Anesthesia for esophagectomy and other esophageal surgery

INTRODUCTION — This topic will discuss anesthetic management of elective and urgent esophageal surgery, both open and endoscopic. Challenges include increased risks for pulmonary aspiration, possible need for one lung ventilation (OLV), and postoperative pain management.

Anesthetic techniques for esophagoscopy are reviewed separately. (See "Anesthesia for gastrointestinal endoscopy in adults".)

PREANESTHETIC CONSULTATION

Preanesthetic planning — General anesthesia with endotracheal intubation is necessary for most esophageal surgery, with or without supplemental neuraxial or regional block, to protect the airway against pulmonary aspiration and avoid pain during the invasive procedure.

Preanesthetic planning for esophageal surgery includes:

●Determine type of anesthesia to be used – Depending on the procedure being performed and patient comorbidities, various approaches to providing anesthesia may be employed. Monitored anesthesia care (MAC), deep sedation, or general anesthesia (with or without supplemental neuraxial or regional block) may be used.

If general anesthesia is planned, the use (and type) of neuromuscular blockade is procedure-dependent. For example, an esophagogastroduodenoscopy (EGD) for biopsy under MAC does not require neuromuscular blockade, while esophagectomy using a video-assisted thoracoscopic surgery (VATS) approach would require such blockade to ensure that the patient does not move.

●Minimize aspiration risk – Many patients with esophageal disease have a high risk of pulmonary aspiration due to esophageal mass, stricture, or achalasia. Furthermore, patients who have had previous esophagectomy are at risk for aspiration [1]. Precautions for a full stomach are always employed since esophageal contents are unknown and retained ingested food may be present even after an appropriate fasting period. Length of NPO period may be lengthened beyond ASA guidelines by the surgeon based on patient history and planned procedure. If general anesthesia is planned, these precautions include a rapid sequence induction and intubation (RSII) technique with a head-elevated position. In some cases, an awake endotracheal intubation may be necessary.

●Assess the airway – Assess the airway and prepare for management of a difficult airway when necessary. (See "Management of the difficult airway for general anesthesia in adults".)

●Determine whether one lung ventilation (OLV) will be necessary – If thoracoscopy or open thoracotomy is planned, plan placement of a device to achieve OLV. An assortment of specialized endotracheal tubes (ETTs) should be prepared, including a variety of double-lumen endotracheal tubes (DLTs) and bronchial blockers. (See "Lung isolation techniques".)

●Assess comorbidities – Chronic obstructive pulmonary disease (COPD) or liver disease are common in patients with esophageal cancer, who often have a history of smoking and/or excessive alcohol consumption. Specific considerations for preoperative and anesthetic management of patients with severe COPD or hepatic insufficiency are discussed separately. (See "Anesthesia for patients with chronic obstructive pulmonary disease" and "Anesthesia for the patient with liver disease".)

Iron deficiency anemia, malnutrition, or frailty are also common, particularly in older adults with esophageal or other types of cancer [2]. Management is discussed in separate topics. (See "Perioperative blood management: Strategies to minimize transfusions", section on 'Treatment of anemia' and "Anesthesia for the older adult", section on 'Assessment for frailty'.)

●Plan postoperative pain control – Thoracic epidural analgesia (TEA), paravertebral block (PVB), erector spinae block (ESB), or another regional anesthetic technique may be necessary to achieve optimal postoperative pain control after esophageal surgery performed via thoracotomy, thoracoscopy, laparotomy, laparoscopy, or combinations of these procedures. (See 'Planning postoperative analgesia' below.)

Although data are scant, most studies of rehabilitation programs emphasizing exercise training before esophageal cancer surgery have noted no improvements in functional capacity [3-5]; however, nutrition prehabilitation may be useful [6]. (See "Overview of prehabilitation for surgical patients".)

Medications

●Chronic medications – Patients chronically treated for gastroesophageal reflux disease (GERD) are instructed to take their usual medications on the evening before and the morning of surgery (eg, proton pump inhibitors, histamine-2 receptor antagonists, calcium carbonate).

●Premedication – Some clinicians administer oral sodium citrate 30 mL approximately 10 minutes prior to induction of general anesthesia to patients with symptomatic GERD, except for those with a significant esophageal obstruction (eg, tumor or stricture) or an esophageal motility disorder. (See "Rapid sequence induction and intubation (RSII) for anesthesia", section on 'Gastroesophageal reflux disease (GERD)'.)

Typically, a benzodiazepine is administered in the preoperative holding area to reduce anxiety (eg, midazolam 1 to 2 mg).

ESOPHAGECTOMY

Surgical considerations — Elective partial or complete esophagectomy may be performed for esophageal cancer resection, resection of an area of severe achalasia, or resection of an area of esophageal tear not amenable to corrective stent placement [7-9]. Approaches include thoracotomy or laparotomy incisions (eg, transthoracic, transabdominal, supracervical, or transhiatal approaches), as well as minimally invasive approaches (eg, video-assisted thoracoscopic surgery [VATS], abdominal laparoscopy). In some cases, combinations of these approaches are necessary, resulting in multiple incision sites and a prolonged duration of surgery. (See "Surgical management of resectable esophageal and esophagogastric junction cancers", section on 'Operative procedures'.)

All patients undergoing esophagectomy require a nasogastric tube, which is secured in place with sutures at the end of the procedure. It is critically important to maintain nasogastric decompression and facilitate avoidance of intrathoracic anastomotic leakage after esophagectomy.

General anesthesia is necessary for any of the surgical approaches for esophagectomy. When feasible, general anesthesia is combined with continuous neuraxial analgesia (eg, thoracic epidural analgesia [TEA] or paravertebral block [PVB]) for thoracotomy or laparotomy approaches, or other suitable regional anesthetic techniques when minimally invasive approaches is planned. (See 'Planning postoperative analgesia' below.)

Planning postoperative analgesia

Open thoracotomy or laparotomy — For postoperative pain control after open thoracotomy or upper abdominal laparotomy, we prefer neuraxial techniques (ie, TEA or PVB).

Neuraxial analgesia (TEA or PVB)

●Benefits of neuraxial analgesia – Similar to other procedures requiring thoracotomy or laparotomy, thoracic epidural analgesia (TEA) or paravertebral block (PVB) analgesia is generally superior to systemic opioid analgesia with regard to pain scores, requirements for supplemental opioid analgesia, and pulmonary complications [10-18]. (See "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management' and "Approach to the management of acute pain in adults", section on 'Regional anesthesia techniques'.)

Specific benefits of TEA after esophagectomy include lower incidences of postoperative pneumonia and esophageal anastomotic leak, shorter length of stay in the intensive care unit, and better postoperative analgesia, compared with use of intravenous (IV) opioids alone [19-21]. Use of neuraxial analgesia (with or without general anesthesia) has also been associated with improved overall survival after cancer surgery, compared with general anesthesia alone [22]. (See 'Use of neuraxial agents' below and "Anesthesia and cancer recurrence", section on 'Regional anesthesia/analgesia'.)

●Neuraxial analgesia techniques – If a neuraxial analgesic technique is planned (eg, TEA or PVB), the neuraxial catheter may be inserted in the immediate preoperative period, or in the operating room shortly before induction of general anesthesia.

Epidural catheter placement is typically at T5-6 for a planned thoracotomy, or at T7-8 if both abdominal and thoracic incisions are planned for the esophagectomy. If thoracic epidural catheter placement is technically difficult due to anatomical considerations, a lumbar epidural technique is a reasonable alternative and may be as effective for postoperative analgesia, particularly if an opioid is added to the continuous epidural infusion [23]. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia' and "Anesthesia for open abdominal aortic surgery", section on 'Epidural anesthesia'.)

PVB techniques are an alternative to epidural analgesia, may be placed before surgery, and are as effective in controlling acute pain in patients undergoing thoracotomy [14,24]. The choice between TEA and PVB is primarily based on clinician expertise and preference. Meta-analyses suggest that continuous PVB analgesia provides comparable pain relief with fewer adverse side effects than TEA after thoracotomy [10,12-14]. Even single-dose bilateral PVB provides superior analgesia, better maintenance of pulmonary function, and shorter length of hospital stay after esophagectomy, compared with IV opioids [24]. Although many clinicians are not familiar with the PVB technique, direct surgical placement into the open chest is an option in open thoracotomy cases. (See "Anesthesia for open pulmonary resection", section on 'Paravertebral block'.)

The erector spinae plane (ESP) block (figure 1) is a common alternative regional analgesic technique for thoracotomy incisions. (See "Erector spinae plane block procedure guide".)

Alternative analgesic strategies — In some cases, neither TEA nor PVB is appropriate for pain control after thoracotomy or upper abdominal laparotomy (eg, coagulopathy, anatomical considerations, patient refusal), or attempts to place a TEA, PVB, or ESP catheter may be unsuccessful. Similar to other procedures requiring thoracotomy, other alternative regional analgesic techniques for thoracotomy incisions include the serratus anterior plane (image 1), pectoral nerve (image 1), or intercostal nerve blocks (figure 2 and figure 3 and image 2) [25-28]. Block duration may be prolonged by a continuous catheter technique [28]. (See "Thoracic nerve block techniques", section on 'Fascial plane blocks of the chest wall'.)

For large abdominal incisions, the transversus abdominis plane (TAP) block is another alternative. In one retrospective study in patients undergoing esophagectomy, bilateral TAP blocks were as effective as epidural analgesia in controlling postoperative pain, and were associated with a lower incidence of postoperative hypotension, less crystalloid volume requirement, and shorter stay in the intensive care unit compared with epidural analgesia [29]. Supplemental IV opioid via patient-controlled analgesia (PCA) may be necessary for adequate control of pain [10,11,30-32]. Another alternative is intrathecal opioid analgesia [33-35]. (See "Transversus abdominis plane (TAP) blocks procedure guide" and "Anesthesia for open abdominal aortic surgery", section on 'Alternative and supplemental techniques for postoperative analgesia'.)

Thoracoscopy — ESP block, TEA, or PVB neuraxial analgesia may be employed for larger thoracoscopy incisions, particularly if combined with other incisions (eg, open laparotomy or laparoscopy incisions) or if opioids or adjunct agents should be minimized or avoided. (See 'Open thoracotomy or laparotomy' above and 'Laparoscopy' below.)

However, performing an ESP, TEA or PVB block may be unnecessary for some patients undergoing a VATS procedure. A regional analgesic block may provide adequate pain control (eg, intercostal, serratus anterior, or erector spinae block), typically combined with IV and/or oral nonsteroidal antiinflammatory agents (NSAIDs) to prevent and treat ipsilateral shoulder pain, and/or supplemental IV or oral opioid. A 2014 systematic review noted that no one regional analgesic block was superior for postoperative analgesia after VATS surgery [36]. Similarly, a 2018 survey noted variability in clinician preferences for specific regional anesthetic techniques to manage postoperative pain after VATS surgery [37]. (See "Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection", section on 'Postoperative pain management'.)

Laparoscopy — The degree of pain after laparoscopic surgery is usually low to moderate. TEA or PVB neuraxial analgesia may be used if laparoscopy is combined with open thoracotomy or thoracoscopy incisions, as described above.

An alternative is use of TAP blocks placed either preoperatively or prior to emergence (figure 4). In some patients with a small laparoscopy incision, local infiltration combined with supplemental IV opioid and nonopioid analgesics may provide adequate analgesia. (See "Anesthesia for laparoscopic and abdominal robotic surgery in adults", section on 'Postoperative pain management' and "Transversus abdominis plane (TAP) blocks procedure guide".)

Monitoring — Monitoring always includes standard American Society of Anesthesiologists (ASA) monitors (table 1). Both leads II and V₅ on the electrocardiogram (ECG) are continuously monitored to detect ischemia or cardiac arrhythmias, which commonly occur during manipulation of mediastinal structures during esophagectomy [38].

Invasive monitoring for patients undergoing intrathoracic or intra-abdominal esophagectomy includes an intra-arterial catheter, which is used to continuously monitor systemic blood pressure and to detect hemodynamic responses to fluid challenges. (See 'Fluid management' below.)

Since large-bore IV access is necessary during esophagectomy, a central venous catheter (CVC) may be inserted, although placement of two large-bore peripheral IV catheters to provide adequate intravascular access is an alternative. A CVC may also be used for vasoactive drug infusions. If present, the central venous pressure (CVP) is typically monitored to provide supplemental data, although it is a poor predictor of intravascular volume status and fluid responsiveness. A bladder catheter is inserted to intermittently monitor urine output. (See "Intraoperative fluid management", section on 'Traditional static parameters'.)

Induction and airway management

Rapid sequence induction and intubation — A standard rapid sequence induction and intubation (RSII) technique is usually employed in patients undergoing esophageal surgery since most are at risk for pulmonary aspiration due to gastrointestinal pathology. It is particularly important to elevate the head of the bed to a 30-degree angle to minimize risk of regurgitation. (See "Rapid sequence induction and intubation (RSII) for anesthesia".)

If an RSII technique is planned, the anesthesiologist should consider the predicted difficulty of endotracheal intubation, then select appropriate equipment and techniques for initial airway management and one lung ventilation (OLV). Selections are based on the patient's anatomy and esophageal pathology, as well as the anesthesiologist's expertise with available equipment. (See "Management of the difficult airway for general anesthesia in adults".)

Considerations for one lung ventilation — If open thoracotomy or thoracoscopy is planned, airway control typically involves placement of a device to achieve OLV. A double-lumen endotracheal tube (DLT) may be inserted as part of the induction and endotracheal intubation sequence, or a single-lumen endotracheal tube (ETT) may be initially inserted with subsequent placement of a bronchial blocker. Final positioning of these devices is accomplished with fiberoptic bronchoscopic guidance. (See "Lung isolation techniques".)

In some cases, both intrathoracic and intra-abdominal procedures may be necessary to complete the esophagectomy. Typically, the intrathoracic portion of the procedure is completed first, then OLV is converted to two lung ventilation (see "One lung ventilation: General principles", section on 'Re-expanding the nonventilated lung'). A protective ventilatory strategy is employed for both OLV and two lung ventilation. (See "One lung ventilation: General principles", section on 'Lung-protective ventilation strategies' and "One lung ventilation: General principles", section on 'Efficacy of lung protective strategies'.)

For a transhiatal approach, airway management is with a single lumen ETT that is ≥8.0 mm internal diameter. It may be necessary to place a bronchial blocker or advance the tube into a mainstem bronchus for OLV if perforation of the trachea or bronchus occurs during the procedure, or if the surgical plan changes and a thoracic approach is unexpectedly needed.

Maintenance

Intravenous versus inhalation agents — Either total intravenous anesthesia (TIVA), an inhalation-based anesthetic technique, or a technique that combines anesthetic agents administered by both routes may be employed to maintain general anesthesia in patients undergoing esophagectomy. (See "Maintenance of general anesthesia: Overview".)

Clinical studies (mostly retrospective) comparing intravenous and inhalation agents have reported mixed results, with some showing beneficial effects with a TIVA technique, while others show no effect compared with inhalation anesthetics. Although some studies in patients with esophageal or other types of cancer noted that inhalation-based anesthesia was associated with lower overall and recurrence-free survival in patients with esophageal cancer compared with propofol-based TIVA [39,40], the clinical significance of these mechanisms is uncertain. (See "Anesthesia and cancer recurrence", section on 'Intravenous versus inhalation anesthetics'.)

Use of inhalation techniques compared with TIVA for general anesthesia has no clinically significant effect on oxygenation during OLV. (See "One lung ventilation: General principles", section on 'Anesthetic choice'.)

Use of muscle relaxants — The need for administration of a neuromuscular blocking agent (NMBA) is procedure-specific. For example, the surgeon may not need muscle relaxation during repair of a Zenker's diverticulum. However, administration of an NMBA is often employed to improve surgical exposure and avoid any movement of the diaphragm during complex procedures, such as esophageal fundoplication, esophagectomy, or repair of an esophagorespiratory fistula. (See "Maintenance of general anesthesia: Overview", section on 'Neuromuscular blocking agents'.)

Use of neuraxial agents — Use of neuraxial analgesia (with or without general anesthesia) has been associated with improved overall survival after cancer surgery compared with general anesthesia alone [22]. However, study results are inconsistent, and may not be relevant for esophageal cancer [41,42]. Theoretically, neuraxial analgesia may reduce surgical stress, opioid consumption, immunosuppression, angiogenesis, and eventual cancer recurrence [43,44]. (See "Anesthesia and cancer recurrence", section on 'Regional anesthesia/analgesia'.)

If an epidural catheter is in place, a local anesthetic agent and/or opioid may be administered to supplement general anesthesia, allowing dose reduction of IV opioids and other intraoperative anesthetic agents. Timing of initiation of neuraxial infusion is based on the planned surgical procedure and hemodynamic stability of the patient.

Thoracic epidural infusion solutions are institution-specific, and typically include a local anesthetic solution (eg, bupivacaine 0.1 to 0.25% or ropivacaine 0.2%) mixed with an opioid (eg, fentanyl 2 to 5 mcg/mL or hydromorphone 10 to 20 mcg/mL); some institutions include epinephrine 2 mcg/mL to enhance analgesia. An example is a mixture of 0.1% bupivacaine, fentanyl 5 mcg/mL, and epinephrine 2 mcg/mL administered as a continuous infusion at a rate of 5 to 8 mL/hour. This relatively low concentration of local anesthetic and slow infusion rate minimizes the risk of hypotension. Paravertebral infusion solutions include only a local anesthetic agent (eg, ropivacaine 0.2%) administered at 4 to 6 mL/hour. (See 'Neuraxial analgesia (TEA or PVB)' above and "Anesthesia for open abdominal aortic surgery", section on 'Intraoperative use'.)

It is important to avoid hypotension with bolus dosing of local anesthetic agents, since hypotensive episodes may be associated with anastomotic leaks, particularly if vasopressor agents are necessary to increase blood pressure [45]. If large fluid shifts are expected and/or if the surgeon requests avoidance of vasopressors (eg, during esophagectomy or open gastrectomy), administration of local anesthetic agents via an epidural or paravertebral neuraxial catheter are typically delayed until most of the procedure has been completed. (See 'Hemodynamic management' below.)

Fluid management — Maintenance of hemodynamic stability depends primarily on maintenance of normovolemia. We employ dynamic indices to detect hemodynamic responses to a fluid challenge (typically 250 mL), using the intra-arterial waveform tracing to visually estimate or manually calculate measurements of systolic pressure variations or pulse pressure variation (figure 5 and figure 6).

Commercially available devices that provide automated calculation of pulse pressure variation, systolic pressure variations, or stroke volume variation may be employed if available (table 2). However, these parameters are not generally useful during open thoracotomy or thoracoscopy [46,47]. (See "Intraoperative fluid management", section on 'Dynamic parameters to assess volume responsiveness' and "Intraoperative fluid management", section on 'Major invasive surgery'.)

In general, the need to replace fluid losses during a prolonged surgical procedure is balanced with the need to avoid fluid overload [48]. Studies suggest that the optimal crystalloid-to-blood loss volume ratio is approximately 1.5:1.0 (or colloid-to-blood loss ratio of approximately 1:1), until a trigger for red blood cell transfusion is reached. (See "Intraoperative transfusion and administration of clotting factors", section on 'When to transfuse' and "Intraoperative transfusion and administration of clotting factors", section on 'Red blood cells'.)

Similar to open pulmonary resection, fluid overload may cause damage to the endothelial glycocalyx and impair vascular homeostasis [8]. Administration of large fluid volumes (ie, ≥4 L) is associated with postoperative pulmonary complications [49,50]. (See "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)

Hemodynamic management — Hypotension may occur during esophagectomy due to compression of the inferior vena cava during manipulation of the esophagus (which decreases venous return), compression of other major intrathoracic blood vessels or the heart, or arrhythmias. If hypotension persists despite maintenance of normovolemia, administration of a vasopressor/inotropic agent is likely to restore systemic arterial blood pressure and blood flow to the esophageal anastomotic site [51]. We prefer norepinephrine administered by infusion to provide vasopressor and inotropic support, since this may produce less splanchnic vasoconstriction and better preservation of cardiac output than vasopressor agents such as phenylephrine (table 3) [52].

Some surgeons request avoidance of any vasopressor during esophagectomy due to concerns regarding potential vasoconstriction of blood vessels supplying the esophageal anastomosis, leading to tissue ischemia, necrosis, and anastomotic leak [53]. However, untreated intraoperative hypotension is also associated with postoperative anastomotic leaks due to poor tissue perfusion at the anastomotic site [45]. Furthermore, complete avoidance of vasopressors may lead to excessive fluid administration during attempts to treat hypotension. Close communication between the anesthesiologist and surgeon is necessary to balance risks of hypotension against risks of vasopressor use and risks of fluid overload.

Emergence and extubation — At the conclusion of the procedure, the ETT is removed when level of wakefulness, ventilation, oxygenation, and muscle strength are adequate so the patient is able to protect his airway with minimal risk of pulmonary aspiration. Early extubation in the operating room is preferable if standard extubation criteria are met. (See "Extubation following anesthesia".)

In some patients, extubation is not possible and a period of postoperative controlled mechanical ventilation is necessary. If a DLT is used to achieve OLV, it is usually changed to a single-lumen ETT before leaving the operating room at the end of the procedure. A tube exchanger is employed to maintain access to the airway during this exchange, as described separately. (See "Management of the difficult airway for general anesthesia in adults", section on 'Extubation'.)

Other aspects of emergence from general anesthesia are discussed separately. (See "Emergence from general anesthesia".)

Enhanced recovery protocols — Enhanced recovery after surgery (ERAS) protocols are used for esophagectomy patients in several centers. Similar to protocols for other types of thoracic surgery, these typically incorporate aspects of preoperative, intraoperative, and postoperative care to reduce morbidity [54-56]. Feasibility studies specific for esophageal surgery are encouraging, but not definitive [8,57,58]. (See "Partial gastrectomy and gastrointestinal reconstruction", section on 'Postoperative care and follow-up'.)

Complications

Intraoperative complications

●Perioperative arrhythmias, particularly atrial fibrillation, are common during esophagectomy; one study noted an intraoperative incidence of 17 percent, with 37 percent of these patients experiencing postoperative reoccurrence [38]. Management of intraoperative arrhythmias is reviewed separately. (See "Arrhythmias during anesthesia".)

●Hypotensive episodes are common and are treated as described above. (See 'Hemodynamic management' above.)

●Trauma to major blood vessels or intrathoracic or intra-abdominal organs with consequent hemorrhage may occur during trocar placement for thoracoscopy or laparoscopy procedures. (See "Intraoperative management of shock in adults", section on 'Hemorrhagic or nonhemorrhagic etiology'.)

●Transdiaphragmatic surgical disruption of the pleural layer surrounding the lung may cause a pneumothorax or tension pneumothorax [59]. Prompt recognition and, in some cases, immediate treatment with surgical placement of a chest tube may be life-saving. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Tension pneumothorax'.)

Early postoperative complications

●Risk of pulmonary complications is increased if pain is inadequately treated, particularly after open thoracotomy or laparotomy, due to factors such as splinting of the injured hemithorax, diaphragmatic dysfunction, impaired pulmonary mechanics, and inadequate coughing and mucociliary clearance. These processes result in development of atelectasis, shunting, and hypoxemia, which may lead to postoperative respiratory failure, pneumonia, or sepsis. Preventive measures include adequate postoperative pain management, lung expansion maneuvers, and pulmonary toilet. (See "Complications of esophageal resection", section on 'Pulmonary' and "Strategies to reduce postoperative pulmonary complications in adults", section on 'Pain control'.)

In some cases, high-flow nasal cannula (HFNC) oxygen therapy or noninvasive positive pressure ventilation may be considered to treat hypoxemia in the early postoperative period, and may avoid the need for reintubation while the underlying cause of respiratory distress is treated [60,61]. Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BPAP) is typically avoided after esophagectomy. (See "Respiratory problems in the post-anesthesia care unit (PACU)".)

●Rarely, recurrent laryngeal nerve injury with vocal cord paralysis may occur, presenting as hoarseness, dyspnea, and/or aspiration pneumonia in the immediate postoperative period. (See "Complications of esophageal resection", section on 'Recurrent laryngeal nerve injury' and "Overview of the management of postoperative pulmonary complications".)

●Rarely, emergency reoperation is necessary after esophageal resection or repair due to bleeding or rupture of an esophageal anastomosis [62]. (See 'Repair of esophageal perforation or rupture' below.)

OTHER ESOPHAGEAL SURGICAL PROCEDURES — Although many aspects of management of other esophageal surgical procedures are similar to those for esophagectomy (see 'Esophagectomy' above), unique aspects for specific procedures are noted below.

Repair of esophageal perforation or rupture — Esophageal perforation is treated as a surgical emergency because the patient would otherwise rapidly develop mediastinitis and sepsis.

Esophageal perforation may be caused by the following:

●Upper gastrointestinal endoscopy procedures, most commonly when therapeutic interventions are performed and/or in patients with esophageal diverticula. Another in-hospital cause is surgical trauma during an intrathoracic procedure. (See "Surgical management of esophageal perforation".)

●Vomiting against an esophageal constriction (ie, Boerhaave syndrome) may cause esophageal rupture. (See "Boerhaave syndrome: Effort rupture of the esophagus".)

●As a result of thoracic trauma (eg, a motor vehicle accident).

Patients presenting with a recent esophageal rupture due to these known causes may be hemodynamically stable initially but may quickly become unstable as leakage of esophageal contents into the mediastinum causes septic shock. (See "Intraoperative management of shock in adults", section on 'Septic shock'.)

Initial management in the emergency department and/or the operating room depends upon whether the patient is hemodynamically stable and whether coexisting traumatic injuries to other mediastinal structures are causing hemorrhagic shock. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Intraoperative management of shock in adults", section on 'Hypovolemic shock management'.)

Advanced cardiovascular system monitoring is employed to manage resuscitation in a patient with either septic shock due to mediastinal leakage of esophageal contents or hemorrhagic shock due to traumatic injuries. An intra-arterial catheter and central venous catheter (CVC) are inserted if not already present, ideally before anesthetic induction. However, insertion should not unduly delay emergency surgical intervention. Insertion of two large-bore peripheral intravenous (IV) catheters (eg, 16 G or larger) is an alternative strategy that allows rapid administration of fluids, blood transfusions, and vasoactive agents during initial resuscitation and major surgery. (See "Intraoperative management of shock in adults", section on 'Intraoperative monitoring'.)

Induction with a rapid sequence induction and intubation (RSII) technique is necessary for these emergency procedures. Typically one lung ventilation (OLV) is required for esophageal repair via a left or right thoracotomy. (See 'Induction and airway management' above.)

Occasionally, laparotomy and a transdiaphragmatic approach may be selected as an alternative approach. Additional surgical procedures are often required for repair of coexisting intrathoracic or intra-abdominal injuries.

Repair of tracheoesophageal fistula — A tracheoesophageal fistula (TEF) is a patent connection between the respiratory and upper gastrointestinal tract. For palliation of a TEF, an occlusive tracheal stent (silicone or self-expanding metallic) may be deployed via flexible or rigid bronchoscopy, and may be combined with an esophageal "kissing stent" placed via esophagoscopy.

The anesthesia for the esophageal portion of the kissing stent can be accomplished with deep sedation. In general, the tracheal stent is performed first, to avoid the complication of inadvertent tracheal occlusion during placement of the esophageal stent for tracheoesophageal fistula repair. For open repair, a transverse low "collar" incision is typically employed, and this incision may be extended via a partial sternotomy if necessary. For open repair of a distally located TEF, a right thoracotomy may be selected.

General anesthesia is typically necessary for either stent occlusion or open repair of a TEF. Considerations for anesthetic management, including preoperative preparation, maintenance of anesthesia, airway management during the surgical intervention, and emergence with extubation are described in a separate topic. (See "Anesthesia for endotracheal stenting or repair of tracheoesophageal fistula", section on 'Open repair or stent occlusion of tracheoesophageal fistula'.)

Procedures for gastroesophageal reflux disease — Patients with gastroesophageal reflux disease (GERD) typically complain of regurgitation symptoms when lying supine, and are at increased risk for perioperative pulmonary aspiration. Also, edema of the laryngeal opening caused by chronic regurgitation of acidic fluid is common, and may cause difficulties with endotracheal intubation. General anesthesia is necessary whether a laparoscopic or open approach is planned. A RSII technique is necessary to protect the airway. (See "Surgical treatment of gastroesophageal reflux in adults" and "Surgical management of paraesophageal hernia".)

Procedures for achalasia — Achalasia is a tonically contracted area of the esophagus resulting in regional constriction.

Precautions against pulmonary aspiration for patients with achalasia include fasting guidelines consisting of a clear-liquid-only diet for 48 to 72 hours prior to surgery and strict nil per os (NPO) status after midnight on the day of surgery [63]. Preoperative holding area medications are commonly not prescribed to these patients if they have a severe stricture, as determined by the surgeon. In the immediate preoperative period, patients are queried regarding adherence to fasting orders as well as any current gastroesophageal reflux disease (GERD) symptoms. Similar to procedures for repair of GERD, general anesthesia with RSII is necessary to protect the airway against aspiration.

Surgical approaches include interventions performed via esophagoscopy and/or a laparoscopic approach to esophageal myotomy. Occasionally, open laparotomy is employed for resection of a constricted section of the esophagus. (See 'Esophagectomy' above and "Surgical myotomy for achalasia".)

Procedures for esophageal diverticuli — An esophageal diverticulum is an outpouching of the esophageal wall that may accumulate ingested material. Patients may have esophageal narrowing with regurgitation and chronic pulmonary aspiration. Location of the diverticulum may be in the pharyngoesophageal (Zenker's diverticulum), midesophageal, or epiphrenic region of the esophagus [64]. Repair of a diverticulum in any esophageal location requires general anesthesia with RSII to protect the airway against pulmonary aspiration.

For repair of a Zenker's diverticulum, a parasternal or supraclavicular approach is employed; neither approach requires one lung ventilation (OLV). For more distal diverticuli, surgical approaches include thoracoscopy via a lateral or posterior incision, or open thoracotomy with a period of OLV. Another approach is via abdominal laparotomy, which does not require OLV.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gastrointestinal perforation" and "Society guideline links: Esophageal strictures, foreign bodies, and caustic injury" and "Society guideline links: Esophagectomy".)

SUMMARY AND RECOMMENDATIONS

●Preanesthetic planning – Planning involves minimizing risk of pulmonary aspiration, preparing for possible difficult airway management, determining whether one lung ventilation (OLV) will be necessary, assessing comorbidities, and planning anesthetic techniques and postoperative pain control. Usual medications for gastroesophageal reflux disease (GERD) are taken on the evening before and the morning of surgery. (See 'Preanesthetic consultation' above.)

●Esophagectomy – Elective partial or complete esophagectomy may include thoracotomy or laparotomy incisions and/or minimally invasive approaches (eg, video-assisted thoracoscopic surgery [VATS], abdominal laparoscopy). A nasogastric tube is secured in place with sutures at the end of the procedure. (See 'Surgical considerations' above.)

•Induction and airway management – A standard rapid sequence induction and intubation (RSII) technique is usually employed. If open thoracotomy or thoracoscopy is planned, a device to achieve OLV is inserted. (See 'Induction and airway management' above.)

•Choice of anesthetic agents – Either total intravenous anesthesia (TIVA), inhalation-based anesthesia, or agents administered by both routes may be employed. (See 'Intravenous versus inhalation agents' above and 'Use of neuraxial agents' above.)

•Planning postoperative analgesia

-Open thoracotomy or upper abdominal laparotomy – We prefer neuraxial techniques (ie, thoracic epidural analgesia [TEA] or paravertebral block [PVB]) or erector spinae plane block (figure 1). Alternative regional analgesic techniques include serratus anterior plane (image 1), pectoral nerve (image 1), or intercostal nerve blocks (figure 2 and figure 3 and image 2) for thoracotomy. For laparotomy, transversus abdominis plane (TAP) block (figure 4), or intrathecal opioid analgesia is typically employed. (See 'Open thoracotomy or laparotomy' above.)

-Thoracoscopy – A regional analgesic block may be used (eg, intercostal, serratus anterior, or erector spinae block), typically combined with IV and/or oral nonsteroidal antiinflammatory agents (NSAIDs) and/or IV or oral opioid. (See 'Thoracoscopy' above.)

-Laparoscopy – For selected cases, local infiltration combined with supplemental IV opioid and nonopioid analgesics may be adequate. (See 'Laparoscopy' above.)

•Monitoring – An intra-arterial catheter is inserted to continuously monitor systemic blood pressure and detect hemodynamic responses to fluid challenges. Since large-bore IV access is necessary during esophagectomy, a central venous catheter (CVC) may be inserted, but two large-bore peripheral IV catheters are a reasonable alternative. (See 'Monitoring' above.)

•Fluid management – We maintain normovolemia by using dynamic indices to detect hemodynamic responses to fluid challenges (typically 250 mL). We typically use the intra-arterial waveform tracing to determine systolic pressure variations or pulse pressure variation (figure 5 and figure 6). We avoid fluid overload since administration of large fluid volumes (ie, ≥4 L) is associated with postoperative pulmonary complications. (See 'Fluid management' above.)

•Hemodynamic management – Hypotension may occur due to compression of the inferior vena cava during manipulation of the esophagus with decreased venous return, compression of other intrathoracic blood vessels or the heart, or arrhythmias. If hypotension persists despite maintenance of normovolemia, we administer a vasopressor/inotropic agent, typically an infusion of norepinephrine (table 3). (See 'Hemodynamic management' above.)

•Extubation – Most patients are extubated at the conclusion of the procedure. (See 'Emergence and extubation' above.)

●Other esophageal surgical procedures

•Emergency repair of esophageal perforation or rupture – An intra-arterial catheter and CVC are inserted since hemodynamic instability may rapidly develop. RSII is necessary. If esophageal repair occurs via a left or right thoracotomy, then OLV will be required. (See 'Repair of esophageal perforation or rupture' above.)

•Repair of tracheoesophageal fistulae (TEF) – Anesthetic management of TEF is discussed separately. (See "Anesthesia for endotracheal stenting or repair of tracheoesophageal fistula", section on 'Open repair or stent occlusion of tracheoesophageal fistula'.)

•Procedures for GERD – RSII is typically employed. However, edema of the laryngeal opening caused by chronic regurgitation of acidic fluid may cause difficulties with endotracheal intubation. (See 'Procedures for gastroesophageal reflux disease' above.)

•Procedures for achalasia – Fastidious precautions against pulmonary aspiration include fasting guidelines with clear-liquid-only diet for 48 to 72 hours before surgery, strict nil per os (NPO) status after midnight on the day of surgery, and RSII. The procedure may be performed via esophagoscopy, a laparoscopic approach, or open laparotomy. (See 'Procedures for achalasia' above.)

•Procedures for esophageal diverticuli – RSII is necessary due to increased risk for regurgitation and chronic pulmonary aspiration.

-Repair of Zenker's diverticulum - Parasternal or supraclavicular approach is employed; neither requires OLV.

-More distal diverticuli - Approaches include thoracoscopy via a lateral or posterior incision, or open thoracotomy with a period of OLV. If the approach is via abdominal laparotomy, OLV is not required. (See 'Procedures for esophageal diverticuli' above.)

●Complications – Intraoperative complications include arrhythmias (particularly atrial fibrillation), trauma to major blood vessels or organs during trocar placement for thoracoscopy or laparoscopy, pneumothorax, or recurrent laryngeal nerve injury. Postoperative pulmonary complications are common. Emergency reoperation is rare (eg, rupture of an esophageal anastomosis or bleeding). (See 'Complications' above.)