypass grafting (CABG); aging
greatest risk factor; collagen, amyloid, and myocytes decrease integrity of atrial geometry; 90% of cells in sinoatrial
node degenerate by ≥70 yr of age; large observational studies identified 4% incidence of symptomatic AF or SVT after
noncardiac surgery; incidence higher after thoracic surgery in 70-yr-old; destroys autonomic nerves and changes electrophysiology
of heart; natural history same for every type of postoperative AF and SVT; <4% incidence after limited
lung resection, 12% to 27% incidence after lobectomy, and 17% incidence after esophagectomy; incidence in pneumonectomy
slightly greater; also higher in single or bilateral lung transplantation; natural history similar; peak onset 2
days postoperatively; may increase postoperative stay; myocardial infarction uncommon; if managed inappropriately,
risk for stroke increased; increased risk if AF lasts >48 hr; AF does not increase mortality, but marker for “sicker” patients;
AHA recommends rate control initially, not cardioversion, unless faced with extreme BP; mortality rate 2% to
5% at speaker’s institution
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| Prophylaxis and β-blockade: β-blockers perfect for intense adrenergic procedure; study using large doses of propranolol
showed no difference in AF; high number of side effects, including bradycardia and hypotension; study showed that,
compared to placebo, immediate prophylaxis with IV diltiazem (then converting to oral diltiazem when patient able to
tolerate) reduced incidence of SVT and AF after thoracic surgery by 50%; patient ≥60 yr of age receives diltiazem; if
BP can tolerate, use β-blocker plus diltiazem; calcium channel blockers better than β-blockers for preventing AF (not
rate-dependent); study shows thoracic epidural does not reduce arrhythmia rate; speaker favors statin use (eg, atorvastatin
[Lipitor])
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| Recommendations from AHA: for acute arrhythmia within 24 hr, control heart rate first, then begin β-blockers (esmolol,
metoprolol, or diltiazem); add amiodarone or ibutilide if patient not at risk for proarrhythmia with structural heart disease;
after 48 hr, make decision whether to anticoagulate; if patient still bleeding, and decision made not to anticoagulate,
use transesophageal echocardiography (TEE) fast-track approach (in ideal candidate); anticoagulate if AF
persistent; determine whether to initiate antithrombotic agent; for moderate risk, aspirin alone or full anticoagulation;
for low risk, aspirin only; speaker favors rate control over rhythm control; digoxin not recommended for management
of acute arrhythmia unless in acute heart failure (Amar)
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Suggested Reading
Ahn HJ et al: Thoracic epidural anesthesia does not improve the incidence of arrhythmias after transthoracic esophagectomy.
Eur J Cardiothorac Surg 28:19, 2005; Amar D et al: Effects of diltiazem prophylaxis on the incidence and clinical
outcome of atrial arrhythmias after thoracic surgery. J Thorac Cardiovasc Surg 120:790, 2000; Bernabe KQ et al: Laparoscopic
hand-assisted versus open transhiatal esophagectomy: a case-control study. Surg Endosc 19:334, 2005; Dapri G
et al: Robot-assisted thoracoscopic esophagectomy with the patient in the prone position. J Laparoendosc Adv Surg Tech A
16:278, 2006; Hahm TS et al: Risk factors for an intraoperative arrhythmia during esophagectomy. Yonsei Med J
48:474, 2007; Hébert PC: Transfusion requirements in critical care (TRICC): a multicentre, randomized, controlled clinical
study. Br J Anaesth 81 Suppl 1:25, 1998; Liu SS et al: Effect of postoperative analgesia on major postoperative complications:
a systematic update of the evidence. Anesth Analg 104:689, 2007; Low DE et al: Esophagectomy--it's not just
about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer.
J Gastrointest Surg 11:1395, 2007; Michelet P et al: Effect of thoracic epidural analgesia on gastric blood flow after
oesophagectomy. Acta Anaesthesiol Scand 51:587, 2007; National Heart, Lung, and Blood Institute Acute Respiratory Distress
Syndrome (ARDS) Clinical Trials Network, Wiedemann HP et al: Comparison of two fluid-management strategies in
acute lung injury. N Engl J Med 354:2564, 2006; Neal JM et al: Near-total esophagectomy: the influence of standardized
multimodal management and intraoperative fluid restriction. Reg Anesth Pain Med 28:328, 2003; Ritchie AJ et al: Cardiac
dysrhythmia in total thoracic oesophagectomy. A prospective study. Eur J Cardiothorac Surg 7:420, 1993; Rudin A
et al: Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective
follow-up of 201 patients. J Cardiothorac Vasc Anesth 19:350, 2005; Wiedemann HP: A perspective on the fluids
and catheters treatment trial (FACTT). Fluid restriction is superior in acute lung injury and ARDS. Cleve Clin J Med 75:42,
2008; Yokoyama M et al: The effects of continuous epidural anesthesia and analgesia on stress response and immune
function in patients undergoing radical esophagectomy. Anesth Analg 101:1521, 2005.
Educational Objectives
| The goal of this program is to improve anesthetic management of the patient undergoing esophagectomy. After hearing
and assimilating this program, the clinician will be better able to:
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| 1. Provide and manage thoracic epidural anesthesia and/or analgesia for upper-abdominal and thoracic surgeries.
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| 2. Provide rational fluid therapy during such procedures.
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| 3. Provide intraoperative ventilation and postoperative respiratory management that minimizes respiratory complications.
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| 4. Predict, treat, and possibly prevent postoperative atrial fibrillation after esophagectomy.
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| 5. Apply the new American College of Cardiology/American Heart Association guidelines for cardiac management
of the patient undergoing noncardiac surgery.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning
committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a
proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Ellis is a consultant and
member of the Speakers’ Bureau for Baxter and holds equity positions with both Progenics and Hospira. Drs. Amar and Jacobsohn
and the planning committee reported nothing to disclose.
Acknowledgements
Drs. Ellis, Amar, and Jacobsohn spoke in San Francisco, CA, at the American Society of Anesthesiologists’ Annual Meeting,
held October 13-17, 2007. The Audio-Digest Foundation thanks the speakers and the ASA for their cooperation in the production
of this program.
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