2. Anatomy of Esophagus
23 to 25 cm
Begins at the level of C6 (cricopharynx)
Pierces the diaphragm atT10.
It is divided into 3 parts:
• Cervical- Neck
• Thoracic- Posterior mediastinum
• Abdominal- Sub diaphragmatic
3. Anatomy of Esophagus
The esophagus has 4 anatomic constrictions.
The first is at the junction with the pharynx
(pharyngeoesophageal junction).
The second is at the crossing with the aortic arch
The third is at the crossing of left main bronchus.
The fourth is at the junction with the stomach.
4. Anatomy of Esophagus
Histology-
Mucosa: nonkeratinized stratified squamous epithelium
Submucosa: esophageal glands and papillae
Muscularis propia: striated muscle on the upper third, smooth and striated muscles in the middle third, smooth
muscle in the lower third
Adventitia: fibroareolar adventitia
Upper third Middle third Lower third
Artery supply Inf. Thyroid artery thoracic aorta Left gastric artery
Venous drainage Inf. thyroid vein Azygos vein Left gastric vein(portal vein)
Lymphatic drainage Deep cervical nodes Sup.& inf.
mediastinal
nodes
Celiac lymph nodes
Nerve supply The sympathetic fibers from the sympathetic trunks.
The parasympathetic supply comes form the vagus nerves.
5. Globocan 2020
Esophageal cancer is the Eight most common
cancer in the world.
It is the 7th most common cancer in men and the
13th most common cancer in women.
There were more than 600,000 new cases of
oesophageal cancer in 2020
It is also the sixth leading cause of death from
cancer worldwide.
More than 80% of cases and deaths from the
cancer occur in developing and less developed
countries
About 90% of the esophageal carcinoma in the
residents of Asia, Africa, and Eastern European
countries is SCC
overall 5 years survival rate- 20%
7. Types of Carcinoma Esophagus (ICD-C 15)
1.According to Site-upper Esophagus-20 %/ middle- most common 50 %/ Lower 30-40%
2. According to histopathology- SCC/Adenocarcinoma/Neuroendocrine
tumor/Lymphoma/sarcoma
Distant metastasis- Liver was the most common metastatic site in the patients of esophageal
cancer and followed by lung, bone and brain.
Esophageal cancer is a disease of advanced age, peak in the seventh and eighth decades of life.
Stage 5-Year Relative Survival Rate
Localized 46%
Regional 26%
Distant 5%
All stages combined 20%
8. Risk factors for Carcinoma Esophagus (C 15)
1. Smoking
2. Alcohol
3. Tobacco chewing
4. History of Mediastinal radiation
10. TNM Staging 8th edition American Joint Committee on Cancer (AJCC) Cancer Staging
11. Treatment for carcinoma Esophagus
1. Recommended treatment is primarily decided by stage, tumor location, and patients’ medical
fitness.
2. T1-2, N0 superficial esophageal cancer - surgery without induction treatment.
3. T3-4a tumors or nodal disease - induction chemoradiation followed by surgical resection is
the optimal treatment.
4. T4b (unresectable) tumors - Definitive chemoradiation is the preferred treatment for patients
with and occasionally can facilitate surgical resection in selected cases.
5. For patients with stage I-III disease who receive surgical treatment, 5-year survival is
28%, compared to 10% for those treated medically
12. Surgery for Carcinoma Esophagus
1.Transhiatal approach
2.Ivor Lewis esophagectomy
3.TTE (The McKeown (or three-incision) esophagectomy
3.MIE-VATS assisted
4.Robot-assisted minimal invasie esophagectomy or (RAMIE)
14. Ivor Lewis
Esophagectomy
Drawings illustrate transthoracic esophagectomy with a laparotomy and a right thoracotomy (Ivor Lewis procedure). In A, an upper abdominal
incision (arrowhead) and a posterolateral thoracotomy (arrow) are made. In B, the esophagus and its adjacent structures are dissected en bloc.
Lymph node dissection is also performed. Arrows indicate resection lines. In C and D, an anastomosis is created between the remaining esophagus
and the gastric tube. Straight arrow indicates the pyloromyotomy, curved arrow indicates the intrathoracic (C) and cervical (D) anastomosis sites,
arrowhead indicates the original cardioesophageal junction.
16. Esophagus is a difficult surgery because…
1.Difficult assess
2. Its lack of serosal coat (parietal peritoneum)
3. It surrounded by structures where infection is especially dangerous and rapid
Post- op 30-day mortality rate as high as 4%
17. Risk factors for increase Morbidity & Mortality
PAT I E N T R E L AT E D
Advance Age
Comorbidities-COPD/ CVD/ Hepatic/Renal
Obesity
Poor Performance status
Poor nutritional status, weight loss
Smoking/Alcohol
Pre-existing abnormal PFT
NACT- Cisplatin, 5FU, Paclitaxel
S U R G E RY R E L AT E D
Duration of OLV
Duration of surgery
Prescence of hypoxemia
Anastomotic dehiscence
Hemodynamic Instability
Experience of Surgeons
18. Preoperative screening and optimisation
Malnutrition-80% patients
1. Optimization of poor nutritional status- weight loss
An overweight patient will have a higher chance of wound infections while an underweight patient has increase
mortality.
2. Particular attention should be given to signs and symptoms of esophageal obstruction, GERD, and silent
aspiration.
Symptoms of obstruction, particularly dysphagia and odynophagia, may lead to reduced oral intake and
malnutrition.
Symptoms of severe GERD with aspiration may include water brash (hypersalivation in response to reflux),
coughing when supine, globus sensation (feeling of lump in throat), laryngitis, and asthma-type symptoms
Screening
Weight loss 10–15% in the previous 6 months
Body mass index 18.5 kg/m2
Serum albumin 3.0 g/l
19. Nutrition screening &Assessment tools
PG-SGA Score
NRS-2002 (Nutritional Risk Screening 2002)
MUST (The Malnutrition Universal Screening Tool.)
Nutrition screening tools
European Society for Clinical Nutrition and Metabolism (ESPEN) recommends: the
Nutritional Risk Screening 2002 (NRS-2002) for the inpatient setting and
Malnutrition Universal Screening Tool (MUST) for the ambulatory setting.
Nutritional Supplementation before operation is indicated where patients fail to take
75% of their goal calories and tube feeding is indicated for patients with deficiencies
of 50% or more
20.
21.
22. Role of CPET in Esophagectomy
2019
the following CPET values are
proposed as predictive of
significant postoperative
complications in esophagectomy.
AT less than 10.1 mL/kg/min
VO2max less than 800
mL/min/m2
Relationship between preoperative CPET variables and
post-esophagectomy complications were determined and
found that discriminatory ability of CPET for determining
high-risk patients was poor in patients undergoing an
esophagectomy.
CPET may only carry an adjunct role to clinical
decision-making.
23. Morbidity & Mortality predictors
POSSUM , P-POSSUM and O-POSSUM (The Physiological and Operative Severity Score for the Enumeration of Mortality and
Morbidity)
24. Morbidity & Mortality
predictors
Assess Respiratory Risk in Surgical
Patients in Catalonia (ARISCAT) score
was developed to provide a predictive
index for the development of
postoperative pulmonary complications
(PPCs).
The score has recently been adopted
as a standard by the European Society
of Anesthesiologists/European Society
of Intensive Care Medicine joint task
force on perioperative outcome
measures.
Most esophagectomy patients will fall into
the calculated ARISCAT high-risk
category.
26. Postoperative Pulmonary complication
Pulmonary damage can be caused by retraction of the collapsed lung during surgery
and by reinsufflation at the end of surgery following resection of the tumor.
Smokers Fluid overload
COPD Inflammatory mediators-Damage to lung lymphatic
& Endothelium
Silent aspiration OLV
GERD RLN Palsy-inadequate cough, aspiration
Malnutrition-↓immunity
27. Preventation of Post-operative Pulmonary
complications
The risk of developing respiratory complications can be minimized by-
1. Adequate analgesia
2. Reversal of muscular block
3. Normothermia, and haemodynamic stability.
4. Extubation at the end of surgery.
5. Post-op Chest physiotherapy
6. Early mobilization
7. Earlier removal of chest drains
28. How to decrease ARDS
1.Lung Protective Ventilation Strategy
2.Judicious fluid management
3. Decrease inflammatory markers
Pulmonary damage can be caused by retraction of the collapsed lung during surgery and by
reinsufflation at the end of surgery following resection of the tumor. In addition, both volutrauma
and atelectrauma should be avoided, and adoption of the principles of the ARDS Net trial is
advocated.
If it occurs, ARDS should prompt consideration of an occult pathology, such as an
unrecognized anastomotic leak or sepsis.
29. high level of positive end-expiratory pressure (12 cm H2O) with
recruitment manoeuvres (higher PEEP group) or a low level of
pressure (≤2 cm H2O) without recruitment manoeuvres (lower PEEP
group).
Interpretation
A strategy with a high level of positive end-expiratory
pressure and recruitment manoeuvres during open
abdominal surgery does not protect against postoperative
pulmonary complications. An intraoperative protective
ventilation strategy should include a low tidal volume and low
positive end-expiratory pressure, without recruitment
manoeuvres
The use of lung protective
ventilation strategies during one
lung ventilation such as the use
of smaller tidal volumes (5
mL/kg), plateau pressures below
35 cmH2O and the application of
PEEP has been shown to
decrease the inflammatory
response and improve
oxygenation.
30. Conventionally, non-invasive ventilation (NIV) has been considered relative
contra-indicated in patients with recent esophageal surgery , with concerns that high
airway pressure transmitted to the conduit may reduce blood flow or lead to
venous engorgement and compromise the anastomosis.. There is a paucity of
data to indicate whether NIV is safe.
If reintubation is needed, care should be taken to avoid oesophageal intubation as
this may directly traumatize the already vulnerable anastomosis.
31. Perioperative pharmacological therapies to decrease
inflammatory marker
Perioperative pharmacological therapies to modulate the immune response are not used routinely in the UK, Europe, or North
America. However, in Japan and South Korea, this practice is more widespread and briefly discussed here.
Methylprednisolone given at the induction of anaesthesia has been shown to reduce pulmonary inflammation. A meta-
analysis identified seven trials, all from Japan.
There was no difference in death rates, but
respiratory complication, sepsis, liver dysfunction,
cardiovascular dysfunction, and surgical
anastomotic leak were significantly decreased by
methylprednisolone pretreatment
Pre-treatment with Simvastatin in
esophagectomy decrease inflammatory
biomarkers as well as pulmonary
endothelial injury
32. Conclusions:
High-dose preoperative treatment with oral cholecalciferol
reduce changes in postoperative pulmonary vascular
permeability index, but not extravascular lung water index.
Patients in the salbutamol group
had significantly lower lung
water, Lower Plateau airway
pressure and lower lung injury
score at Day 7 than the placebo
group
VINDALOO TRIAL
33. Postoperative surgical
complications - Anastomotic
leak
Incidence-10% to 37%
Account for as much as 35% of perioperative mortality.
Distant anastomosis
Avoiding both tissue oedema and excessive
vasoconstriction are important.
Major leaks present in the first 5 days with severe sepsis
Smaller leaks tend to manifest at around 1 week after
operation with local neck wound infection, collections,
and pleural effusions.
Small leaks are managed by keeping the patient nil by
mouth, giving high protein enteral feed or total parenteral
nutrition, antibiotics, radiologically guided drainage of
collection, chest physiotherapy, and performing serial
contrast studies.
Major leaks require surgical exploration and revision
surgery.
34. Fluid management
Specific concern in esophagectomy
Prolonged surgery,
Third-spacing,
Evaporative losses
Blood loss
Restrictive strategy / Liberal fluid strategy
Moreover, restrictive fluid regimens rely on the use of vasopressors to maintain perfusion pressure.
For patients undergoing esophagectomy, the perfusion of the gastric conduit depends on the right gastro-epiploic artery and
there may be concerns that vasoconstriction can adversely affect flow to the gastric conduit.
The ERAS guidelines recommend ‘optimal’ fluid therapy using balanced crystalloids aiming for
a weight gain of not more than 2 kg/day
Hypotension related
to GA &
Neuraxial
anaesthesia
35. Increase Postoperative mortality & Postoperative
morbidities Heart morbidities ,Pulmonary morbidities
Empyema and wound infection , Anastomotic leakage
,Pulmonary embolism ,Recurrent laryngeal nerve palsy,
Acute gastric dilatation
Cumulative fluid balance from the intraoperative
period to postoperative day 2 was identified as
an independent risk factor for adverse
postoperative outcomes
Body mass index, preoperative serum albumin level,
use of ACEI or ARB, colloid infusion during surgery,
hypertension, peripheral vascular disease, and
thoracoscopy were independent risk factors for
postoperative AKI (18.3%, out of these 70.3%
experienced improved renal function within 48
hours.)
There was no association between
perioperative crystalloid volumes and AKI;
however, exposure to hydroxyethyl starch
exhibited a dose-dependent effect on the
occurrence of AKI, with each 250-mL aliquot
increasing the odds of AKI 1.5-fold
36. Fluid management
SVV is traditionally used during positive pressure ventilation, with a closed chest, and tidal volumes of 8
mL/kg. During thoracotomy the intrathoracic pressure changes that cause a drop in preload, leading to SVV,
are not consistent; therefore SVV, as a sole observation, is of limited value.
Abdominal phase: optimize SV Thoracic phase: maintain SV (avoiding aggressive fluid
loading)
The OPTIMISE trial is the largest single study thus far of GDFT in major GI surgery, and patients having
upper GI. Although statistical outcome showed no difference in postoperative complications between
the 2 groups, there was a trend toward fewer complications in the GDFT intervention group, and there
was also no difference in total amount of fluid given between the 2 groups.
38. Norepinephrine may be a better option than
phenylephrine as it more readily preserves
cardiac output and produces less splanchnic
vasoconstriction and a lesser rise in lactate
concentrations than phenylephrine.
The notion of completely avoiding vasopressor
boluses or infusions is unfounded and likely results
in excess fluid administration, a known precipitant
of morbidity
39. Anastomosis site
examples are Laser Doppler Flowmetry, Near Infrared Spectroscopy (NIRS), Laser Speckle
(Contrast) Imaging (LSI), Fluorescence Imaging (FI), Sidestream Darkfield Microscopy (SDF)
and Optical Coherence Tomography (OCT). Although these techniques are very promising most
are not yet validated and may be difficult to use and interpret at the bedside.
40. ICG fluorescent imaging
Due to allergic reactions to ICG, it can cause anaphylactic shock in rare cases, as well
as cardiovascular reactions, dyspnea, or urticaria . Furthermore, the application of ICG
generates significant costs, while it has a half-life of 3–4 min only.
In addition, it can lead to interference with the measurement of NIRS (cerebral oximetry
& pule oximetry)
Potential modalities to ascertain anastomotic integrity - endoscopy, contrast swallow
and computed tomography (CT) scan with oral contrast. There is inadequate evidence to
justify the routine use of any modality prior to starting oral intake or to establish one
modality as superior
41. Cardiac Arrhythmias
Incidence ranges between 12.6- 40%. (3rd MC complication)
Mechanisms – Surgical injury to the atria and sympathovagal fibers that innervate SA node is an important
mechanism since it may sensitize myocardium to catecholamines and promote arrhythmia.
Bilateral vagal section might cause supraventricular tachycardia (SVT). Thoracic dissection or pericardial
irritation
Postop-Mechanical effects of the gastric tube, sepsis due to anastomotic leak, anaesthesia induced cardiac
depression and as hypo- and hypervolemia.
Risk factors
Old Age, Male gender, Smoking , history of HTN, CHF, PVD and DM ,acid-base imbalance, intraoperative
hypoxia and NACT, raised right atrial pressure after OLV
AF could function as an early warning sign for other complications in the postoperative course and may thus
be of clinical value.
The prophylactic use of use of anti-arrhythmic agents is not indicated since it may mask an early warning
signal for other complications.
42. Cardiac Arrhythmias
Conclusions:
Atrial arrhythmias (AAs) after esophagectomy are
associated with higher perioperative mortality, longer
hospital LOS, and more incidences of complications.
AF generally develops within 3 days after an
esophagectomy. Peak incidence on POD2
Conclusions:
MIE may reduced the incidence of POAF
Moreover, the specific mechanism of MIE
providing this possible advantage needs to
be determined by larger prospective cohort
studies with specific biomarker information
from laboratory tests.
43. Cardiac Arrhythmias
Message
Prophylactic IV amiodarone is
associated with a reduction in AF
following esophagectomy, but does not
reduce length of hospital stay, and is
associated with hypotension, brady-
cardia, and QT interval prolongation
Prevention
Oral beta-blockers should be continued after surgery to
avoid withdrawal
All patients should receive magnesium (i.v.)
perioperatively if the serum magnesium level is low
For increased risk, preventive administration of diltiazem
or amiodarone may be reasonable
AF seldom occurs without complications, so it could
function as an early warning sign for anastomotic leaks
and may, thus, be of clinical importance.
The major adverse effects of β-blockers are
bronchospasm in patients with asthma, particularly if the
asthma is not well controlled
47. Pain Mechanism
Most painful surgical incisions - muscle-sparing approaches Thoracotomy, VATS.
Risk factors- Surgery only
Good pain relief is important for postoperative adequate respiratory function, compliance with
physiotherapy, mobilization, and prevention of complications.
TEA is Gold standard
TEA has also been associated with decreased incidence of anastomotic leakage, possibly
resulting from improved microcirculation in the gastric conduit.
Hypotension with TEA can cause problems such as reduction in splanchnic blood flow and,
therefore, a decrease in oxygen flux at the gastric anastomosis
Chronic pain is also a significant problem after thoracotomy in particular and this can be reduced
by good pain relief in the early postoperative period
The incidence of chronic pain in VATS appears to be similar to open thoracotomy
48. Pain Mechanism
.
This amplified response to pain is called primary sensitization and leads to intensified
pain on breathing or coughing after operation.
Neuropathic pain -after intercostal nerve injury-results in the paradox of reduced
sensory input (from touch, temperature, and pressure) with hypersensitivity
(dysaesthesia, allodynia, hyperalgesia, and hyperpathia).
Nociceptive Somatic Pain
Stimulation- skin incision, rib retraction,
muscle splitting, injury to the parietal pleura,
and chest drain insertion
Somatic Afferents - intercostal nerves to
the ipsilateral dorsal horn of the spinal
cord (T4–T10).
limbic system and somatosensory cortices
via the contralateral anterolateral system of
the spinal cord.
Nociceptive Visceral Pain
Stimulations- injury to the bronchi, visceral
pleura, and pericardium.
Inflammatory mediators, such as
prostaglandins, histamine, bradykinin, and
potassium, are released. These mediators
directly activate nociceptors, enhance their
activity, and reduce the pain threshold
afferents are conveyed by the phrenic and
vagus nerves
49. Pain Mechanism
Referred pain to the ipsilateral shoulder is common after thoracotomy.
This suggests that irritation of the visceral pleura, pericardium or chest drain placed too far into
the apex of the hemithorax, referred to the shoulder by the phrenic nerve, is the most likely
source of this pain.
As the nerves arise from C3 to C5, TEA is ineffective in blocking this pain.
Studies have demonstrated a reduction in shoulder pain by infiltrating local anaesthetic to block
the phrenic nerve at the level of the pericardial fat pad, or alternatively by interscalene block
50. Systematic review by the Procedure
Specific Postoperative Pain
Management working group
PROSPECT recommend that
Ist line of Analgesia-Either TEA with local anaesthetics and an opioid or continuous PVA with
local anaesthetics combined with parenteral paracetamol and an NSAID should be used as first-line
analgesia for thoracotomy.
IInd line of Analgesia-Where these techniques are not possible, or are contraindicated,
intrathecal opioid or intercostal nerve block are recommended, which requires the use of
supplementary systemic analgesia.
51. Chronic post-thoracotomy pain (CPTP)
Incidence- 57% of patients at 3 months and 47% at 6 months.
This incidence has not improved since the 1990s despite improvements in perioperative care.
Pain Character- burning, numbness, or a cutting sensation along the thoracotomy scar.
Frequency- Constant or Intermittent
Stimulating factors- may be evoked by non-painful stimuli such as changes in temperature or
donning clothing.
Management- Ideally begin with a review of any modifiable risk factors. TEA decrease its incidence.
Exclude other D/D such as malignancy recurrence or the effects of radiotherapy and
chemotherapy.
A multidisciplinary personalized plan - pharmacological agents, and nerve blocks Agents used
include NSAIDs, amitriptyline, gabapentin, opioids, and ketamine.
Nonpharmacological treatments used have shown varying success and include behavioural therapies,
transcutaneous electrical nerve stimulation, cryoanalgesia, radiofrequency ablation, and spinal cord
stimulation
The underlying goal of all these agents is to reduce the peripheral and central sensitization that has
52. Minimally Invasive Esophagectomy
A single randomized controlled trial found that
MIE reduced blood loss, respiratory
complications, and length of stay, and
provided a better quality of life at 6 weeks
without any difference in node harvest.
The anesthetic challenges of MIE include
prolonged surgery, often in the prone
position, the subsequent increased
difficulties of lung isolation and OLV in the
prone position, and complications relating
to extraperitoneal CO2 (pneumothorax,
pneumomediastinum, and surgical
emphysema)
53. Regional analgesic techniques such as paravertebral
block and erector spinae plane block are
recommended. Serratus anterior plane block can be
used as a second choice.
Systemic analgesia should include paracetamol and
non-steroidal anti-inflammatory drugs or cyclo-
oxygenase-2-specific inhibitors administered pre-
operatively or intra-operatively and continued
postoperatively.
Intra-operative administration of intravenous
dexmedetomidine is recommended when basic
analgesics cannot be given.
Opioids should be used as rescue analgesics
postoperatively.
Thoracic epidural analgesia is not recommended for
postoperative analgesia.
54. The grade of the recommendation was also assessed at three levels of quality:
strong, moderate or weak. Strong recommendations are made when the desirable
effects of an intervention clearly outweigh the undesirable effects, whereas moderate
or weak recommendations result, either because of low quality of evidence or
because evidence suggests that desirable and undesirable effects are closely
balanced
56. Timing of surgery following neoadjuvant therapy
The recommended interval was 3-4 weeks after the last day of chemotherapy.
Recent meta-analysis reported that a longer interval to surgery (more than the standard 7–8 weeks) did not
increase the pCR rate and was considered to lead to worse long-term outcomes.
57. Palliative concern
Approximately 50% of patients have evidence of distant metastatic disease at the time of
diagnosis .
Best supportive care is often the most appropriate treatment option.
Patients’ performance status should determine whether chemotherapy is added to best
supportive care.
Specific symptoms that often need palliation include dysphagia, pain, and nausea.
Palliative procedures-
feeding tubes in some select patients.
Endoscopic stenting can be used to palliate dysphagia or cases of bleeding from
esophageal tumors.
