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

www.co-anesthesiology.com Volume 30  Number 1  February 2017

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.


KEY POINTS
 Postoperative pulmonary complications remain
prevalent and are associated with major morbidity.
 Low tidal volume ventilation, optimization of PEEP, and
routine recruitment maneuvers decrease
pulmonary complications.
 Fluid therapy aims to avoid overhydration, a known
contributor of pulmonary complications and
anastomotic leaks.
 Thoracic epidural analgesia reduces the systemic
inflammatory response, decreases pulmonary
complications and improves postoperative pain control.
 Patient centered evidence-based surgical and anesthetic
pathways facilitate a low mortality rate.
MECHANICAL VENTILATION
On the basis of recent national surgical quality
improvement program (NSQIP) data, postoperative
pulmonary complications (PPCs) remain a frequent
occurrence after esophagectomy with a prevalence
of 20–40% [5]. The most devastating PPC is acute
respiratory distress syndrome (ARDS), which con-
tinues to occur in up to 25% of esophagectomy
cases, with associated markedly increased morbidity
and prolonged intensive care and hospital length of
&
stay [6 ]. Early postoperative ARDS may be related
to lung injury precipitated by intraoperative mech-
&
anical ventilation [6 ], particularly when one-lung
ventilation (OLV) is required. Protective OLV has
previously been shown to reduce inflammatory
mediator release after esophagectomy and should
be a routine component of any intraoperative venti-
&
lation strategy [7 ]. These findings have recently
been reconfirmed in a randomized control trial
comparing protective ventilation with tidal vol-
umes of 5 ml/kg and positive end-expiratory pres-
sure (PEEP) during three-hole minimally invasive
esophagectomy (MIE), which demonstrated reduced
PPC when compared with tidal volumes of 8 ml/kg
and no PEEP [8]. Additionally, continuous positive
airway pressure (CPAP) applied to the collapsed lung
during the intrathoracic stage of esophagectomy
reduces local inflammation in the collapsed lung
and may therefore be a strategy to further reduce
lung injury [9]. A recent review summarizing the
mechanisms of postoperative lung injury after
OLV highlights the benefits of low tidal volumes
(4–5 ml/kg predicted body weight) and optimiz-
ation of PEEP (5–10 cm H2O) with routine recruit-
&
ment maneuvers [7 ]. These strategies, coupled with
mild permissive hypercapnea and attempts to limit
the duration of OLV, should now be routine for OLV
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Current trends in anesthesia for esophagectomy Durkin et al.
during the intrathoracic portion of esophagectomy
procedures. A PEEP level of 5 cm H2O has been
shown to be insufficient during OLV in patients
with relatively normal lung function. Individualized
PEEP levels should therefore be determined by opti-
mizing dynamic lung compliance in a PEEP titration
study after a recruitment maneuver [10]. When OLV
is not required, as during transhiatal esophagectomy
(the predominant approach at our center) open lung
ventilation is similarly advisable. We routinely pro-
vide pressure control ventilation with tidal volumes
of 4–6 ml/kg, PEEP of at least 5–10 cm H2O, while
limiting peak pressures to less than 30 cm H2O.
PERIOPERATIVE FLUID THERAPY
The association between excess perioperative fluid
and respiratory complications after esophagectomy
is well established [11]. Hypoalbuminemia, which is
not uncommon in esophagectomy patients, appears
to increase the risk of respiratory complications with
&
excess fluid administration [12 ] yet also increases
the risk of acute kidney injury (AKI) [13].
Instead of the classical debate comparing restric-
tive versus liberal fluid therapy in anesthesia [14] the
focus is increasingly on achieving rational fluid
replacement aimed at optimizing tissue perfusion
[3]. What constitutes appropriate fluid volumes
remains to be elucidated as we balance the risk of
hypovolemia resulting in gastric conduit and organ
ischemia with the risk of hypervolemia that precipi-
tates acute lung injury and anastomotic leaks.
Higher fluid balances have clearly been associated
with increased PPC after esophagectomy [11].
Intraoperative fluid volumes that were previously
shown to be associated with PPC are in excess of
4 liters (corresponding to >10 ml/kg/h) [11].
Similarly, higher fluid balances on postoperative
day one (3815  1353 vs. 2669  1315 ml) were
shown to be independent risk factors for PPC in a
&
high volume center [15 ]. Interestingly, higher fluid
balances on postoperative day 2 did not show a
similar correlation, demonstrating that patients
are particularly vulnerable in the early perioperative
period. This vulnerability may be partially explained
by the realization that the endothelial glycocalyx,
which is essential for vascular homeostasis, sustains
significant perioperative damage in response to
hypervolemia, inflammation and oxidative stress,
justifying a more cautious approach to fluid admin-
&
istration [7 ,16].
With the realization that AKI is prevalent and
morbid concern has been expressed about the
traditional fluid restriction in thoracic surgery
[17]. However, recent retrospective evidence of
&
1442 patients from Ahn et al. [18 ] demonstrated
www.co-anesthesiology.com 31
Thoracic anesthesia
that crystalloid restriction to <3 ml/kg/h was not
associated with AKI after thoracic surgery (including
esophagectomy). A subgroup analysis of patients
receiving <2 ml/kg/h similarly showed no increased
AKI risk but was inadequately powered for firm
&
conclusions [18 ]. These data are confirmation of
earlier studies that showed AKI to be independent of
intraoperative crystalloid volume [17,19] and con-
trasts with the prevailing notion that liberal fluid
therapy is protective of renal injury. Fluid ‘restric-
tion’ as it has classically been practiced in thoracic
surgery is a misnomer and does appear to achieve
normovolemia, likely because we now realize that
&
there is no ‘third space’ [7 ,16]. Determining which
patients require more volume remains a challenge as
commonly proposed mechanisms of stroke volume
variation and pulse pressure variation are not pre-
dictive of fluid responsiveness after abdominothora-
cic esophagectomy [20] and have not been validated
in the open chest setting. Correspondingly, goal-
directed fluid therapy only achieved a level C recom-
mendation in a recent evidence-based guideline for
esophagectomy [21]. While intuitively intriguing,
the role of noninvasive cardiac output monitors
in the absence of supportive evidence at present
is likely limited to optimization at the start of
the operation prior to commencement of the intra-
thoracic portion. On the basis of the above, it
appears reasonable to provide maintenance fluids
of 2–3 ml/kg/h and replace blood losses with an
appropriate volume of crystalloid or colloid to
achieve a total intraoperative fluid volume of at
least 3 ml/kg/h but not exceeding 10 ml/kg/h.
VASOPRESSORS
The major cause of anastomotic leaks and strictures
following esophagectomy is conduit ischemia
[22,23]. Hypotension related to general or neuraxial
anesthesia, intraoperative blood loss or vasocon-
striction because of endogenous and exogenous
catecholamines are some of the potential nonsur-
gical causes of ischemia [23,24]. Hypotension
secondary to thoracic epidural local anesthetic
administration reduces gastric tube blood supply;
this however, is rapidly correctible with a phenyl-
ephrine infusion [25]. Norepinephrine may be a
better option than phenylephrine as it more readily
preserves cardiac output and produces less splanch-
nic vasoconstriction and a lesser rise in lactate con-
&
centrations than phenylephrine [26 ]. The notion of
completely avoiding vasopressor boluses or infu-
sions is unfounded and likely results in excess
fluid administration, a known precipitant of mor-
bidity [11]. In our experience, vasopressor infusions
are rarely necessary intraoperatively even when
32 www.co-anesthesiology.com
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
providing epidural anesthesia; however, they are
almost universally required during the first post-
operative night. We frequently use low-dose norepi-
nephrine infusions during the first postoperative
night to counteract the epidural sympathectomy
and avoid overhydration.
PERIOPERATIVE ANALGESIA
Thoracic epidural analgesia (TEA) remains the main-
stay of perioperative analgesia for esophagectomy.
In three-hole esophagectomy, TEA reduces the inci-
dence of pneumonia from 32 to 19.7% and anasto-
motic leak from 23 to 14% at the expense of lower
average blood pressure and longer urinary catheter-
&
ization [27 ]. In Ivor Lewis esophagectomy, TEA
reduces the systemic proinflammatory response
and provides better postoperative analgesia com-
pared with intravenous opioid alone [28]. In
addition, a recent retrospective analysis showed that
&
TEA significantly reduced ICU length of stay [29 ].
However, prolonged hypotension due to excess
epidural bolus doses must be avoided as it has been
shown to be associated with a higher rate of anas-
tomotic leaks [30]. Paravertebral analgesia is a viable
alternative to TEA for the management of the thor-
acotomy pain. We are unaware of any head to head
study comparing the techniques; however, paraver-
tebral analgesia has proven superior to intravenous
opioid alone following esophagectomy in terms of
analgesia, pulmonary function, and hospital length
of stay [31]. The optimal pain management strategy
for MIE remains to be determined, however, we
continue to utilize TEA in MIE to limit the inflam-
matory response and optimize postoperative pain
control and respiratory mechanics in light of the
multitude of port sites and the significant dissection
required in the abdominal and thoracic cavities.
ENHANCED RECOVERY PROTOCOLS
Fast track or enhanced recovery after surgery (ERAS)
protocols aim to optimize and standardize care in
order to minimize postoperative complications and
accelerate discharge from hospital [21]. They have
proven useful in a variety of surgical populations
and several recent publications have evaluated
& &
their effectiveness after esophagectomy [4 ,21,32 ,
&
33–35]. Porteous et al. [4 ] described the evolution
of a standardized perioperative pathway including
preoperative optimization, TEA, lung protective
ventilation, restrictive fluid strategies, and early
postoperative extubation. Utilizing their multidisci-
plinary evidence-based perioperative approach in a
high-volume center they were able to achieve a low
30-day mortality rate of 0.5% despite a steady rise in
Volume 30  Number 1  February 2017

comorbid conditions in their esophagectomy
&
cohort [4 ]. It is likely that marginal gains in
each category combine to produce measurable
improvements in postoperative complications, akin
to the recently published reduction in perioperative
mortality in a surgical cohort seen in a preoperative
anesthetic assessment clinic [36]. Implementing
formalized enhanced recovery protocols by itself
may not improve outcomes in the absence of
changes to prevailing clinical care, as demonstrated
&
by Findlay et al. [37 ] who found no improvement
in morbidity, length of stay or mortality in their
high-volume center after establishing enhanced
recovery protocols around established care patterns.
Evidence-based guidelines have been suggested
for esophagectomy based on limited and hetero-
geneous evidence [21]. Only a small number of
the grade A recommendations related to anesthetic
care, including preoperative carbohydrate loading
with a reduced fasting period of 2 h for liquids
and 6 h for solids and pre-emptive analgesia with
thoracic epidural, NSAIDs and local anesthesia. The
remainder of the grade A recommendations related
to surgical approach (MIE), early postoperative
feeding and thromboprophylaxis [21].
While not carrying the same level of evidence,
preoperative optimization of hemoglobin and nutri-
tion as well as early postoperative mobilization
and daily evaluation of appropriate drain, catheter
and tube removal are important components of an
enhanced protocol that have been shown to reduce
length of hospital stay [33]. In a pooled analysis
of studies on enhanced recovery protocols for
&
esophagectomy Markar et al. [32 ] were able to dem-
onstrate significant decreases in anastomotic leaks,
PPC and hospital length of stay, however no impact
on overall patient mortality. ERAS protocols, there-
fore, have to cover the full breadth of perioperative
factors and need to be devised and revised in a
multidisciplinary fashion by surgeons, anesthesiol-
ogists and other perioperative care providers. There
is a need for large scale, prospective, multicenter
trials to establish optimal care pathways.
MINIMALLY INVASIVE ESOPHAGECTOMY
MIE is being performed with increasing
frequency throughout the world since 2007 and is
receiving considerable attention in the literature
&
[38 ]. MIE combines laparoscopic and thoracoscopic
approaches for both esophageal resection and
reconstruction and was introduced in an attempt
to reduce the morbidity associated with laparotomy
with or without thoracotomy. Multiple approaches
have been described analogous to the classic open
approaches. The most common is a modification of
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Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
Current trends in anesthesia for esophagectomy Durkin et al.
the Ivor Lewis approach with multiple port sites
in the thoracic and abdominal cavities and the
patient in the left lateral position [2]. MIE is
comparable in terms of postoperative mortality
and major morbidity, hospital readmission and
&
5-year survival [38 ,39–41] but provides improved
lymph node retrieval, shorter hospital length of stay
(by 1 day), less ileus, wound infection and allogeneic
&
transfusion [38 ]. MIE has, therefore, been given a
grade A recommendation in a recent evidence-based
guideline on esophagectomy care [21]. However,
MIE requires prolonged operating times, and
is associated with an increased risk of reoperation
(9.5 vs. 4.4%) and higher rates of empyema,
which may be reflective of a learning curve but
&
this is unproven [38 ]. Robotic-assisted MIE
&
does not appear to bestow an advantage [38 ,39].
Randomized comparisons of MIE versus open
approaches are absent but a feasibility study pub-
lished earlier this year may indicate that these data
are forthcoming [42]. Until then it will be important
to critically evaluate single center and multi-
institutional databases.
CONCLUSION
Esophagectomy remains integral to curative
therapy for esophageal cancer and the surgical
approach while varied across institutions is trend-
ing towards minimally invasive techniques.
Despite increased operative times and requiring
more reoperations MIE tends to reduce overall
length of hospital stay. There are ongoing efforts
to improve surgical approaches and perioperative
medical care. Large cohort data demonstrates
steadily improving outcomes despite a patient
population that is older, with more comorbidities,
a lower functional status and who presents follow-
ing neoadjuvant chemoradiotherapy. The idea
that marginal gains in multiple components of
perioperative care while not affecting outcome
on their own can combine and translate into
improved patient care is the basis for enhanced
recovery and explains recent improvements.
Despite the progress, still roughly a quarter of
patients will experience a pulmonary compli-
cation, 15% an anastomotic leak and 2% will die
after their esophagectomy, which leaves sufficient
potential for further improvements in the care for
this high risk patient group. Our profession with its
intimate knowledge of preoperative optimization,
fluid and vasopressor management and multimo-
dal analgesia may positively influence periopera-
tive outcomes by seeking further marginal gains
and facilitating the implementation of enhanced
care protocols.
www.co-anesthesiology.com 33
Thoracic anesthesia
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
Contribution: All authors prepared the manuscript.
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READING
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& of special interest
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