REVIEW

CURRENT
OPINION Current trends in anesthesia for esophagectomy
Chris Durkin, Travis Schisler, and Jens Lohser

Purpose of review
Despite marked improvements in perioperative outcomes, esophagectomy continues to be a high-risk
operation associated with significant morbidity and mortality. Progress has been achieved through
evidence-based changes in preoperative optimization, intraoperative ventilation strategies, fluid therapy,
and analgesia, as well as expedited postoperative recovery pathways. This review will summarize the
recent literature on the anesthetic management of patients undergoing esophageal resection.
Recent findings
The current focus in publications on the perioperative management of esophagectomy patients can be
summarized under the umbrella term of enhanced recovery pathways, focusing on ventilation, fluid
therapy, analgesia and minimally invasive surgical approaches. Lung protective ventilation reduces
pulmonary complications in cases requiring one-lung ventilation. Excess fluid administration contributes
to morbidity while restrictive approaches have not resulted in an increased risk of acute kidney injury.
Goal-directed fluid therapy remains intuitive yet unproven. Thoracic epidural analgesia reduces the
systemic inflammatory response, pulmonary complications, and enhances postoperative pain control, yet if
causing perioperative hypotension may be associated with anastomotic leaks. Enhanced recovery
pathways have facilitated low morbidity and mortality rates in a high-risk population but are heterogeneous
and limited by a weak evidence base. Minimally invasive surgical approaches are increasingly popular
and appear to have at least equivalent outcomes to open procedures.
Summary
The morbidity and mortality after esophagectomy remains high despite significant improvements over the
last decades. Enhanced recovery pathways appear promising in achieving further marginal gains but at
present are lacking large scale, prospective, multicenter evidence.
Keywords
enhanced recovery, esophagectomy, fluid restriction, lung protective ventilation, thoracic anesthesia

INTRODUCTION supportive evidence for current changes in the peri-

Esophagectomy is a fundamental component of operative management of esophagectomy patients
curative therapy for esophageal cancer yet remains including ventilator management, fluid adminis-
one of the highest risk thoracic surgical procedures tration, methods of analgesia, enhanced recovery
with a perioperative mortality around 3% and major protocols, and minimally invasive surgical tech-
morbidity occurring in up to 30% of cases according niques. Where appropriate we include our manage-
to a recent Society of Thoracic Surgeons analysis [1]. ment biases for illustration.
Many of the predictors of major perioperative mor-
bidity and mortality are nonmodifiable, such as age
greater than 65, BMI greater than 35 kg/m2, prior Department of Anesthesiology, Pharmacology and Therapeutics, Univer-
smoking history, squamous cell histology, and sity of British Columbia, Vancouver General Hospital, Vancouver, British
three-hole surgical approach [1]. However, poten- Columbia, V5Z-1M9, Canada
tially modifiable patient comorbidities, such as Correspondence to Dr Jens Lohser, MD, MSc, FRCPC, Clinical Associ-
current smoking history, congestive heart failure ate Professor, Department of Anesthesia, University of British Columbia,
Department of Anesthesiology, Pharmacology and Therapeutics, Univer-
and impaired functional status (Zubrod score greater sity of British Columbia, Vancouver General Hospital, JPP2 Room 2449,
than 1) may adversely affect perioperative outcomes 899 West 12th Avenue, Vancouver, British Columbia, V5Z-1M9, Canada.
[2,3]. Low morbidity and mortality rates are achiev- Tel: +1 604 875 4304; fax: +1 604 875 5209;
able even in high-risk populations using patient e-mail: [email protected]
centered and evidence-based surgical and anesthetic Curr Opin Anesthesiol 2017, 30:30–35
&
pathways [4 ]. In this article, we aim to highlight DOI:10.1097/ACO.0000000000000409

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 Current trends in anesthesia for esophagectomy Durkin et al.

during the intrathoracic portion of esophagectomy

KEY POINTS procedures. A PEEP level of 5 cm H2O has been
 Postoperative pulmonary complications remain shown to be insufficient during OLV in patients
prevalent and are associated with major morbidity. with relatively normal lung function. Individualized
PEEP levels should therefore be determined by opti-
 Low tidal volume ventilation, optimization of PEEP, and mizing dynamic lung compliance in a PEEP titration
routine recruitment maneuvers decrease
study after a recruitment maneuver [10]. When OLV
pulmonary complications.
is not required, as during transhiatal esophagectomy
 Fluid therapy aims to avoid overhydration, a known (the predominant approach at our center) open lung
contributor of pulmonary complications and ventilation is similarly advisable. We routinely pro-
anastomotic leaks. vide pressure control ventilation with tidal volumes
 Thoracic epidural analgesia reduces the systemic of 4–6 ml/kg, PEEP of at least 5–10 cm H2O, while
inflammatory response, decreases pulmonary limiting peak pressures to less than 30 cm H2O.
complications and improves postoperative pain control.

 Patient centered evidence-based surgical and anesthetic PERIOPERATIVE FLUID THERAPY

pathways facilitate a low mortality rate.
The association between excess perioperative fluid
and respiratory complications after esophagectomy
is well established [11]. Hypoalbuminemia, which is
MECHANICAL VENTILATION not uncommon in esophagectomy patients, appears
On the basis of recent national surgical quality to increase the risk of respiratory complications with
improvement program (NSQIP) data, postoperative
&
excess fluid administration [12 ] yet also increases
pulmonary complications (PPCs) remain a frequent the risk of acute kidney injury (AKI) [13].
occurrence after esophagectomy with a prevalence Instead of the classical debate comparing restric-
of 20–40% [5]. The most devastating PPC is acute tive versus liberal fluid therapy in anesthesia [14] the
respiratory distress syndrome (ARDS), which con- focus is increasingly on achieving rational fluid
tinues to occur in up to 25% of esophagectomy replacement aimed at optimizing tissue perfusion
cases, with associated markedly increased morbidity [3]. What constitutes appropriate fluid volumes
and prolonged intensive care and hospital length of remains to be elucidated as we balance the risk of
&
stay [6 ]. Early postoperative ARDS may be related hypovolemia resulting in gastric conduit and organ
to lung injury precipitated by intraoperative mech- ischemia with the risk of hypervolemia that precipi-
&
anical ventilation [6 ], particularly when one-lung tates acute lung injury and anastomotic leaks.
ventilation (OLV) is required. Protective OLV has Higher fluid balances have clearly been associated
previously been shown to reduce inflammatory with increased PPC after esophagectomy [11].
mediator release after esophagectomy and should Intraoperative fluid volumes that were previously
be a routine component of any intraoperative venti- shown to be associated with PPC are in excess of
&
lation strategy [7 ]. These findings have recently 4 liters (corresponding to >10 ml/kg/h) [11].
been reconfirmed in a randomized control trial Similarly, higher fluid balances on postoperative
comparing protective ventilation with tidal vol- day one (3815  1353 vs. 2669  1315 ml) were
umes of 5 ml/kg and positive end-expiratory pres- shown to be independent risk factors for PPC in a
sure (PEEP) during three-hole minimally invasive
&
high volume center [15 ]. Interestingly, higher fluid
esophagectomy (MIE), which demonstrated reduced balances on postoperative day 2 did not show a
PPC when compared with tidal volumes of 8 ml/kg similar correlation, demonstrating that patients
and no PEEP [8]. Additionally, continuous positive are particularly vulnerable in the early perioperative
airway pressure (CPAP) applied to the collapsed lung period. This vulnerability may be partially explained
during the intrathoracic stage of esophagectomy by the realization that the endothelial glycocalyx,
reduces local inflammation in the collapsed lung which is essential for vascular homeostasis, sustains
and may therefore be a strategy to further reduce significant perioperative damage in response to
lung injury [9]. A recent review summarizing the hypervolemia, inflammation and oxidative stress,
mechanisms of postoperative lung injury after justifying a more cautious approach to fluid admin-
OLV highlights the benefits of low tidal volumes
&
istration [7 ,16].
(4–5 ml/kg predicted body weight) and optimiz- With the realization that AKI is prevalent and
ation of PEEP (5–10 cm H2O) with routine recruit- morbid concern has been expressed about the
&
ment maneuvers [7 ]. These strategies, coupled with traditional fluid restriction in thoracic surgery
mild permissive hypercapnea and attempts to limit [17]. However, recent retrospective evidence of
the duration of OLV, should now be routine for OLV
&
1442 patients from Ahn et al. [18 ] demonstrated

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Thoracic anesthesia

that crystalloid restriction to <3 ml/kg/h was not providing epidural anesthesia; however, they are
associated with AKI after thoracic surgery (including almost universally required during the first post-
esophagectomy). A subgroup analysis of patients operative night. We frequently use low-dose norepi-
receiving <2 ml/kg/h similarly showed no increased nephrine infusions during the first postoperative
AKI risk but was inadequately powered for firm night to counteract the epidural sympathectomy
&
conclusions [18 ]. These data are confirmation of and avoid overhydration.
earlier studies that showed AKI to be independent of
intraoperative crystalloid volume [17,19] and con-
trasts with the prevailing notion that liberal fluid PERIOPERATIVE ANALGESIA
therapy is protective of renal injury. Fluid ‘restric- Thoracic epidural analgesia (TEA) remains the main-
tion’ as it has classically been practiced in thoracic stay of perioperative analgesia for esophagectomy.
surgery is a misnomer and does appear to achieve In three-hole esophagectomy, TEA reduces the inci-
normovolemia, likely because we now realize that dence of pneumonia from 32 to 19.7% and anasto-
&
there is no ‘third space’ [7 ,16]. Determining which motic leak from 23 to 14% at the expense of lower
patients require more volume remains a challenge as average blood pressure and longer urinary catheter-
&
commonly proposed mechanisms of stroke volume ization [27 ]. In Ivor Lewis esophagectomy, TEA
variation and pulse pressure variation are not pre- reduces the systemic proinflammatory response
dictive of fluid responsiveness after abdominothora- and provides better postoperative analgesia com-
cic esophagectomy [20] and have not been validated pared with intravenous opioid alone [28]. In
in the open chest setting. Correspondingly, goal- addition, a recent retrospective analysis showed that
&
directed fluid therapy only achieved a level C recom- TEA significantly reduced ICU length of stay [29 ].
mendation in a recent evidence-based guideline for However, prolonged hypotension due to excess
esophagectomy [21]. While intuitively intriguing, epidural bolus doses must be avoided as it has been
the role of noninvasive cardiac output monitors shown to be associated with a higher rate of anas-
in the absence of supportive evidence at present tomotic leaks [30]. Paravertebral analgesia is a viable
is likely limited to optimization at the start of alternative to TEA for the management of the thor-
the operation prior to commencement of the intra- acotomy pain. We are unaware of any head to head
thoracic portion. On the basis of the above, it study comparing the techniques; however, paraver-
appears reasonable to provide maintenance fluids tebral analgesia has proven superior to intravenous
of 2–3 ml/kg/h and replace blood losses with an opioid alone following esophagectomy in terms of
appropriate volume of crystalloid or colloid to analgesia, pulmonary function, and hospital length
achieve a total intraoperative fluid volume of at of stay [31]. The optimal pain management strategy
least 3 ml/kg/h but not exceeding 10 ml/kg/h. for MIE remains to be determined, however, we
continue to utilize TEA in MIE to limit the inflam-
matory response and optimize postoperative pain
VASOPRESSORS control and respiratory mechanics in light of the
The major cause of anastomotic leaks and strictures multitude of port sites and the significant dissection
following esophagectomy is conduit ischemia required in the abdominal and thoracic cavities.
[22,23]. Hypotension related to general or neuraxial
anesthesia, intraoperative blood loss or vasocon-
striction because of endogenous and exogenous ENHANCED RECOVERY PROTOCOLS
catecholamines are some of the potential nonsur- Fast track or enhanced recovery after surgery (ERAS)
gical causes of ischemia [23,24]. Hypotension protocols aim to optimize and standardize care in
secondary to thoracic epidural local anesthetic order to minimize postoperative complications and
administration reduces gastric tube blood supply; accelerate discharge from hospital [21]. They have
this however, is rapidly correctible with a phenyl- proven useful in a variety of surgical populations
ephrine infusion [25]. Norepinephrine may be a and several recent publications have evaluated
& &
better option than phenylephrine as it more readily their effectiveness after esophagectomy [4 ,21,32 ,
&
preserves cardiac output and produces less splanch- 33–35]. Porteous et al. [4 ] described the evolution
nic vasoconstriction and a lesser rise in lactate con- of a standardized perioperative pathway including
&
centrations than phenylephrine [26 ]. The notion of preoperative optimization, TEA, lung protective
completely avoiding vasopressor boluses or infu- ventilation, restrictive fluid strategies, and early
sions is unfounded and likely results in excess postoperative extubation. Utilizing their multidisci-
fluid administration, a known precipitant of mor- plinary evidence-based perioperative approach in a
bidity [11]. In our experience, vasopressor infusions high-volume center they were able to achieve a low
are rarely necessary intraoperatively even when 30-day mortality rate of 0.5% despite a steady rise in

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 Current trends in anesthesia for esophagectomy Durkin et al.

comorbid conditions in their esophagectomy the Ivor Lewis approach with multiple port sites
&
cohort [4 ]. It is likely that marginal gains in in the thoracic and abdominal cavities and the
each category combine to produce measurable patient in the left lateral position [2]. MIE is
improvements in postoperative complications, akin comparable in terms of postoperative mortality
to the recently published reduction in perioperative and major morbidity, hospital readmission and
&
mortality in a surgical cohort seen in a preoperative 5-year survival [38 ,39–41] but provides improved
anesthetic assessment clinic [36]. Implementing lymph node retrieval, shorter hospital length of stay
formalized enhanced recovery protocols by itself (by 1 day), less ileus, wound infection and allogeneic
&
may not improve outcomes in the absence of transfusion [38 ]. MIE has, therefore, been given a
changes to prevailing clinical care, as demonstrated grade A recommendation in a recent evidence-based
&
by Findlay et al. [37 ] who found no improvement guideline on esophagectomy care [21]. However,
in morbidity, length of stay or mortality in their MIE requires prolonged operating times, and
high-volume center after establishing enhanced is associated with an increased risk of reoperation
recovery protocols around established care patterns. (9.5 vs. 4.4%) and higher rates of empyema,
Evidence-based guidelines have been suggested which may be reflective of a learning curve but
&
for esophagectomy based on limited and hetero- this is unproven [38 ]. Robotic-assisted MIE
&
geneous evidence [21]. Only a small number of does not appear to bestow an advantage [38 ,39].
the grade A recommendations related to anesthetic Randomized comparisons of MIE versus open
care, including preoperative carbohydrate loading approaches are absent but a feasibility study pub-
with a reduced fasting period of 2 h for liquids lished earlier this year may indicate that these data
and 6 h for solids and pre-emptive analgesia with are forthcoming [42]. Until then it will be important
thoracic epidural, NSAIDs and local anesthesia. The to critically evaluate single center and multi-
remainder of the grade A recommendations related institutional databases.
to surgical approach (MIE), early postoperative
feeding and thromboprophylaxis [21].
While not carrying the same level of evidence, CONCLUSION
preoperative optimization of hemoglobin and nutri- Esophagectomy remains integral to curative
tion as well as early postoperative mobilization therapy for esophageal cancer and the surgical
and daily evaluation of appropriate drain, catheter approach while varied across institutions is trend-
and tube removal are important components of an ing towards minimally invasive techniques.
enhanced protocol that have been shown to reduce Despite increased operative times and requiring
length of hospital stay [33]. In a pooled analysis more reoperations MIE tends to reduce overall
of studies on enhanced recovery protocols for length of hospital stay. There are ongoing efforts
&
esophagectomy Markar et al. [32 ] were able to dem- to improve surgical approaches and perioperative
onstrate significant decreases in anastomotic leaks, medical care. Large cohort data demonstrates
PPC and hospital length of stay, however no impact steadily improving outcomes despite a patient
on overall patient mortality. ERAS protocols, there- population that is older, with more comorbidities,
fore, have to cover the full breadth of perioperative a lower functional status and who presents follow-
factors and need to be devised and revised in a ing neoadjuvant chemoradiotherapy. The idea
multidisciplinary fashion by surgeons, anesthesiol- that marginal gains in multiple components of
ogists and other perioperative care providers. There perioperative care while not affecting outcome
is a need for large scale, prospective, multicenter on their own can combine and translate into
trials to establish optimal care pathways. improved patient care is the basis for enhanced
recovery and explains recent improvements.
Despite the progress, still roughly a quarter of
MINIMALLY INVASIVE ESOPHAGECTOMY patients will experience a pulmonary compli-
MIE is being performed with increasing cation, 15% an anastomotic leak and 2% will die
frequency throughout the world since 2007 and is after their esophagectomy, which leaves sufficient
receiving considerable attention in the literature potential for further improvements in the care for
&
[38 ]. MIE combines laparoscopic and thoracoscopic this high risk patient group. Our profession with its
approaches for both esophageal resection and intimate knowledge of preoperative optimization,
reconstruction and was introduced in an attempt fluid and vasopressor management and multimo-
to reduce the morbidity associated with laparotomy dal analgesia may positively influence periopera-
with or without thoracotomy. Multiple approaches tive outcomes by seeking further marginal gains
have been described analogous to the classic open and facilitating the implementation of enhanced
approaches. The most common is a modification of care protocols.

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Thoracic anesthesia

16. Collins SR, Blank RS, Deatherage LS, Dull RO. Special article: the endothelial
Acknowledgements glycocalyx: emerging concepts in pulmonary edema and acute lung injury.
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None. & restriction and hydroxyethyl starch in thoracic surgery. Anesth Analg 2015;
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This retrospective review of 1442 patients undergoing thoracic surgery (including
Conflicts of interest esophagectomy) shows that a restrictive approach to fluid management is un-
related to AKI.
There are no conflicts of interest. 19. Licker M, Cartier V, Robert J, et al. Risk factors of acute kidney injury according to
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34 www.co-anesthesiology.com Volume 30  Number 1  February 2017

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 Current trends in anesthesia for esophagectomy Durkin et al.

38. Sihag S, Kosinski AS, Gaissert HA, et al. Minimally invasive versus open 40. Thirunavukarasu P, Gabriel E, Attwood K, et al. Nationwide analysis of short-
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