Surgery Medical School Crash Course (Unabridged) - 12 A_T_F

This information is about esophagus surgery. It discusses the surgical treatment options for benign esophageal problems and esophageal cancer. Anesthesia management is important for these surgeries, considering the challenges such as pulmonary aspiration syndrome and pain control. Special monitoring and interventions are needed during surgery, including the use of specific endotracheal tubes, regional anesthesia, and pain medications. Fluid balance and blood pressure monitoring are crucial. Complications that can occur during and after surgery are also mentioned. Surgery for esophageal cancers is aimed at curing the cancer, and various diagnostic tests are done before surgery to evaluate the extent of the cancer. Chapter 9, Esophagus Surgery. This section of the course involves surgical treatment of the esophagus. The esophagus can be managed surgically for benign problems of the esophagus, of which there are many, as well as esophageal cancer surgery, which represents a high-risk surgical procedure that carries a high risk of complications, both from the surgery and from the invasive cancer itself. Anesthesia Management of Patients Having Esophageal Surgery. Patients need preoperative evaluation before surgical treatment of their esophagus, even if the procedure is endoscopic. There are special challenges in this type of surgery, such as pulmonary aspiration syndrome, the possibility of only ventilating one lung, and pain after surgery. Most patients with esophageal disease have a high risk for aspiration because of a stricture, a mass in the esophagus, or achalasia, which involves an area of increased tone in a section of the esophagus. Even if the patient has fasted, food may be present in the stomach, so rapid induction of anesthesia is always the norm. The airway needs to be assessed before surgery. In addition, the possibility of one lung ventilation is something to consider, especially if a thoracoscopy is planned during surgery. Special endotracheal tubes are recommended for this procedure. If the patient has a lot of other problems, such as chronic obstructive pulmonary disease, liver problems, smoking history, or other problems that have led to esophageal problems, they need special anesthesia treatment to avoid complications. Patients may have thorascopic epidural anesthesia, a paravertebral block, or other regional anesthesia to achieve pain control without having to have a lot of narcotic pain control. General anesthesia and the possibility of epidural analgesia is necessary to avoid pain as this is a very invasive procedure. Patients need special monitoring with an intra-arterial catheter to constantly monitor the blood pressure. A bladder catheter is included to monitor urine output. A central venous catheter may be necessary to monitor intravascular volume. Prior to intubations, patients will take antacids to treat gastroesophageal reflux disease, GERD, and will take their H2 blockers or proton pump inhibitors or calcium the night before surgery. Oral sodium citrate is given 10 minutes before intubation in patients who have symptomatic GERD. Benzodiazepines are given to control anxiety before surgery. If thoracic epidural anesthesia, TEA, or a paravertebral block, PVB, is necessary, the nuraxial catheter is put in just before surgery and before general anesthesia. This will help for pain after the procedure is completed. A PVB can be placed in the thoracic spine during delivery. These techniques both improve pain and improve survival after cancers are removed. No one knows exactly how this happens. If there is an open thoracotomy to be done or a video-assisted thoracoscopy or VATS, there needs to be a consideration for a single lung ventilation. It requires a double lumen endotracheal tube that will block one side of the bronchus but not the other. Intravenous or inhalational agents may be used to induce anesthesia. They are both effective even if one lung only is ventilated. Inhalation agents have a lower survival potential compared to intravenous anesthetics with cancer patients for unknown reasons. Epidural relaxants may or may not be necessary depending on the procedure being done. If an epidural anesthesia is placed before surgery, an opioid is given to help the anesthetic process. This is continued after surgery to manage pain. Common drugs used include hydromorphone or fentanyl with or without the anesthetic bupivacaine. Vasopressors may be necessary if large volumes of fluids are lost in surgery. After emergency of anesthesia, the ET tube is removed and the patient continues with norexial anesthesia in the spine to control pain after surgery. The pain should be adequately controlled so the patient can avoid lung problems associated with splinting of the lungs. If TEA or PVB can't be used or is unsuccessful, the doctor can do intercostal nerve blocks for patients that have had an open soricotomy. Intravenous opioids also work but are less effective than applying a block. Even anti-inflammatory agents like NSAIDs are used to treat pain secondary to inflammation, but this is less successful than the other agents. Fluid balance in patients requiring an esophagectomy involves replacing fluid losses during the long procedure. First crystalloids are given and then colloids are given. Only packed red blood cells are given if the intraoperative hemoglobin is less than 8 grams per deciliter. Giving too much fluid, however, is associated with complications such as pulmonary edema. There are goal-directed fluid therapy techniques used to keep the fluid balance normal. If the vena cava is compressed in surgery, there may be hypotension that has nothing to do with fluid losses. If there is still hypotension after giving crystalloids, colloids, and blood products, vasopressors can be used to maintain normal tension. Norepinephrine is the drug of choice for this and is better than other vasopressors. If the patient can't be extubated, both arms of the double lumen ET tube are opened to allow both lungs to expand in a prolonged period of mechanical ventilation. If the esophagus is punctured, this is a medical emergency as it can cause rapidly progressive mediastinitis and sepsis. Perforation can happen with a simple endoscopy procedure or during intrathoracic surgery to the esophagus. Proceeding after surgery to the esophagus can also rupture the esophagus if it is in spasm. Leakage of esophageal contents can happen, leading to infection in the mediastinum and eventual sepsis and shock. A tracheoesophageal fistula, or TEF, can happen when a person has a connection between their esophagus and their respiratory airways. It can happen at birth as a birth defect or can happen later in life because of an inflammation of the esophagus, a cancer of the esophagus, or trauma to either the trachea or the esophagus. It needs to be repaired under general anesthesia, usually with an esophageal approach and rarely with a trachea approach. The ET tube must be placed above the fistula to allow for surgery to be safely done with a one-lung intubation procedure. A nasogastric tube is placed to keep the stomach empty during the surgery. Those patients with gastroesophageal reflux, or GERD, will have regurgitation when they lie down and have an increased risk of aspiration during surgery because of swelling of the larynx, because of ongoing regurgitation of acid from the stomach. General anesthesia is always done in these cases so that no acidic contents can get into the lungs and so the airway can be protected. Patients who have achalasia have a chronically constricted area in their esophagus, which increases the risk of pulmonary aspiration. Patients need to be on a clear liquid diet for 48 to 72 hours before surgery and can have nothing to eat after midnight on the day of surgery. They need to be asked about any GERD symptoms before surgery. Surgery to remove the constricted area can be done with a laparoscope or with an open surgery. The airway needs to be protected as aspiration is likely. Esophageal diverticuli are outpouchings of the esophageal wall that collects eaten materials and regurgitates the contents into the lungs. A Zenker's diverticulum is one that is located close to the pharynx. There can be mid esophageal and lower esophageal diverticuli as well. General surgery is necessary with protection of the airway as aspiration is likely. The diverticulum repair can be done in an open surgery or with a thoracoscope. The main complications during surgery are arrhythmias, which can also show up after surgery, hypotensive episodes, disruption of the pleural lining leading to a pneumothorax or a tension pneumothorax. There can also be trauma to the major vessels or to the intra-abdominal organs, particularly in video-assisted surgery or VATS. Surging or rupture of the esophagus may require an urgent re-operation and lung problems are common after surgery. Patients can have bronchospasm, worsening of chronic lung diseases, pulmonary embolism or acute respiratory distress syndrome. Damage to the recurrent laryngeal nerve can show up right after surgery. Surgery to remove esophageal cancers. Most esophageal cancers are localized when they are found. They can be adenocarcinoma or squamous cell cancers. Thirty percent of patients have metastatic disease to the regional lymph nodes when found to have cancer. The goal of doing surgery on these patients is to cure the cancer rather than palliative surgery. More patients have adenocarcinoma than have squamous cell carcinoma. If the cancer can't be cured with surgery, surgery is still done, but patients have radiation therapy or chemotherapy before or after surgery to prolong the patient's life and sometimes to make surgery easier. The two main types of esophageal cancer come from different parts of the esophagus. Squamous cell carcinoma comes from the cells lining the upper part of the esophagus, whereas adenocarcinoma comes from the glandular cells that are near the stomach and lower esophagus. Both types of cancer use the TNM staging approach to identify the severity of the cancer. Tumors that come from the gastroesophageal junction or GEJ or in the top part of the stomach are staged as esophageal cancers, except those that are about two centimeters away from the esophagus. These are technically stomach cancers. Before surgery, the patient is evaluated to see if surgery can cure the cancer. They have a CT scan of the abdomen and chest and an endoscopic biopsy, a diagnostic laparoscopy, a thoracoscopy, and an endoscopic ultrasound of the esophagus. Tumor surgery as a first-line treatment is initially done in patients with stage T1M0M0 cancer and some patients with stage T2M0M0 cancer. All other patients are given neoadjuvant chemotherapy or radiotherapy before surgery to shrink the tumor, making it easier to perform surgery. The tumor is removed en bloc if there is no nodal or metastatic disease. The main site of metastasis is the liver, but colon metastases can be found as well. Patients with metastatic disease are generally given chemotherapy alone as resection will not cure the disease. If they respond well to chemotherapy and don't seem to have any metastases, surgery is offered on a case-by-case basis. Patients with adenocarcinoma have a better chance with surgery than patients with squamous cell carcinoma. Only about 25% of patients will respond so well to chemotherapy that surgery is no longer necessary. The rest will need surgery to reset any remaining surgery. This takes place about four to six weeks after finishing chemotherapy treatments or radiation therapy. Extra indications to having an esophagectomy include being of an advanced age with a limited lifespan anyway, having a comorbid illness that makes surgery a dangerous option, and patients who have unresectable cancer because of metastatic disease. Patients are offered intensive respiratory therapy and rehabilitative treatments before surgery to decrease the chances of respiratory complications. It just takes about seven days of respiratory therapy to increase the odds of not having any lung problems during surgery. There are a variety of surgical options for esophageal cancer patients. Most patients get some kind of radiation or chemotherapy before or after surgical management. Surgery involves complete removal of the pharynx, the thyroid gland, the larynx, and part of the proximal pharynx in those patients who have upper-level esophageal cancer. The operation may take up to three separate phases. Most patients end up with a permanent tracheostomy as they have a lot of the pharyngeal tissue removed. Neck dissections for lymph node involvement are done, and attempts are made at connecting the healthy part of the esophagus to healthy parts of the pharynx so the patient can eat. Grafts from the jejunum can be taken to add to the length of the esophagus, but this is risky with a lot of complications. If a cancer is in the thorax, the entirety of the esophagus must be removed because this is often a multifocal disease, so there will be areas all along the esophagus involved in the cancer. Any esophagus left behind must be evaluated to make sure there is no cancer in those parts of the esophagus. This is a difficult surgery with a lot of complications. There are many approaches that can be done to remove the esophagus. Lymph nodes are removed as well, as they are often involved in cancer. A passageway for food can be done by bringing the stomach upward, or part of the small or large bowel can be grafted to make a makeshift esophagus. This carries a lot of complications, but has a good outcome if it is successful. A transhiatal esophagectomy can be done to get rid of cervical, thoracic, and esophagogastric junction cancers of the esophagus. A midline abdominal and neck incision is made and the thoracic esophagus is pulled through the thorax to be removed at the base of the esophagus. The big disadvantage of doing this is that the incision in the upper chest is very small and a complete thoracic lymphadenectomy can't be done this way. The rate of death is about 1% after surgery, while 14% of patients suffer some type of leakage at the surgical sites. Only 2% get postoperative pneumonia, while things like damage to the recurrent laryngeal nerve, chylothorax, and tracheal lacerations are extremely rare complications. An Ivor Lewis transthoracic esophagectomy is done to remove lower esophageal cancers, but isn't a good option for mid-thoracic cancers. A laparotomy and a right thoracostomy is done, the tumor is removed, and the healthy parts of the esophagus are connected to the stomach. This is an open approach that allows for complete lymph node dissection and removal of suspicious lymph nodes. The main disadvantage of this procedure is that sometimes there isn't enough healthy esophagus to connect to the stomach, and about 20% of patients will regurgitate bile. The leakage rate is high, and the mortality rate is high as well. About 4% of patients die after or during this surgery. Leakage was the main cause of death. A tri-incisional esophagectomy is a combination of the transhiatal approach and transthoracic approach. The entire esophagus is removed, and the upper part of the esophagus is connected to the stomach. The incisions are required to do this surgery to get at the lymph nodes in the cervical, mid-thoracic, and lower thoracic area. The three incisions include a thoracotomy to see if the cancer is resectable, a laparotomy to check for metastatic disease, and a neck incision to connect the upper esophagus to the stomach after the esophageal cancer, and the rest of the esophagus are removed. This approach is preferred because if there is leakage, it can be better managed, and patients have a lesser incidence of reflux after surgery. The mortality rate around the time of surgery is about 4%. Cancers of the esophagogastric junction can be managed by doing an esophagectomy and a partial gastrectomy. A thoracotomy may not be necessary as the lesion is extremely distal. At least 15 nodes need to be removed as part of this surgery. The biggest disadvantage of doing this approach solely by opening the abdomen is that the proximal part of the healthy cancer may be too high to be reached by this method, and cancer may be left behind. Open versus minimally invasive surgery. An esophagectomy can be done laparoscopically. A minimally invasive esophagectomy, or MIE, can be done with a thoracoscope, removing the thoracic esophagus and the lymph nodes in the mediastinum. A laparoscopy needs to be done to remove the intra-abdominal parts of the esophagus, parts of the stomach, and the abdominal lymph nodes. The advantages of doing a minimally invasive surgery is that the incisions are much smaller, the blood loss is less, the hospital stay is shorter, and there are fewer lung complications. The mortality rate, however, isn't changed. Doing a minimally invasive esophagectomy is a feasible option, but this is still experimental and the data isn't out there to prove that it is any better than the other surgical options. Most people, however, who do this type of surgery are successful at removing the esophagus about 90% of the time, while the rest needed to have bigger incisions and more invasive surgery in the end. There isn't any data available comparing this type of surgery with open surgery, so it should only be done by surgeons who are extremely skilled in minimally invasive surgeries. It is debatable as to how many lymph nodes to remove. The general consensus is that as many lymph nodes as possible should be removed, as 75% of patients who have at least 18 nodes removed were still alive after 5 years, while the 5-year survival rate for patients having less than 11 nodes resected was only 55%. Ideally, the cervical, thoracic, and upper abdominal nodes should be removed when they are accessible. The anastomosis of the healthy parts of the esophagus to the stomach can be hand-sewn by the surgeon or stapled together. The rate of leakage is about the same, but surgeons skilled at hand-sewing have a better chance of avoiding leakage versus the stapling technique. Patients having both hand-sewing and stapling statistically do better than either technique alone. It is equally safe to do a cervical anastomosis as it is to do a thoracic anastomosis. Cervical anastomoses tend to leak more, but are more easily managed when they leak. Cervical anastomoses also carry an increased risk of causing injury to the recurrent laryngeal nerve. A pyloroplasty or pyloromyotomy can be done to decrease the risk of aspiration of gastric contents and can decrease the risk of gastric outlet obstruction after pulling the stomach up from the abdomen to the thorax. As the risk of recurrent laryngeal nerve damage is high, it always needs to be identified in the neck before going about the process of removing the entire esophagus. All patients need jejunal feeding tubes placed at the time of the surgery to give them nutritional support while they receive chemotherapy or radiation therapy to the esophagus after surgery. Enteral feedings through the tube are done on the second postoperative day and are advanced to maximal feeding at about the fifth day. Barium swallows are done a week after surgery to look for leaks and patency of the esophagus and food passage, and, if no leak is found, a liquid oral diet commences for a total of two weeks after that. The morbidity and mortality after this very extensive procedure varies according to the volume of these types of surgery. The patient's quality of life is strongly affected right after surgery, and recovery to normal life functioning can take up to three years with ongoing problems with eating, shortness of breath, diarrhea, acid reflux, and tiredness. After five years, 86% of patients report normal physical functioning. Patients who had surgical complications had a worse quality of life even years after surgery, particularly having more shortness of breath, more tiredness, and more restrictions on eating. Key Takeaways Esophageal surgery can be done for benign or cancerous reasons. Some benign reasons for esophageal surgery include achalasia, diverticuli, esophageal strictures, and esophageal fistulas. There are several ways to manage pain after esophageal surgery. Cancers of the esophagus are either squamous cell cancers located in the upper esophagus or adenocarcinomas located in the lower part of the esophagus. There are several surgical approaches for esophageal cancer, including minimally invasive surgeries and surgeries that combine minimally invasive and open techniques. Quiz Number 1. Which surgery technique or option is the least effective in managing pain after esophageal surgery? A. Thoracic Epidural Anesthesia B. Paravertebral Block C. Intercostal Nerve Block D. Intravenous Opioids Answer D. The first three options offer significant relief for patients with esophageal surgery after the procedure, while intravenous opioids are less effective in managing this type of pain. Number 2. Anesthesiologists must carefully and quickly intubate the patient having esophageal surgery for what reason? A. There is an increased risk of tension pneumothorax B. These patients have a high risk of aspiration C. The patient's airway is usually compromised already in esophageal diseases D. The patient usually needs to have only one lung ventilated at a time during this surgery Answer B. Patients with esophageal problems have many reasons why aspiration is at a higher risk during induction of anesthesia and intubation, so a rapid-sequence intubation needs to be done on all of these patients. Number 3. A patient with achalasia needs special preparation before surgery because of a high risk of what complication? A. Tension pneumothorax B. Pulmonary embolism C. Pulmonary aspiration D. Recurrent laryngeal nerve paralysis Answer C. Patients with achalasia have a high pulmonary aspiration risk, so they need a prolonged period of fasting before they have surgery to remove the stricture in the esophagus. Number 4. Why do patients with esophageal cancer need a jejunostomy placed at the time of surgery to remove their cancer? A. They can't eat solid food right away after surgery B. They don't tolerate any oral intake during chemotherapy and radiation after surgery C. The motility of the esophagus is low after this type of surgery D. There is a higher risk of gastroesophageal reflux disease after an esophagectomy Answer B. These patients cannot eat or drink anything orally in the days after surgery because they will be having radiotherapy and chemotherapy directed at their esophagus. Number 5. What best predicts a good 5-year survival after an esophagectomy from esophageal cancer? A. Whether the cancer was an adenocarcinoma or a squamous cell carcinoma B. The location of the cancer in the esophagus C. The number of lymph nodes removed at the time of surgery D. The route in which the surgeon removed the esophagus Answer C. The best predictor of long-term survival after an esophagectomy for esophageal cancer is the number of lymph nodes removed at the time of surgery Number 6. Where would a person most likely develop an adenocarcinoma of the esophagus? A. At the gastroesophageal junction B. At about two-thirds of the way down the esophagus D. In the mid-thoracic area of the esophagus D. In the cervical esophagus Answer A. The most likely place to have an adenocarcinoma of the esophagus is at the gastroesophageal junction Number 7. What is the most common way to treat a cervical squamous cell carcinoma of the esophagus? A. Removing the cancer and connecting the distal esophagus to the pharynx B. Removing the upper esophagus, pharynx, larynx, cervical lymph nodes and thyroid gland C. Removing the larynx and all of the esophagus, connecting the stomach to the pharynx D. Irradiating the cancer and then endoscopically removing the cancerous portion of the esophagus Answer B. The most common treatment of cervical squamous cell carcinoma of the esophagus is to remove the upper esophagus, the pharynx, the larynx, cervical lymph nodes and the thyroid gland Number 8. Why is a total esophagectomy performed for patients with mid-thoracic esophageal cancer? A. Lymph nodes all up and down the esophagus can be involved with cancer B. The patient is always at a higher risk of having a second primary esophageal cancer C. This disease is usually multifocal in nature D. The chance of anastomotic leak is lower if the stomach is attached to the pharynx Answer C. The biggest problem with mid-thoracic esophageal cancer is that it is a multifocal disease so the entire esophagus needs to be removed Number 9. At which connection point is the greatest chance of anastomotic leak in the management of esophageal cancer? A. Cervical anastomosis B. Mid-thoracic anastomosis C. Lower thoracic anastomosis D. Gastroesophageal junction anastomosis Answer A. The greatest chance of leakage in doing an anastomosis of the esophagus after esophageal cancer is at the cervical area Number 10. At which place should the surgeon look first for widely disseminated metastatic esophageal cancer? A. Bone B. Liver C. Colon D. Lung Answer B. Most metastatic disease from esophageal cancer stems from having liver metastases with colon metastases being the second place where anastomosis occur.