Chapter 17

1. Esophagectomy is associated with considerable morbidity and mortality despite improvements in surgical technique and perioperative care.

2. The optimal technique in a particular patient depends on specific patient characteristics as well as surgeon- and center-specific experience and preference more than tumor morphology or staging.

3. Multimodal anesthetic management utilizing thoracic epidural analgesia, protective ventilation, prevention of tracheal aspiration, and judicious fluid management helps reduce postoperative morbidity, particularly pulmonary complications and anastomotic leakage.

A 65-year-old male patient who presents with advanced Barrett esophagus is scheduled to undergo an esophagectomy. He has a long standing history of gastroesophageal reflux, a 20 pack-year history of smoking and consumes 2 to 4 drinks per night.

His only medication is omeprazole.

Vital signs: BP 140/80, HR 80, RA SpO2 94%.

Laboratory examination is notable only for marginally elevated AST and ALT.

An exercise-stress echocardiogram was normal.

Esophageal cancer is the most common indication for esophagectomy. The incidence of esophageal cancer is increasing and the epidemiology is changing such that adenocarcinoma, which is linked to obesity and gastroesophageal reflux disease, is now more common than squamous cell carcinoma. Mortality following esophagectomy has decreased but still exceeds that of most surgical procedures and long-term survival remains poor. Consequently, it is of critical importance to minimize perioperative morbidity in any manner possible. Esophageal resection can be performed via several different techniques, with the most appropriate technique for any specific individual patient being dependent on both patient and surgeon factors.

### Epidemiology

With less than 14,000 new cases annually in the United States, esophageal cancer is relatively uncommon. However, its incidence is steadily increasing and its epidemiology is changing significantly.1-3 Recent evidence indicates that the incidence among white males has almost doubled while the incidence among blacks has decreased by almost 50%.1

Esophageal cancers are differentiated by histologic type and location, but also have many features in common. More than 90% of esophageal cancers in the United States are either adenocarcinomas (57%) or squamous cell carcinomas (37%).1,3 The distribution of tumor types varies according to race: 64% cases in whites are adenocarcinomas, while among the black population, 82% are of squamous cell origin.1 Tobacco use and a history of mediastinal radiation are risk factors for both tumor types. Other risk factors for adenocarcinoma include gastroesophageal reflux disease (GERD), obesity, and Barrett esophagus. Barrett esophagus with high-grade dysplasia is considered a premalignant condition as 50% are found to harbor occult malignant disease at the time of biopsy.4 Additional risk factors for squamous cell carcinoma are conditions that cause chronic esophageal irritation and inflammation such as alcohol abuse, achalasia, esophageal diverticuli, and frequent consumption of extremely hot beverages.2 Tumor location also distinguishes these two common cell types. Approximately three quarters of all adenocarcinomas are found in the distal esophagus, whereas squamous-cell carcinomas are more evenly ...

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