oesophagectomy
Matthew Rucklidge BSc MB BS FRCA
David Sanders BM BCh MA DPhil FRCA
Alastair Martin MB ChB FRCA
doi:10.1093/bjaceaccp/mkq004
Advance Access publication 21 February, 2010
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 10 Number 2 2010
& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org
Oesophageal cancer is
increasing in the UK and
rates are among the worst
in Europe.
Oesophagectomy by any
operative approach is a
high-risk surgical procedure.
Minimally invasive
oesophagectomy (MIO) may
enhance recovery and
quality of life compared
with open techniques.
MIO is a long procedure
that usually demands a
period of one lung
ventilation.
Passage of carbon dioxide
from the abdomen into the
chest (capnothorax and
capnomediastinum) is a
specific complication of
MIO.
43
Key points
Patient preparation
Stage
Surgical steps
Stage 1: thoracoscopy
Stage 2: laparoscopy
Stage 3: cervical
anastomosis
Anaesthetic challenges
There are a number of challenges common to all methods of MIO:
44
Prolonged surgery
Prolonged period of one lung ventilation
Difficulties with assessment of fluid status and potential pulmonary complications of fluid overload
Complications of extra-peritoneal CO2 (capnothorax, capnomediastinum, and surgical emphysema)
Effective postoperative analgesia.
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 10 Number 2 2010
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 10 Number 2 2010
45
MIO requires a period of one lung ventilation during the mobilization of the thoracic oesophagus. Inadequately managed lung isolation has been shown to contribute to mortality and morbidity
after oesophagectomy.7 Mobilization of the oesophagus is usually
performed in the right chest either with the patient positioned in
the left decubitus or prone position. As surgery is performed thoracoscopically, retraction of an inadequately collapsed lung or lobe
is more difficult than in open surgery and this is important when
considering the method used to achieve lung isolation. Lung isolation can be provided through a left or right double lumen tube or
a single lumen tracheal tube and bronchial blocker. Right-sided
double-lumen tubes are perceived to be less reliable than left-sided
tubes, because there is a greater chance of occluding the opening
to the upper lobe of the right bronchus that arises a shorter distance from the carina than on the left. This belief has been challenged recently by a retrospective study that found no difference in
intraoperative hypoxaemia, hypercapnia, and high airway pressures
whether a left- or right-sided tube was placed for one lung ventilation.8 Intubating the bronchus opposite the side of surgery may
reduce the likelihood of intraoperative tube displacement and
because most techniques of MIO involve access to the right chest,
a left-sided double-lumen tube is preferable. If a bronchial blocker
is chosen, this will have to be placed on the right side as the right
lung must be collapsed; however, the blocker cuff may occlude the
opening to the right upper lobe impairing its collapse. Although a
bronchial blocker may sometimes be necessary (e.g. in cases of
difficult intubation), our experience suggests that MIO is probably
best performed using a left-sided double-lumen tube. Whichever
method of lung isolation is selected, a fibreoptic bronchoscope
should be used to check correct positioning both after intubation
and after moving the patient before surgery.9
Acute lung injury is a complication of oesophagectomy. Features
associated with this risk have been identified and include duration of
one lung ventilation and perioperative cardiorespiratory instability,
including periods of hypoxia and high airway pressure.10 Although
the duration of one lung ventilation is mostly determined by surgical
factors, inadequate lung isolation may prolong this time period. It is
essential therefore that anaesthetists are skilled in correctly positioning double-lumen tubes, restrict tidal volume to 56 ml kg21 during
one lung ventilation and use strategies to avoid hypoxia and high
airway pressures. Pressure-controlled ventilation reduces peak
airway pressure during one lung ventilation compared with volumecontrolled ventilation. This strategy may potentially reduce the risk
of barotrauma during mechanical ventilation but is unlikely to result
in improvement in arterial oxygenation.11
Cardiovascular
Respiratory
Renal/metabolic
Gastro-intestinal
Other
chest and into the soft tissues resulting in subcutaneous emphysema around the chest, axilla, and neck. An early indication that
gas is entering these spaces is a rapid increase in end-tidal CO2 as
the gas is exposed to an additional large area of tissue through
which it can be absorbed before returning to the lungs for elimination. If CO2 passes into the chest and is not vented, then capnothorax may develop. In this situation, in addition to an
increasing end-tidal CO2, airway pressures are likely to increase
and lung compression leading to oxygen desaturation may occur. If
significant capnothorax or capnomediastinum occurs, then cardiac
output may be compromised. Management of this complication
depends, to some extent, on the severity of the problem. By simply
reducing the set pressure at which the capnoperitoneum is maintained, the extra-abdominal escape of gas may significantly be
reduced without impairing the operative view of the surgeon. If
extra-abdominal CO2 results in significant cardiac or respiratory
compromise, then the capnoperitoneum should be evacuated at
once. It may be necessary in some cases to consider insertion of
an intercostal drain to vent gas that passes into the left chest. If significant surgical emphysema has developed during the procedure,
then a reservoir of CO2 will have built up and patients should not
be extubated until normocarbia has been achieved.
Although capnothorax is more likely to occur in the setting of
MIO, barotrauma as a complication of high ventilatory pressures
during laparoscopy may result in pneumomediastinum, pneumothorax, and subcutaneous air emphysema. This constitutes a
greater risk than extra-peritoneal CO2 because of the reduced solubility of air.
46
Complications
Complications are common after either open or minimally invasive
oesophagectomy and are shown in Table 3.
Some complications may be more common in MIO than with
open oesophagectomy though the reasons remain unclear. The risk
of thermal injury to the airway by diathermy may be higher during
thoracoscopic mobilization of the oesophagus compared with open
Table 3 Complications of oesophagectomy
Complications
Pulmonary failure: acute lung injury/adult respiratory distress syndrome/infection
Chylothorax
Gastric conduit failure: anastomotic leak/gastric tube necrosis
Airway injury
Recurrent laryngeal nerve injury
Atrial fibrillation
Thrombo-embolic complications
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 10 Number 2 2010
Physiological
system
5. Schilling T, Kozian A, Kretzschmar M et al. Effects of propofol and desflurane anaesthesia on the alveolar response to one-lung ventilation. Br J
Anaesth 2007; 99: 36875
6. De Conno E, Steurer MP, Wittlinger M et al. Anaesthetic-induced
improvement of the inflammatory response to one-lung anaesthesia.
Anesthesiology 2009; 110: 131626
7. Sherry K. Management of patients undergoing oesophagectomy. In: Gray
AJG, Hoile RW, Ingram GS, Sherry KM, eds. The Report of the National
Confidential Enquiry into Perioperative Deaths 1996/1997. London:
NCEPOD, 1998; 5761
8. Ehrenfeld JM, Walsh JL, Sandberg WS. Right and left-sided Mallinckrodt
double-lumen tubes have identical clinical performance. Anesth Analg
2008; 106: 184752
9. Pennefather SH, Russel GN. Placement of double lumen tubestime to
shed light on an old problem. Br J Anaesth 2000; 84: 30810
Conclusions
References
13. Davies RG, Myles PS, Graham JM. A comparison of the analgesic
efficacy and side-effects of paravertebral vs. epidural blockade for
thoracotomya systematic review and meta-analysis of randomized
trials. Br J Anaesth 2006; 96: 41826
14. Michelet P, Roch A, DJourno X et al. Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy. Acta Anaesthesiol Scand
2007; 51: 58794
15. Al-Rawi OY, Pennefather SH, Page RD, Dave I, Russell GN. The effect
of thoracic epidural bupivacaine and an intravenous adrenaline infusion
on gastric tube blood flow during esophagectomy. Anesth Analg 2008;
106: 884 7
Continuing Education in Anaesthesia, Critical Care & Pain j Volume 10 Number 2 2010
47