Peri-operative management of the oesphagectomy patient

SummaryCarcinoma of the oesophagus is increasing in incidence in the West and the only current cure is surgical resection. Other treatments (neo-adjuvant chemotherapy and radiotherapy) can render previously unresectable tumours operable but controversy remains as to the overall benefit of these therapies and ongoing trial results are awaited. Approximately 200 oesophagectomies are performed annually in England with a 30-day mortality was between 9.5 and 10.5%.Pre-operative investigations should evaluate cardiorespiratory co-morbidities, particularly with respect to the risks of intra-operative one-lung ventilation, post operative respiratory failure and potential overall outcome. Cardiopulmonary exercise testing and shuttle testing are recent additions to the investigative armamentarium that may augment the accuracy of morbidity and mortality prediction. The size and type of double lumen endotracheal tube can be gauged from assessment of the left main bronchus on the CXR.Intra-operative management includes consideration of positioning and preparation for one-lung ventilation. Careful fluid management and judicious fluid restriction help to limit post operative complications. Analgesia is important and the thoracic epidural or paravertebral blocks are said to be beneficial post operatively.Complications include anastomotic breakdown and cardiovascular complications such as acute coronary syndrome and arrhythmias (most commonly atrial fibrillation) which occur in approximately 15–25% of cases. Chylothorax occurs in 2–3% of cases.It is likely that increasing numbers of patients will present with resectable oesophageal tumours. A systematic approach to pre-assessment, pre-optimisation, intra-operative management and post operative care can bear dividends for patients and anaesthetist alike.