Esophagectomy, the surgical removal of part or all of the esophagus, is a complex procedure often performed to treat esophageal cancer or other serious conditions affecting the esophagus. Patients who have undergone esophagectomy in the past present unique challenges and considerations when undergoing anesthesia for subsequent medical procedures 1. Understanding these considerations is crucial for anesthesiologists and healthcare providers to ensure safe perioperative management.
Esophagectomy can result in significant physiological changes that impact anesthesia management. For instance, alterations in anatomy, such as the creation of a gastric conduit or esophagogastric anastomosis, can affect airway management and ventilation strategies during anesthesia induction and maintenance.
Patients who have undergone esophagectomy may also experience impaired pulmonary function due to factors such as reduced lung volumes, decreased compliance, and impaired cough reflexes. These changes require careful monitoring and optimization of respiratory parameters during anesthesia to prevent complications such as atelectasis, pneumonia, or respiratory insufficiency 2.
Cardiovascular considerations are also important, as patients with past esophagectomy may have comorbidities such as cardiovascular disease, arrhythmias, or compromised cardiac function that complicate anesthesia management3. Providers must monitor for signs of anesthesia-induced hypotension or hemodynamic instability to avoid compromising tissue perfusion, particularly in patients with compromised cardiac reserves.
Anesthesia in patients with past esophagectomy requires special attention to gastrointestinal considerations as well. Altered anatomy, a gastric conduit, or a gastric pull-up may predispose patients to an increased risk of aspiration during anesthesia induction or emergence. Several published case studies have documented the risk of aspiration in patients after esophagectomy 4,5. Precautions such as preoperative fasting, rapid sequence induction, and the use of aspiration prophylaxis measures can mitigate this risk.
Furthermore, post-esophagectomy patients are at an increased risk of developing gastrointestinal complications such as reflux esophagitis, anastomotic leaks, or gastric stasis 6. Anesthesia management should aim to minimize factors that exacerbate these complications, such as avoiding excessive intra-abdominal pressure, optimizing fluid balance, and utilizing prokinetic agents to promote gastric emptying.
Selecting appropriate anesthetic techniques and drugs is paramount in patients with a history of esophagectomy. Regional anesthesia techniques, such as neuraxial blocks or regional nerve blocks, may offer advantages in certain cases, providing effective analgesia while minimizing systemic opioid use and its associated side effects, including nausea and vomiting 7.
When administering general anesthesia, anesthetic agents with favorable hemodynamic profiles and minimal respiratory depressant effects are preferred. Inhalational agents and short-acting opioids may be advantageous in maintaining hemodynamic stability and facilitating rapid emergence from anesthesia, particularly in patients with compromised respiratory function 8.
In conclusion, anesthesia management in patients with past esophagectomy requires a thorough understanding of the physiological changes, gastrointestinal considerations, and anesthetic implications associated with the procedure. By using tailored anesthesia strategies, vigilant monitoring, and multidisciplinary collaboration, healthcare providers can optimize perioperative care and enhance outcomes for this unique patient population.
References
1. Esophagectomy & Surgery for Esophageal Cancer | Penn Medicine. Available at: https://www.pennmedicine.org/cancer/types-of-cancer/esophageal-cancer/esophageal-cancer-treatment/surgery-for-esophageal-cancer. (Accessed: 9th May 2024)
2. Veelo, D. P. & Geerts, B. F. Anaesthesia during oesophagectomy. Journal of Thoracic Disease (2017). doi:10.21037/jtd.2017.03.153
3. Hahm, T. S., Lee, J. J., Yang, M. K. & Kim, J. A. Risk factors for an intraoperative arrhythmia during esophagectomy. Yonsei Med. J. (2007). doi:10.3349/ymj.2007.48.3.474
4. De Souza, D. G. & Gaughen, C. L. Aspiration risk after esophagectomy. Anesthesia and Analgesia (2009). doi:10.1213/ANE.0b013e3181b21b2a
5. Jankovic, Z. B., Mikhail, M. S. & Black, D. R. High risk of aspiration and difficult intubation in post- esophagectomy patients [3] (multiple letters). Acta Anaesthesiologica Scandinavica (2000). doi:10.1034/j.1399-6576.2000.440720-5.x
6. Edmondson, J. et al. Understanding Post-Esophagectomy Complications and Their Management: The Early Complications. Journal of Clinical Medicine (2023). doi:10.3390/jcm12247622
7. Hutton, M., Brull, R. & Macfarlane, A. J. R. Regional anaesthesia and outcomes. BJA Education (2018). doi:10.1016/j.bjae.2017.10.002
8. Grubb, T. Anesthesia for patients with respiratory disease and/or airway compromise. Topics in Companion Animal Medicine (2010). doi:10.1053/j.tcam.2010.01.001
