Oesophagectomy - Dr Stephanie Phillips - Sydney Adventist Hospital

Upper Gastrointestinal Seminar-2012 

Anaesthesia for Oesophagectomy 

Dr Stephanie Phillips BMed, DA, FRCA, FANZCA 

Specialist Anaesthetist, Sydney Adventist Hospital 

Senior Lecturer, Sydney Medical School


Levels of evidence 

2


› Anaesthetic Preparation 

› Intra-operative anaesthetic management 

› Postoperative management 

› Risks 

3


Anaesthetic Preparation 

Preadmission Clinic 

› RN 

› Anaesthetist 

› Physiotherapist 

› Case manager 

› Preoperative investigations 

4


Anaesthetic Consultation 

› History 

› Examination 

- Airway 

- Venous access 

- Analgesia 

Information & risk discussion 

Order & review investigations 

Premedication & preparation 

Medications: anti-platelet, B Blockers, statins, ACE inhibitors, 

Premedication: GABA analogues, anxiolytics, DVT prophylaxis, PPI 

Fasting 

5


Intra-operative anaesthetic management 

- Preparation 

- Time out 

- Venous access 

- Lung isolation 

- Positioning 

- Monitoring 

- Temperature 

- Fluids 

- Nasogastric tube 

6


Venous Access 

› Peripheral 

› Central 

- Porta catheter access 

- Percutaneous 

- Subclavian 

- Internal Jugular 

Suture for nasogastric tube 

7


Tracheal Intubation 

positive pressure ventilation 

deflate right lung for surgical access 

› Double lumen tracheal tube or bronchial blocker 

Nasogastric tube 

8

Positioning of the double lumen tracheal tube 


Testing the position of the DLT. 

Bronchoscopic view of DLT 

9


Positioning and patient care 

› Prep for case taking 6 hours 

- Maintain normothermia 

- Infection 

- Bleeding 

- Hypoxia on shivering 

- Abnormal drug metabolism 

- Positioning 

- Laparotomy and right thoracotomy 

- Prevent neuropathy, corneal damage 

- Potential for blood loss 

- IV fluid management 

- Nasogastric low suction 

10


MONITORING 

› SpO 2 

› ECG 

› Intra-arterial blood pressure 

› Central venous pressure 

› Temperature 

› Entropy 

› Neuromuscular function 

› Inspired & expired O 2 & CO 2 , anaesthetic agents 

› Airway pressures & volumes 

› Urine output 

› Blood loss 

11


End of stage 1 

Drain 

Wound catheters 

Jejunostomy 

12


Positioning for Right thoracotomy 

13


One Lung Anaesthesia 

14


Oesophago-gastrectomy 

Pull back ng tube 

Test anastomosis 

15


End of stage 2 

Prepare for extubation: 

General condition (blood loss, 

temp etc) 

2 under water seal pleural drains 

Para-vertebral catheter 

Analgesia-top up epidural 

Reversal 

Extubation- if fails re-intubation 

with a single lumen tracheal tube 

Transfer to ICU 

16


Intensive Care Management 

› Excellent analgesia 

› Physiotherapy- chest and mobilisation 

› Nutrition 

› Avoid DVT 

› Careful haemodynamic management 

- Too much fluid- pulmonary oedema 

- Too little ischaemia of oesophagus 

IPPV? 

17


Excellent Multi-modal Analgesia 

› Epidural Anesthesia 

› Para vertebral 

› Intra-pleural 

› Pre-peritoneal 

› Patient Controlled Intravenous or Epidural 

› Local anaesthetics +low dose opioids 

› Epidural Opioids 

› Paracetamol 

› NSAIDS 

› GABA analogues 

› Tramadol 

18


Thoracic Epidural Analgesia 

Local anaesthetic + opioid 

PCEA + wound infusions 

19

Post operative Complications 

Pulmonary- 

Collapse/consolidation 

Infection 

Oedema 


Surgical: 

Confusion 

Infection: 

DVT 

Haemorrhage 

Anastomotic leak 

Chyle leak 

Wound 

Line 

Urinary catheter 

Pulmonary Embolus 

Malnutrition 

20


Pulmonary Complications -25% 

10-20% ARDS 

50% mortality 

Causes: 

Preop-smoking 

Pulmonary fibrosis 

Intra-operative hypoxia 

One lung ventilation time 

Fluid overload 

Prevention 

Physio 

Fluid Balance 

Mobilisation 

Humidifcation 

21


Anastomotic leak 10-15% 

- Gastric tube ischaemia 

- Hypotension 

• Epidural 

• Vasoconstrictors 

- Surgical tension 

22


Cardiovascular 

- AMI (24% in thoracotomy) 

- Dysrhythmias-60% 

23


RISK 

› Patient- 

- Co-morbidities 

- Body habitus 

- Nutritional status 

- Immunological status 

› Anaesthetic 

› Surgery 

24

RISK-Very common 1 in 2 -10 

Anaesthesia for oesophagectomy 

1:2 -heads or tails 

- Pain- severe after major surgery. 

- Sore throat 1in 2 after intubation, more with double lumen tube & ng 

1:4 

-Cognitive dysfunction at 1 week 

1:6 -rolling a 6 on a dice 

-backache 

25


RISK-Common 1 in 10- 99 

1:10- 3 balls in Lotto 

Thrombophlebitis 

Cognitive dysfunction at 3 months (>60) 

1:20- 2 pairs in poker 

All oral trauma after intubation more with DLT 

1:35 rolling a double 6 

Accidental puncture of carotid artery on jugular cannulation 

26


RISK-Moderately common 1 in 100-999 

1:100-dying of any cause in the next year! 

Permanent cognitive dysfunction (>60) 

Permanent damage from arterial cannulation 

1:200 

Arterial puncture of subclavian artery 

Perioperative death at 1 month- all patients 

1:500– flush in poker 

Awareness 

27


RISK-Less common 1:1000-9999 

1:1000 Corneal abrasion 

Neuropathy 

1:1500 Local anaesthetic toxicity 

1:2000 Permanent neuropathy after epidural 

1:3000 Painful awareness 

1:5000 Epidural abscess (spontaneous epidural abscess 1:10000) 

Death related to anaesthesia ASA3-4 

28


RISK-rare 1:10,000 – 99 999 (accidental death at home 1:11,000) 

1:10,000 

Anaphylaxis 

Systemic LA toxicity 

1:100,000 

Paraplegia due to epidural 

Death related to anaesthesia-ASA 1-2 

royal straight flush 

1:10,000,000 Lightening strike 

29

Morbidity & Mortality 


›In hospital mortality-5% (cardiac


Level 4 evidence: expert opinion 

‘X’- an unknown quantity 

“spurt”- a drip under pressure 

31

Oesophagectomy - Dr Stephanie Phillips - Sydney Adventist Hospital

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