Specific operations
General points in all oesophageal operations
The site and size of the pathology / carcinoma, in combination with physical attributes of the patient determine the incision, and the selection and placement of conduits.
General points in all oesophageal operations
Pre operatively
Cream may be administered 50 to 100ml Full fat to help in intra operative identification of the chyle duct.
Pre induction
Some anesthetists insert the epidural preinduction if their is not a contraindication.
Arterial line inserted.
Post induction Pre incision
If the patient has had cream immediately pre induction they are crash induced with cricoid pressure, and a single lumen endotracheal tube is inserted.
Esophagoscopy is performed to assess the size, and location of the tumour, and also to suck out any excess cream that may be still present.
Bronchoscopy may be performed in oesophageal carcinoma particularly in mid third tumours to eliminate invasion of the tracheobronchial tree. This can be either via a frelible scope down the ET tube or with a rigid scope now that all the cream has been sucked out to reduce the chance of aspiration.
The patient is then reintubated with a left sided double lumen tube.
CVP line inserted if thought necessary - a debated point. This must be inserted on the side that is to undergo a thoracotomy.
Depending on the reason for operating a bougie may be placed in the esophagus to aid in its intraoperative localisation. (usually spontaneous rupture)
If the epidural has not been inserted with the patient awake it is now inserted.
The patient is now positioned appropriately depending on the incision to be made.
Malignant disease
Orringer Transhiatal esophagectomy (THE)
Endothoracic endooesophageal pull through
Total gastrectomy and Roux-en-Y reconstruction
Anastomotic leak post eosphagectomy
Benign disease
Hellers cardiomyotomy and extended myotomoy
Boerhaave's or ruptured oesopahgus