Esophageal Adenocarcinoma Methods and Protocols

45

water seal, if no lung adhesions have required lysis [ 12 ]. This

type of small drains is much more comfortable for the patient

and encourages early mobilization as no under-water seal is

needed.

The appropriate selection of surgical procedure, its meticulous

execution, and perioperative care have causal relationship with

morbidity and mortality. For most patients, a standardized clinical

pathway is helpful, along the lines of ERAS protocol (Table 1 ).

●● Most patients have endotracheal tube extubation in the recov-

ery room, unless the surgery has been prolonged, complicated,

or performed in high-risk patients.

●● Epidural analgesia is most important in postoperative pain

relief. It is continued for the first 4–5 days after surgery and

can be replaced by patient-controlled analgesia or oral medica-

tions. Adequate pain control is essential to lessen the chance of

pulmonary complications [ 13 ].

●● At the author’s unit, the nasogastric tube is usually removed

the day after surgery. Early removal of the tube results in more

comfort and facilitates coughing. There is no need to replace

the tube unless progressive dilatation of the gastroplasty is

seen, but this is uncommon with a narrow gastric tube with a

drainage procedure.

●● All patients have a bronchoscopic examination on the first

postoperative day to check for recurrent laryngeal nerve injury

although this is unusual in the absence of superior mediastinal

or cervical lymphadenectomy. Judicious use of intravenous

fluid is also important to avoid over-hydration and pulmonary

edema.

3.4 Postoperative
Management

Fig. 9 The esophago-gastrostomy has been completed at the apex of the tho-

racic cavity using a hand-sewn technique

Surgery for Esophageal Adenocarcinoma