Anaesthesia for minimally invasive

oesophagectomy
Matthew Rucklidge BSc MB BS FRCA
David Sanders BM BCh MA DPhil FRCA
Alastair Martin MB ChB FRCA

Epidemiology and risk factors

The incidence of oesophageal cancer is increasing in the UK with rates much higher than in
the rest of Europe. Oesophageal cancer is the
sixth most common cause of cancer death in
England and Wales. It affects men twice as frequently as women and is responsible for over
6000 deaths per year.3 There is a huge variation
in the incidence of oesophageal cancer around
the world. The incidence is highest in China,
Japan, and India where squamous cell carcinoma of the oesophagus is the predominant cell
type. The UK has the highest incidence of
oesophageal cancer of all European nations.
There has been a recent increase in the incidence of oesophageal adenocarcinoma in the
UK, and this appears to be increasing more
rapidly than squamous cell carcinoma. While
mortality rates for oesophageal cancer have
increased in the UK, mortality rates in neighbouring countries, including France, have
fallen.
The precise explanation for the increase in
oesophageal cancer in the UK, particularly adenocarcinoma, is unknown but may be associated with a number of factors. Gastric reflux
appears to be a major risk factor for adenocarcinoma and conditions that increase gastric
reflux, including obesity, are associated with an
increased incidence of adenocarcinoma. The
rising levels of obesity in the UK may therefore
be fuelling the increase in oesophageal cancer
observed in this country. Other possible explanations for the increase in adenocarcinoma
include low dietary intake of fruit and vegetables
and
reduced
infection
with
Helicobacter pylori. Although H. pylori is
itself harmful, it may convey some protection
against oesophageal cancer.

doi:10.1093/bjaceaccp/mkq004
Advance Access publication 21 February, 2010
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 10 Number 2 2010
& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia.
All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

Oesophageal cancer is
increasing in the UK and
rates are among the worst
in Europe.
Oesophagectomy by any
operative approach is a
high-risk surgical procedure.
Minimally invasive
oesophagectomy (MIO) may
enhance recovery and
quality of life compared
with open techniques.
MIO is a long procedure
that usually demands a
period of one lung
ventilation.
Passage of carbon dioxide
from the abdomen into the
chest (capnothorax and
capnomediastinum) is a
specific complication of
MIO.

Matthew Rucklidge BSc MB BS FRCA

Consultant Anaesthetist, Department of
Anaesthesia
Royal Devon and Exeter Hospital
Exeter EX2 5DW
UK
Tel: 44 (0) 1392 402474
Fax: 44 (0) 1392 402472
E-mail: mattrucklidge@yahoo.co.uk
(for correspondence)
David Sanders BM BCh MA DPhil
FRCA
Consultant Anaesthetist, Department of
Anaesthesia
Royal Devon and Exeter Hospital
Exeter EX2 5DW
UK
Alastair Martin MB ChB FRCA
Consultant Anaesthetist, Department of
Anaesthesia
Royal Devon and Exeter Hospital
Exeter EX2 5DW
UK

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Oesophagectomy is a high-risk surgical procedure which is associated with significant

morbidity and mortality. Open oesophagectomy
results in considerable trauma of access, generates a substantial systemic inflammatory
response, and is associated with significant
postoperative pain and reduced postoperative
mobilization.
Although
oesophagectomy
remains the primary treatment for patients with
non-metastatic cancer of the oesophagus, outcomes are poor. In-hospital mortality of 5%
and major morbidity of 25% are typical and
even after successful tumour resection, only
20 25% of patients will be alive at 5 years.
Open oesophagectomy has a significant impact
upon quality of life. Quality of life may sometimes never return to preoperative levels and at
best may take up to 6 months to achieve. Given
the considerable morbidity, impact upon
quality of life and poor overall life expectancy,
less invasive methods of oesophageal resection
are very appealing.
There have been substantial advances in
laparoscopic and thoracoscopic equipment,
skills, and techniques over the last decade. Less
traumatic techniques of surgery using minimally invasive techniques are now being
adopted for more challenging and complex
surgical procedures. A minimally invasive
approach to oesophagectomy was pioneered in
the early part of this century by Luketich1 and
NICE produced guidance on thoracoscopically
assisted oesophagectomy in 2006.2 Since then,
there has been a marked increase in the number
of units adopting minimally invasive techniques to oesophageal resection, and several
different approaches to MIO have developed
bringing with them their own specific anaesthetic challenges.

Key points

Anaesthesia for MIO

Patient preparation

Stage

Surgical steps

Stage 1: thoracoscopy

Thoracoscopic oesophageal mobilization and mediastinal

lymph node dissection
Performed in right chest under one lung anaesthesia in left
decubitus position
Intercostal chest drains inserted at end of this stage
Paravertebral catheter placed under thoracoscopic vision
Laparoscopic gastric mobilization, abdominal
lymphadenectomy, and gastric tube formation
Performed supine in LloydDavies position with steep
head up tilt
Diseased oesophagus and newly formed gastric tube pulled
up via cervical incision
Oesophagus transected and cervical anastomosis performed
Nasogastric drainage tube positioned within gastric conduit
Feeding tube inserted (either nasojejunal or jejunostomy)

Stage 2: laparoscopy

Stage 3: cervical
anastomosis

outside the abdomen to ensure the correct length is achieved

before anastomosis.
Anastomosis performed in the chest.
It is essential that the anaesthetist understands the different surgical
steps involved, because they may significantly influence anaesthetic management.

Anaesthetic challenges
There are a number of challenges common to all methods of MIO:

Surgical steps for oesophagectomy

Both open and minimally invasive oesophagectomies involve the
following operative steps:
Resection of oesophagus and upper stomach
Removal of lymph node fields
Restoration of gastrointestinal continuity and function.
It is difficult to define MIO because different combinations of thoracoscopic, laparoscopic, and open incisions have been performed
and studied. A recent consensus document has helped to clarify
these different approaches.4 In addition, the positioning of patients
during surgery may vary and may include the prone position.
Whatever the specific surgical approach, the aims remain the
same; namely, minimization of the significant trauma of access
associated with open oesophagectomy and promotion of early
recovery.
MIO was originally described as a three stage procedure as
shown in Table 1.
There are many variations to original descriptions of MIO and
more recent modifications include:
Thoracoscopic dissection with the patient in the prone position.
Reported advantages include improved surgical access as a
result of the mediastinum and lungs falling forward with gravity.
Mini-laparotomy after laparoscopic mobilization of the
stomach. The stomach is delivered via this incision along with
the resected oesophagus. The gastric conduit is then created

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Prolonged surgery
Prolonged period of one lung ventilation
Difficulties with assessment of fluid status and potential pulmonary complications of fluid overload
Complications of extra-peritoneal CO2 (capnothorax, capnomediastinum, and surgical emphysema)
Effective postoperative analgesia.

The challenge of prolonged surgery

MIO is a long procedure and may take over 8 h, especially if performed by surgeons new to the technique. Such prolonged surgery
increases the risk of hypothermia. Perioperative hypothermia has
many detrimental effects, including reduced oxygen delivery,
increased myocardial work, increased stress response, and
increased postoperative infection. Appropriate measures must be
taken to maintain normothermia. If surgery has proceeded uneventfully and the patient is normothermic at the end of surgery, there is
no indication for postoperative ventilation and patients should be
woken and extubated.
Balanced anaesthesia, either by an inhalation approach or by
propofol target-controlled infusion in conjunction with a remifentanil infusion, may help promote early recovery after MIO.
Inhalation anaesthesia may be favourable because volatile anaesthetic agents have recently been shown to exert an immunomodulatory effect on the pulmonary inflammatory response to one lung

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Oesophageal cancer often presents late with features that include

dysphagia, pain, and weight loss. While dysphagia is a common
presenting symptom, the current practice of preoperative neoadjuvant chemotherapy may improve this symptom. As a result, many
patients are able to swallow normally and maintain oral nutrition
by the time of surgery. Anaesthetists, however, must always
remain vigilant to the presence of dysphagia and potential risk of
reflux and take appropriate measures at induction of anaesthesia
and on extubation of the trachea. While neoadjuvant chemotherapy
has been shown to improve survival in patients with oesophageal
carcinoma, it is important to identify complications of recent chemotherapy, including bone marrow suppression and infection.
All patients undergoing MIO must have a thorough physical
and nutritional assessment, including an evaluation of respiratory
and cardiac function. The changing epidemiology of oesophageal
cancer in the UK has led to a change in the characteristics of
patients presenting for oesophagectomy. They are more likely to be
older and present with obesity and gastro-oesophageal reflux
disease rather than cachexia and smoking-related pulmonary
disease. Echocardiography, although commonly performed, does
not accurately predict perioperative risk. Cardiopulmonary exercising testing may provide more objective and valuable information
on functional capacity and perioperative risk.

Table 1 Typical sequence of steps of original three stage technique of MIO

Anaesthesia for MIO

anaesthesia.5,6 Compared with propofol i.v. anaesthesia, inhalation

anaesthesia with sevoflurane may result in reduced generation of
inflammatory mediators during one lung ventilation and also a
reduction in adverse postoperative events.6 Remifentanil infusion
lends itself to MIO on account of its short half life time and
because MIO commonly results in periods of significant stimulation, especially during the laparoscopic stage, that can result in
tachycardia and hypertension. The intense analgesia provided by
remifentanil along with the ability to rapidly titrate dosage may
help to counteract these episodes and help facilitate rapid recovery
after prolonged surgery.

One lung ventilation

Assessment of fluid status

In common with other major operative procedures, oesophageal
surgery demands close attention to fluid balance. There is evidence
that excessive fluid administration may be associated with increased
postoperative pulmonary complications and oesophagectomy has
more recently been managed with restrictive fluid strategies.
Conversely, inadequate intravascular volume may compromise tissue
oxygenation, organ perfusion, and potentially increase the risk of
anastomotic failure and leak. Appropriate fluid therapy should therefore be provided; however, defining exactly what is appropriate is
made more challenging by limited means of assessing volume status
in MIO. While there is increasing evidence that oesophageal Doppler
monitoring may help guide fluid therapy and influence postoperative
outcome, this device is obviously of no use in oesophagectomy.
Other indicators of fluid status are also of limited value in MIO.
Urine output may often be significantly reduced during prolonged
periods of capnoperitoneum because of the effect of increased
intra-abdominal pressure. Central venous pressure measurement is at
best a crude indicator of left-sided filling pressure and may be inaccurate in the prone or left lateral position and during laparoscopy
where it is increased by the influence of the capnoperitoneum.
Central venous access, however, allows sampling of central venous
blood and monitoring of central venous oxygen saturation (ScvO2)
which may have some value in identifying an imbalance between
oxygen delivery and consumption. A low ScvO2 perioperatively has
been shown to be related to increased risk of postoperative complications in high-risk surgery.12 A central line may also be useful for
perioperative administration of vasopressors if required.

Complications of extra-peritoneal carbon dioxide

MIO may require a prolonged period of capnoperitoneum during
laparoscopic dissection and mobilization of the stomach. The physiological effects of a capnoperitoneum are well known and shown
in Table 2.
Passage of carbon dioxide from the abdomen into the chest is a
specific complication of MIO because a surgical communication
has to be made between the chest and abdomen. If the gas passes
into the right chest in which chest drains have been placed at the
conclusion of the first stage of surgery, then the gas from the
abdomen will be vented via the chest drains. In this situation, there
may be little clinical compromise; however, problems with maintaining an adequate capnoperitoneum may occur because the
intra-abdominal gas is vented from the chest. Carbon dioxide may
also pass into the mediastinum (capnomediastinum), into the left

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MIO requires a period of one lung ventilation during the mobilization of the thoracic oesophagus. Inadequately managed lung isolation has been shown to contribute to mortality and morbidity
after oesophagectomy.7 Mobilization of the oesophagus is usually
performed in the right chest either with the patient positioned in
the left decubitus or prone position. As surgery is performed thoracoscopically, retraction of an inadequately collapsed lung or lobe
is more difficult than in open surgery and this is important when
considering the method used to achieve lung isolation. Lung isolation can be provided through a left or right double lumen tube or
a single lumen tracheal tube and bronchial blocker. Right-sided
double-lumen tubes are perceived to be less reliable than left-sided
tubes, because there is a greater chance of occluding the opening
to the upper lobe of the right bronchus that arises a shorter distance from the carina than on the left. This belief has been challenged recently by a retrospective study that found no difference in
intraoperative hypoxaemia, hypercapnia, and high airway pressures
whether a left- or right-sided tube was placed for one lung ventilation.8 Intubating the bronchus opposite the side of surgery may
reduce the likelihood of intraoperative tube displacement and
because most techniques of MIO involve access to the right chest,
a left-sided double-lumen tube is preferable. If a bronchial blocker
is chosen, this will have to be placed on the right side as the right
lung must be collapsed; however, the blocker cuff may occlude the
opening to the right upper lobe impairing its collapse. Although a
bronchial blocker may sometimes be necessary (e.g. in cases of
difficult intubation), our experience suggests that MIO is probably
best performed using a left-sided double-lumen tube. Whichever
method of lung isolation is selected, a fibreoptic bronchoscope
should be used to check correct positioning both after intubation
and after moving the patient before surgery.9
Acute lung injury is a complication of oesophagectomy. Features
associated with this risk have been identified and include duration of
one lung ventilation and perioperative cardiorespiratory instability,
including periods of hypoxia and high airway pressure.10 Although
the duration of one lung ventilation is mostly determined by surgical
factors, inadequate lung isolation may prolong this time period. It is
essential therefore that anaesthetists are skilled in correctly positioning double-lumen tubes, restrict tidal volume to 56 ml kg21 during

one lung ventilation and use strategies to avoid hypoxia and high
airway pressures. Pressure-controlled ventilation reduces peak
airway pressure during one lung ventilation compared with volumecontrolled ventilation. This strategy may potentially reduce the risk
of barotrauma during mechanical ventilation but is unlikely to result
in improvement in arterial oxygenation.11

Anaesthesia for MIO

Table 2 Effects of carbon dioxide insufflation during laparoscopy

Effect

Cardiovascular

Hypertension and tachycardia (sympathetic stimulation)

Hypotension (impaired venous return)
Bradycardia (vagal stimulation)
Arrhythmia
Reduced FRC
Reduce compliance
Increased ventilatory pressures
Barotrauma including pneumothorax
Atelectasis
Reduced renal perfusion
Activation of the renal angiotensin aldosterone system
Increased antidiuretic hormone
Raised intra-abdominal pressures and increased risk of gastric
regurgitation
Splanchnic ischaemia
Carbon dioxide embolus
Complications of extra-peritoneal spread of carbon dioxide
(see text)

Respiratory

Renal/metabolic

Gastro-intestinal

Other

chest and into the soft tissues resulting in subcutaneous emphysema around the chest, axilla, and neck. An early indication that
gas is entering these spaces is a rapid increase in end-tidal CO2 as
the gas is exposed to an additional large area of tissue through
which it can be absorbed before returning to the lungs for elimination. If CO2 passes into the chest and is not vented, then capnothorax may develop. In this situation, in addition to an
increasing end-tidal CO2, airway pressures are likely to increase
and lung compression leading to oxygen desaturation may occur. If
significant capnothorax or capnomediastinum occurs, then cardiac
output may be compromised. Management of this complication
depends, to some extent, on the severity of the problem. By simply
reducing the set pressure at which the capnoperitoneum is maintained, the extra-abdominal escape of gas may significantly be
reduced without impairing the operative view of the surgeon. If
extra-abdominal CO2 results in significant cardiac or respiratory
compromise, then the capnoperitoneum should be evacuated at
once. It may be necessary in some cases to consider insertion of
an intercostal drain to vent gas that passes into the left chest. If significant surgical emphysema has developed during the procedure,
then a reservoir of CO2 will have built up and patients should not
be extubated until normocarbia has been achieved.
Although capnothorax is more likely to occur in the setting of
MIO, barotrauma as a complication of high ventilatory pressures
during laparoscopy may result in pneumomediastinum, pneumothorax, and subcutaneous air emphysema. This constitutes a
greater risk than extra-peritoneal CO2 because of the reduced solubility of air.

Postoperative pain control

Even with the reduction in trauma of access, MIO may still result
in significant postoperative pain unless optimal multimodal analgesia is utilized. Effective analgesia is essential for prompt

46

extubation, rapid recovery, and early mobilization. In addition to

regular postoperative simple analgesia, some sort of regional technique is essential. Either paravertebral or epidural analgesia is
commonly used. Paravertebral block has recently been shown to
provide analgesia comparable with a thoracic epidural after thoracotomy, but may be associated with reduced incidence of failed
block and reduced side-effects including hypotension and urinary
retention.13 In addition, pulmonary complications may occur more
commonly in patients managed with a thoracic epidural rather than
a paravertebral nerve block. This increase in pulmonary problems
may be explained by the sympathetic block caused by a thoracic
epidural that results in additional fluid administration to correct the
epidural-induced hypotension. The effect of thoracic epidural
analgesia on gastric blood flow has been investigated, but the findings of studies are conflicting.14,15 While vasodilatation, secondary
to an epidural-induced sympathetic block might be expected to
increase blood flow to the gastric tube, thoracic epidural administration of bupivacaine has been shown to decrease both systemic
blood pressure and blood flow at the anastamotic end of a newly
formed gastric tube. Moreover, an adrenaline infusion was shown
to reverse this reduction in blood flow and the authors of this study
cautioned against accepting intraoperative hypotension secondary
to thoracic epidural block during oesophagectomy.15
The paravertebral catheter can be placed by the surgeon under
thoracoscopic guidance at the end of the thoracoscopic dissection
and local anaesthetic infused during the remainder of the procedure
and run for 45 days after operation. Additional opioid analgesia
is likely to be required if a paravertebral infusion is used and this
is best provided by patient-controlled analgesia (PCA). PCA opiod
requirements can be reduced by regular co-administration of
simple analgesia, including paracetamol, that can be administered
i.v. and non-steroidal anti-inflammatory drugs (NSAIDS). NSAIDS
should be used with caution if the patient has low urine output and
should be withdrawn if renal function deteriorates.

Complications
Complications are common after either open or minimally invasive
oesophagectomy and are shown in Table 3.
Some complications may be more common in MIO than with
open oesophagectomy though the reasons remain unclear. The risk
of thermal injury to the airway by diathermy may be higher during
thoracoscopic mobilization of the oesophagus compared with open
Table 3 Complications of oesophagectomy
Complications
Pulmonary failure: acute lung injury/adult respiratory distress syndrome/infection
Chylothorax
Gastric conduit failure: anastomotic leak/gastric tube necrosis
Airway injury
Recurrent laryngeal nerve injury
Atrial fibrillation
Thrombo-embolic complications

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Physiological
system

Anaesthesia for MIO

surgery, and it has been recommended that surgeons new to

MIO should avoid resection of tumours of the proximal third of
the oesophagus which may be adherent to the airway.4 Gastric tube
ischaemia and anastomotic leak may also be more common in
MIO. There is some evidence that ischaemic conditioning of the
stomach by left gastric artery ligation at laparoscopy a few weeks
before oesophagectomy may improve the vascularity of the
gastric conduit and reduce the risk of this complication. Above
all, effective communication between surgeon and anaesthetist is
vital to avoid a number of potentially serious intraoperative
problems.

5. Schilling T, Kozian A, Kretzschmar M et al. Effects of propofol and desflurane anaesthesia on the alveolar response to one-lung ventilation. Br J
Anaesth 2007; 99: 36875
6. De Conno E, Steurer MP, Wittlinger M et al. Anaesthetic-induced
improvement of the inflammatory response to one-lung anaesthesia.
Anesthesiology 2009; 110: 131626
7. Sherry K. Management of patients undergoing oesophagectomy. In: Gray
AJG, Hoile RW, Ingram GS, Sherry KM, eds. The Report of the National
Confidential Enquiry into Perioperative Deaths 1996/1997. London:
NCEPOD, 1998; 5761
8. Ehrenfeld JM, Walsh JL, Sandberg WS. Right and left-sided Mallinckrodt
double-lumen tubes have identical clinical performance. Anesth Analg
2008; 106: 184752
9. Pennefather SH, Russel GN. Placement of double lumen tubestime to
shed light on an old problem. Br J Anaesth 2000; 84: 30810

Conclusions

References

10. Tandon S, Batchelor A, Bullock R et al. Peri-operative risk factors for

acute lung injury after elective oesophagectomy. Br J Anaesth 2001; 86:
633 8
11. Unzueta MC, Casas JI, Moral MV. Pressure-controlled versus volumecontrolled ventilation during one-lung ventilation for thoracic surgery.
Anesth Analg 2007; 104: 1029 33
12. Collaborative Study Group on Perioperative ScvO2 Monitoring.
Multicentre study on peri and postoperative central venous oxygen
saturation in high-risk surgical patients. Crit Care 2006; R158: http://
ccforum.com/content/10/6/R158.

1. Luketich JD, Alvelo-Rivera M, Buenaventura PO et al. Minimally invasive

esophagectomy. Ann Surgery 2003; 238: 48695

13. Davies RG, Myles PS, Graham JM. A comparison of the analgesic
efficacy and side-effects of paravertebral vs. epidural blockade for
thoracotomya systematic review and meta-analysis of randomized
trials. Br J Anaesth 2006; 96: 41826

2. National Institute for Health and Clinical Excellence. Thoracoscopically

Assisted Oesophagectomy. London: National Institute for Health and
Clinical Excellence, 2006; http://guidance.nice.org.uk/IPG189

14. Michelet P, Roch A, DJourno X et al. Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy. Acta Anaesthesiol Scand
2007; 51: 58794

3. Department of Health. A Pathological Concern. Understanding the Rise in

Oesophageal Cancer. Annual Report of the Chief Medical Officer on the State
of Public Health. Department of Health, 2007

15. Al-Rawi OY, Pennefather SH, Page RD, Dave I, Russell GN. The effect
of thoracic epidural bupivacaine and an intravenous adrenaline infusion
on gastric tube blood flow during esophagectomy. Anesth Analg 2008;
106: 884 7

4. The Association of Upper Gastrointestinal Surgeons (AUGIS). A

Consensus View and Recommendations on the Development and Practise of
Minimally Invasive Oesophagectomy. The Association of Upper
Gastrointestinal Surgeons (AUGIS), 2009; www.augis.org/news/
documents/MIO_Consensus.pdf

Please see multiple choice questions 7 9

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Minimally invasive techniques for oesophagectomy have the

potential to reduce postoperative pain, improve recovery, and
hasten the patients return to a normal quality of life. MIO presents
a number of anaesthetic challenges, some unique to the procedure,
and demands an understanding of the specific surgical steps undertaken and recognition of the potential complications of one lung
anaesthesia and extra-peritoneal spread of carbon dioxide.