Perioperative management - Esophageal resection

Esophageal malignancies:

• Carcinoma (squamous cell carcinoma, adenocarcinoma)
• Sarcoma (rare)

Benign long stenoses:

• Caustic burns (acid/ alkali)

• Cirrhosis
• Severe obstructive and restrictive lung disease (COPD, pulmonary fibrosis)
• Severe heart failure
• Severe coronary artery disease

Bioptic confirmation

The diagnosis is primarily confirmed by endoscopy with biopsy. In malignancies the biopsy should clarify whether the tumor is an adenocarcinoma or squamous cell carcinoma of the esophagus. Often, this differentiation has already been made during the initial endoscopic study. However, there remain cases where the differentiation has not been conclusive, thereby necessitating rebiopsy. In addition, the workup in adenocarcinoma must establish whether it is a Barrett's carcinoma or rather a carcinoma of the gastroesophageal junction.

This histological diagnosis will determine the subsequent steps:

• Squamous cell carcinoma

During preoperative staging in squamous cell carcinoma, which over the past few years has become less common, the following should be considered: In view of the longitudinal spread of squamous cell cancer, endoscopy should look for mucosal metastases proximal and distal to the tumor. In addition, endoscopy should rule out a possible second tumor, especially in the region of the hypopharynx. Furthermore, endoscopy should be complemented by endoscopic ultrasonography (EUS) to gain an understanding of the depth of any mural invasion and the relationship of the tumor to the adjacent tissues. Endosonographycannot visualize the tracheobronchial system or can only do so inadequately. If the tumor is related to the tracheobronchial systemor located superior to the tracheal bifurcation, the tracheobronchial system must be studied endoscopically to rule out tumor invasion into this system. In order to rule out distant metastases and to assess the tumor in relation to adjacent organs, diagnostic endoscopy must be supplemented by a CT study of the chest and abdomen.

• Adenocarcinoma

If it is adenocarcinoma, histological confirmation of the Barrett's mucosa adjacent to the tumor should also be attempted, to the extent that this is still possible next to the malignancy. Endoscopy should rule out the presence of adenocarcinoma of the gastroesophageal junction Sievert type II or III because this would have other therapeutic consequences (e.g., extended transhiatal total gastrectomy). If Barrett's carcinoma is present, staging should in principle be conducted in the same way, i.e., by endoscopy, EUS and CT, although assessment of the tracheobronchial system is secondary, since Barrett's carcinomas are usually located inferior to the tracheal bifurcation. However, since most tumors are located distad, involvement of the abdominal cavity is not uncommon; for this reason, diagnostic laparoscopy may be performed in locally advanced Barrett's carcinoma to detect possible peritoneal metastasis (in about 20% of cases). The subsequent therapeutic approach is primarily determined by R0 resectability and the differentiation between T1/T2 and T3/T4 tumors. Treatment is stratified in terms of primary surgery or neoadjuvant therapy protocols based on the T category and R0 resectability.

PET imaging

Recently, PET imaging, preferably as PET-CT, has become increasingly important in preoperative staging. Apart from the identification of distant metastases, PET-CT also allows assessment of the intensity of the tumor metabolism and therefore permits early response evaluation with corresponding therapeutic consequences, especially if decision making favors neoadjuvant therapy.

Routine diagnostic workup of the colon, e.g., by colonoscopy, regarding the possible transposition of the colon does not appear necessary.

Preoperative risk assessment 

Since patients suffering from squamous cell carcinoma of the esophagus or Barrett's carcinoma are distinctly different populations, the necessary studies assessing the preoperative risk of these two tumor entities also differ. With both groups, however, one must presume alcohol and nicotine abuse. This results in significantly impaired pulmonary and hepatic function (COPD, pulmonary fibrosis, fatty liver, liver cirrhosis). The appropriate preoperative studies, e.g., diagnostic pulmonary function testing and evaluation of liver function parameters in serum (albumin, cholinesterase, Quick, y-GT, AP, bilirubin, platelets, etc.) are mandatory. On the other hand, patients with Barrett’s carcinoma often have a long-standing history of reflux and are usually overweight. A body mass index of more than 25 is even debated as being a causative factor in the development of Barrett's carcinoma. The obesity and age of these patients are responsible for a high rate of concomitant cardiac disorders. In about 30% of these patients, coronary artery disease can be expected, which must be assessed (ergometry, echocardiography, possibly myocardial perfusion scintigraphy) and possibly treated (cardiac catheterization) before surgery. The overall surgical risk can be quantified with a score (so-called Bartels’ score), thus objectifying risk assessment.

After surgery has been indicated, the patient should be prepared for it as soon as possible. Particularly in dehydrated and cachectic patients, preoperative fluid and calorie replacement or a hypercaloric diet should first be initiated. At the same time an intensive physical preparation should be instituted, especially in terms of breathing exercises and a no smoking policy.

• Regarding nutrition see above.
• Special preoperative preparation, such as intensive laxative measures, is not required. As required by the anesthetists, the patient should have nothing by mouth (for at least 2 – 6 hours) before surgery.

Specific intraoperative complications

• For instance, possible spleen injury with subsequent splenectomy.

Specific postoperative complications

• Failure of the esophagogastrostomy or the lateral suture/staple line of the gastric tube
• Anastomotic stricture requiring dilatation
• Development of pleural empyema
• Development of mediastinitis
• Ischemia of the gastric tube
• Pulmonary fistula
• Atelectasis
• Pancreatic fistula
• Pancreatitis

General risks:

• Postoperative bleeding
• Thrombosis
• Embolism
• Pneumonia
• Infectious complications, i.e., wound abscess, intraabdominal abscess

In oncological surgery:

• Large tumors may prevent the R0 resection originally planned
• Catheter jejunostomy for postoperative enteral nutrition with associated complications (ileus, small bowel fistula).
• In the case of intraoperative complications during construction of the gastric tube or too short a gastric conduit, transposition of the colon may have to be employed as replacement organ.