Oesophagectomy

8 min read Last updated April 8, 2026

Surgical approach

  • Indication usually oesophageal cancer (mid/lower oesophagus) ± neoadjuvant chemo(radio)therapy
  • Key steps (principles)
    • Mobilise oesophagus and perform lymphadenectomy (mediastinal ± abdominal nodes)
    • Create gastric conduit (tubularised stomach) based on right gastroepiploic artery
    • Resect tumour-bearing oesophagus; pull-up conduit; create anastomosis (cervical or intrathoracic)
    • Place feeding jejunostomy (common) and drains; chest drain if thoracic phase
  • Common approaches
    • Ivor Lewis: laparotomy/laparoscopy + right thoracotomy/thoracoscopy; intrathoracic anastomosis
    • McKeown (3-stage): abdomen + right chest + neck; cervical anastomosis
    • Transhiatal: abdominal + cervical without thoracotomy (blunt mediastinal dissection)
    • Minimally invasive / hybrid: laparoscopic + thoracoscopic components; often requires OLV
  • Positioning varies with approach
    • Thoracic phase: lateral decubitus or prone/semi-prone (thoracoscopy)
    • Abdominal phase: supine (often reverse Trendelenburg); neck phase: head turned, shoulder roll

Anaesthetic management

  • Type of anaesthesia: General anaesthesia with tracheal intubation; regional analgesia strongly recommended
  • Airway device: cuffed ETT; often double-lumen tube (DLT) or bronchial blocker if thoracic phase/OLV required
    • Neck anastomosis and postoperative airway oedema risk: consider smaller tube, careful fixation, cuff pressure monitoring
  • Typical duration: 4–8 hours (longer for 3-stage or complex MIO)
  • Pain: severe (thoracotomy + upper abdominal incision); high opioid-sparing requirement to facilitate extubation and mobilisation
    • Analgesia options: thoracic epidural (T5–T8), paravertebral catheter, erector spinae plane (ESP), intrathecal opioid (selected), multimodal
  • Ventilation: lung-protective strategy; OLV if required with FiO2 titration and recruitment/PEEP to dependent lung
  • Monitoring: invasive arterial line; large-bore IV access; consider CVC for vasoactive infusions; temperature, urine output; consider cardiac output monitoring in high-risk
  • Fluids: goal-directed, avoid overload (pulmonary complications/anastomotic oedema) but maintain conduit perfusion; early vasopressors often preferable to excess fluid
  • Postoperative destination: HDU/ICU; aim for extubation at end if stable; otherwise planned ventilation for physiological derangement/airway concerns

Preoperative assessment and optimisation

  • Comorbidity burden is high: smoking/COPD, IHD, malnutrition, frailty; neoadjuvant therapy increases risk (myelosuppression, cardiopulmonary toxicity)
  • Symptoms/physiology: dysphagia, weight loss, aspiration, reflux; consider dehydration and electrolyte disturbance
  • Investigations (typical): FBC/U&E/LFT/coag; group & save/crossmatch; ECG; CXR; spirometry; ABG if severe lung disease; echo/functional testing if indicated
  • Risk stratification: CPET (VO2peak, AT) commonly used; poor exercise capacity predicts pulmonary complications and prolonged critical care
    • Interpretation varies by centre; use alongside clinical picture rather than a single cut-off
  • Optimisation: smoking cessation, bronchodilator optimisation, prehabilitation, nutrition (dietitian, enteral support), treat anaemia, physiotherapy for sputum clearance
  • Aspiration risk planning: prolonged fasting may not empty oesophagus; consider pre-induction suction of oesophagus if NG/OG in situ; plan RSI where appropriate

Induction and airway strategy

  • High aspiration risk: consider RSI with head-up positioning; avoid mask ventilation if high risk; have suction ready
  • Choice of lung isolation: DLT (usually left) for thoracic phase; bronchial blocker if difficult airway, need for postoperative ventilation with single-lumen tube, or surgeon preference
    • Confirm position with fibreoptic bronchoscopy after positioning and after any major movement
  • NG/OG tube: often placed by surgeon after induction; avoid traumatic insertion (tumour bleeding/perforation); may be removed before anastomosis and re-sited under direct vision
  • Airway oedema risk (neck phase, long case, fluid shifts): cuff-leak assessment if concern; consider staged extubation with airway exchange catheter in high-risk

Intraoperative management

  • Monitoring and access: A-line before induction if unstable; 2 large-bore IVs; CVC for vasopressors/TPN planning; consider epidural before induction (awake) or after induction depending on local practice
  • Ventilation (two-lung): Vt 6–8 mL/kg PBW, moderate PEEP, avoid high plateau pressures; recruitment as needed
  • Ventilation (OLV): Vt ~4–6 mL/kg PBW, PEEP to dependent lung, permissive hypercapnia if acceptable; keep driving pressure low
  • Hypoxaemia during OLV: stepwise management
    • Check DLT position with FOB; exclude obstruction, secretions, pneumothorax, low CO
    • Increase FiO2; optimise dependent lung ventilation (PEEP, recruitment); consider CPAP to non-dependent lung if surgical field allows
    • Consider intermittent two-lung ventilation; treat hypotension; consider pulmonary vasodilator rarely (specialist)
  • Haemodynamics: aim for adequate conduit perfusion (avoid prolonged hypotension); use vasopressors early (noradrenaline commonly) rather than large fluid boluses
  • Fluid strategy: balanced crystalloid; goal-directed boluses; avoid positive balance; consider albumin/blood if indicated; transfuse based on bleeding/physiology and local thresholds
  • Temperature management: forced-air warming, fluid warmers; hypothermia increases bleeding and infection risk
  • Analgesia: thoracic epidural local anaesthetic/opioid infusion; if epidural contraindicated—paravertebral/ESP + IV PCA opioid + paracetamol ± NSAID (if renal function/bleeding risk acceptable)
  • PONV prophylaxis: multimodal (e.g., dexamethasone + ondansetron ± droperidol) to reduce retching (anastomosis stress) and aspiration risk
  • Thromboprophylaxis: mechanical intraop; pharmacological per protocol (balance with epidural timing/ASRA/RA-UK guidance)

Postoperative care and complications

  • Destination: HDU/ICU with close respiratory monitoring; early mobilisation, chest physiotherapy, incentive spirometry
  • Respiratory complications common: atelectasis, pneumonia, ARDS; risk increased by thoracotomy, OLV, fluid overload, poor preop lung function
  • Anastomotic leak: typically day 5–10; features include sepsis, tachycardia, chest pain, new AF, respiratory deterioration, increased drain output; requires urgent surgical review and CT contrast study/endoscopy as per protocol
  • Conduit ischaemia/necrosis: severe sepsis, mediastinitis; catastrophic—early recognition critical
  • Cardiac: atrial fibrillation common; manage triggers (pain, sepsis, hypoxia, electrolytes), rate/rhythm control per local policy; consider anticoagulation balancing bleeding risk
  • Chyle leak (thoracic duct injury): high drain output, milky fluid, lymphopenia, hypoproteinaemia; management includes dietary modification/TPN ± octreotide ± re-operation
  • Recurrent laryngeal nerve injury (esp cervical dissection): hoarseness, aspiration; may affect extubation and swallowing
  • Gastric emptying delay and aspiration: pyloromyotomy/pyloroplasty sometimes performed; NG management per surgical protocol
  • Analgesia goals: effective dynamic analgesia to enable deep breathing/cough; monitor epidural hypotension and motor block; avoid oversedation
You are asked to anaesthetise a patient for an Ivor Lewis oesophagectomy. What are the key anaesthetic issues you will discuss at the team brief?

Structure around airway/aspiration, lung isolation, haemodynamics/fluids, analgesia, and postoperative critical care.

  • Aspiration risk: dysphagia, reflux, retained oesophageal contents → plan RSI, head-up, suction ready
  • Lung isolation: need for OLV during thoracic phase → DLT/bronchial blocker, FOB confirmation after positioning
  • Analgesia plan: thoracic epidural vs paravertebral/ESP; impact on extubation and pulmonary complications
  • Haemodynamic strategy: goal-directed fluids, avoid overload; early vasopressors to maintain MAP and conduit perfusion
  • Monitoring/access: A-line, 2 IVs, consider CVC, temperature management, urinary catheter
  • Postop destination and extubation plan: HDU/ICU; criteria for extubation vs ventilation; airway oedema considerations if neck phase
How would you manage induction in a patient with obstructing oesophageal cancer and high aspiration risk?
  • Preoxygenate thoroughly (head-up), suction immediately available; consider arterial line pre-induction if unstable
  • RSI with cricoid pressure (if trained team and appropriate) and avoid mask ventilation unless necessary; gentle ventilation with low pressures if desaturation
  • Choose induction drugs mindful of haemodynamics (often hypovolaemic/malnourished); have vasopressor boluses ready
  • Secure airway with ETT (or DLT if proceeding directly and appropriate); confirm with capnography; consider FOB if difficulty anticipated
  • OG/NG insertion only if safe and per surgical plan; avoid traumatic passage through tumour
Describe a stepwise approach to hypoxaemia during one-lung ventilation in oesophagectomy.
  • Immediate checks: FiO2 to 1.0; check circuit, ETT/DLT patency, suction secretions, confirm haemodynamics and Hb
  • Confirm DLT/BB position with fibreoptic bronchoscopy (most common correctable cause)
  • Optimise dependent lung: recruitment manoeuvre then appropriate PEEP; adjust Vt/resp rate to avoid high pressures
  • Consider CPAP to non-dependent lung (if surgeon agrees) or intermittent two-lung ventilation
  • Exclude surgical causes: pneumothorax in dependent lung, compression, major bleeding; liaise with surgeon
Discuss fluid management for oesophagectomy.

Balance pulmonary risk from overload against need to maintain organ and conduit perfusion.

  • Use goal-directed therapy (stroke volume variation/CO monitoring where available) and small boluses rather than liberal fluids
  • Avoid large positive fluid balance: associated with pulmonary complications and tissue oedema (including anastomosis)
  • Treat vasodilation/epidural-related hypotension with vasopressors (e.g., noradrenaline infusion) rather than repeated fluid boluses
  • Transfusion guided by bleeding, physiology, and local thresholds; correct coagulopathy and hypocalcaemia if massive transfusion
Compare thoracic epidural with paravertebral/ESP analgesia for oesophagectomy.
  • Thoracic epidural: excellent dynamic analgesia; may reduce pulmonary complications; risks include hypotension, motor block, urinary retention, failure, epidural haematoma/infection
  • Paravertebral: unilateral analgesia, less hypotension; useful for thoracotomy/MIO; risks include pneumothorax, local anaesthetic toxicity, failure
  • ESP: technically easier, potentially safer (more superficial); evidence base evolving; may be less dense than epidural for thoracotomy pain
  • Choice depends on approach (thoracotomy vs MIO), anticoagulation, patient factors, and local expertise
A patient becomes hypotensive after starting a thoracic epidural during oesophagectomy. How do you manage this?
  • Assess: depth of anaesthesia, bleeding, epidural level, heart rhythm, ventilation pressures; check surgical field and drains
  • Immediate treatment: vasopressor bolus (metaraminol/phenylephrine/ephedrine depending on HR) and start/adjust noradrenaline infusion if ongoing
  • Judicious fluid bolus only if fluid responsive; avoid chasing epidural sympathectomy with litres of crystalloid
  • Reduce epidural infusion rate/concentration temporarily if needed; ensure adequate analgesia via adjuncts
What postoperative complications are you particularly concerned about after oesophagectomy, and how would you recognise an anastomotic leak?
  • Respiratory: atelectasis, pneumonia, ARDS; monitor oxygenation, work of breathing, CXR, inflammatory markers
  • Cardiac: AF (common), myocardial ischaemia; monitor ECG, troponin if indicated, correct triggers
  • Anastomotic leak (often day 5–10): sepsis, persistent tachycardia, new AF, chest/neck pain, respiratory deterioration, increased drain output
  • Immediate actions if suspected leak: urgent senior surgical review, resuscitate, broad-spectrum antibiotics per protocol, imaging (CT with oral contrast) as directed
How would you plan extubation at the end of a McKeown (three-stage) oesophagectomy?
  • Assess readiness: normothermia, adequate gas exchange, stable haemodynamics with minimal vasoactive support, acceptable lactate/acid-base, adequate analgesia
  • Airway concerns: neck dissection → airway oedema/RLN injury; consider cuff-leak test and direct/FOB airway assessment if concern
  • If high risk: staged extubation with airway exchange catheter; plan ICU extubation with ENT backup if severe oedema suspected
  • Post-extubation: high-flow nasal oxygen/CPAP if appropriate, aggressive physiotherapy, careful fluid balance, antiemetics
What is a chyle leak, how does it present after oesophagectomy, and what are the anaesthetic/critical care implications?
  • Cause: thoracic duct injury during mediastinal lymphadenectomy
  • Presentation: high chest drain output, milky appearance after enteral feeding; biochemical confirmation (triglycerides/chylomicrons)
  • Consequences: hypovolaemia, electrolyte disturbance, hypoproteinaemia, immunosuppression (lymphocyte loss), malnutrition
  • Management: drain, fluid/protein replacement, dietary fat restriction or TPN, consider octreotide; may require surgical ligation

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