Minimally Invasive Oesophagectomy

Question 1

What are the risk factors for the development of oesophageal adenocarcinoma?

Answer 1

• Smoking.
• Alcohol intake.
• Male.
• Poor diet.
• History of reflux or Barrett’s oesophagus.
• Family history.

Question 2

What aspects of this patient’s preoperative assessment are key prior to his procedure?

Answer 2

• Assessment of comorbidities: Patients with oesophageal malignancy typically have a number of comorbidities, attributed to smoking or alcohol excess. A thorough assessment of both cardiovascular and respiratory systems is essential, as well as relevant investigations such as an echocardiogram, CPET, and lung function tests.
• Nutrition: Alcohol excess, cancer cachexia and anorexia due to treatment or dysphagia may all cause malnutrition in these patients, so assessment and nutrition supplementation are key in the perioperative period.
• Preoperative optimisation: Patients should be prepared psychologically and physically for a major procedure, the recovery period, and the risks associated with it. Local hospital programmes can facilitate a holistic and multidisciplinary approach using surgery schools and prehabilitation programmes. Smoking cessation in particular should be encouraged.

Question 3

What are the challenges associated with anaesthetising this patient for his procedure?

Answer 3

• Abdominal and thoracic surgical insults.
• Potential requirement for one-lung ventilation depending upon the
  surgical approach.
• Pneumoperitoneum and thoracoscopic insufflation with the potential
  physiological implications.
• High risk for postoperative complications including VTE, infection, anastomotic leak and arrhythmias.
• High analgesic requirements during the perioperative period with the associated side effects of medication.

Question 4

What complications of pneumoperitoneum are more likely in patients during a MIO?

Answer 4

• As well as the known systemic physiological implications of pneumoperitoneum, due to creation of a passage between the peritoneum and the thoracic cavity, this patient is particularly at risk of:
• Surgical emphysema.
• Pneumothorax/tension pneumothorax.
• Capnothorax.
• Hypercapnia.
• Hypotension due to reduced venous return and capno-
  pneumomediastinum.
• Arrhythmias due to capno-pneumomediastinum and surgical irritation of the myocardium.
• A surgical chest drain is inserted electively in the perioperative period to mitigate the risks.

Question 5

What is your plan for analgesia in this patient?

Answer 5

Preoperative:
* Consideration of a thoracic epidural inserted into the patient awake.
* Paracetamol 1 g orally.
* Gabapentin 300–600 mg orally.

Intraoperative:
* Intravenous paracetamol.
* Intravenous fentanyl.
* Non-opioid-based analgesic agents: consider magnesium and a
ketamine bolus or infusion.
* Placement and loading of a paravertebral catheter on the operative side.

Postoperative:
* Thoracic epidural infusion.
* Paravertebral catheter local anaesthetic infusion.
* PCA with fentanyl/morphine.
* Regular paracetamol.

Question 6

What are the benefits of an epidural catheter infusion in this patient?

Answer 6

• Good pain control during the perioperative period.
• Decreased stress response to surgery.
• Reduced opioid requirement with fewer respiratory and
  gastrointestinal side effects as a result.
• Decreased incidence of postoperative pulmonary complications.
• Lower risk of postoperative myocardial ischaemia and venous
  thromboembolism.
• Allows early mobilisation reducing chest complications and risk of
  VTE.