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1. Anesthesia For Esophageal Surgery
By:Desta.O,Msc Lecturer in ACA,2023

2. Outline
o Anatomy and physiology
o Common Surgical pathologies and procedures
o Diagnosis
o Anesthesia Management
o Summary
o Reference

3. Objective
At the of this session,you should;
o Mention common esophageal pathologies
o Describe the relationship between Esophageal
muscles with aspiration
o Manage Patients admitted for esophageal surgery

4. Anatomy and Physiology
ANATOMY PHYSIOLOGY
 To propagate a bolus from
the upper oropharynx to the
stomach by the coordination
of ;
o Esophageal muscle
contractions
o Vagal innervations
o Sphincter relaxation

5. Cont...
o Anatomic relationships between the esophagus, airway, aorta,
diaphragm, and stomach.

6. Common Surgical pathologies and procedures
Esophageal pathologies
o Achalasia
o Hiatal hernia
o Esophageal Diverticulum
o GERD
o Esophageal Varices/Stricture
o Esopheal Tumors/Ring/Web
Esophageal procedures
o Endoscopy
o Esophageal dilation
o Cervical esophagomyotomy
o Open or thoracoscopic distal
esophagomyotomy
o Insertion or removal of
esophageal stents
o Open or minimally invasive
esophagectomy

7. Cont…
Achalasia
Definition
o Wikipedia-Failure of smooth muscle fibers to relax,
which can cause the LES to remain closed
 Degeneration of ganglion cells in the myenteric plexus
in the esophageal wall, leading to failure of relaxation
of the LES

8. Birds beak sign of achalasia

9. Cont…
Hiatal Hernia
o A condition in which part of the stomach pushes up
through the diaphragm muscle
o Called the "great mimic" because its symptoms can
resemble many disorders

10. Cont…

11. Cont…
Esophageal Diverticulum
o Pocket-like structure can appear anywhere in the
esophageal lining between the throat and stomach.
o Esophageal diverticula (pleural of diverticulum) are
classified by their location within the esophagus:
 Zenker’s diverticula-above the esophagus
 Midthoracic diverticula/True, or traction, in the mid-chest
 Epiphrenic diverticula/pulsion diverticulum,above the
diaphragm

12. Cont…

13. Diagnosis
o HX
o P/E
o LAB

14. Anesthesia Management
Preoperative Evaluation and Preparation
o Regardless of the procedure,a common anesthetic
concern in patients with esophageal disease is:
o The risk of pulmonary aspiration,so premedicate
 Operative treatment may be palliative or curative
 A thorough history and physical examination
should be performed prior to anesthetisia.
 Comorbid conditions should be evaluated and
optimized prior to surgery,RS vs CVS

15. Cont…
 Drugs for cancer
o The chemotherapeutic agents cause bone marrow suppression
and assess anemia and thrombocytopenia.
o Need of optimizing prior to major surgery should be balanced
with the risk of delaying the resection of malignant tumors.
o Evaluate for coexisting COPD, CAD,and liver
dysfunction

16. Cont…
Intraoperative management.
o Some are lengthy procedures
o Intraoperative monitoring for esophageal surgery
cases should be commensurate with the
 Degree of physiological trespass inherent in the
planned procedure
 The nature and severity of patient comorbidity.
o Transthoracic approaches mandate a more aggressive
approach to monitoring.

17. Cont…
 Induction and Airway Management
o Lung Isolation and One Lung Ventilation
o RSI with CP?/TIVA?
o Most practitioners favor propofol, thiopental, etomidate, or
ketamine in conjunction with
 A rapidly acting NMBAs sux/rocu to facilitate smooth, rapid
induction and intubation.
 Maintenance-many authors prefer a balanced anesthetic
technique??
 With IAA iso/sevo/desflurane, a NDMR, opioids and/or local
anesthetic agents via an epidural catheter.

18. Cont…
Anesthetic techniques for postoperative pain control
play an extremely important role in
o Optimizing outcomes after transthoracic esophageal
procedures
o Both too much and too little fluid administration can
negatively impact outcome-GDFT
o TEA-gold standard pain management in thoracic
surgery
o Hypotension occurs not infrequently after esophageal
surgery-careful hypovolemic/non hypovolemic causes

19. Cont…
Postoperative
o PACU/HDU/ICU transfer?
o Lung protective ventilation and multimodal perioperative
analgesia should be used postoperatively.
o Postoperative management of patients after esophageal
surgery is largely depend on
 The specific procedure performed
 The patient’s response to anesthesia and surgery

20. Cont…
 Extubation in the OR is generally appropriate,Provided that
patients are
o Stable from a hemodynamic and metabolic standpoint
o Neuromuscular and respiratory functions are adequate
o Plan for suitable analgesia has been initiated

21. Cont…
o Reading assignment.
Anesthesia considerations for patients with
Esophageal cancer
Anesthesia Management of patients with
specific Esophageal surgery,Hiatal
Hernia,Achalasia and Esophageal Diverticulum.

22. Summary
o Patients presenting for esophageal surgery frequently have
comorbidities COPD, Alcohol, Smoking,CAD
o Esophageal surgery commonly have pathology which
increases risk of regurgitation and aspiration.
o Anesthetic mgt strategies based on the severity of conditions
and the nature of the planned procedure.

23. Reference
 Morgan and Mikhail’s clinical anesthesiology,7TH
Edition
 Miller’s Anesthesia,9th Edition
 Wiktionary/Wikipedia.com
 Anesthesia for Esophageal Surgery,Randal S. Blank,
Julie L. Huffmyer, and J. Michael Jaeger,2022.

24. THANKS!