38
●● Optimization of bronchodilator therapy in patients with
asthma or significant chronic obstructive airway disease.
●● Consideration of coronary revascularization with angioplasty
and coronary stenting in the presence of significant coronary
ischemia. Antithrombotic medications such as aspirin and
clopidogrel are often indicated post-coronary intervention for
a period of time. In such patients, it may be prudent to treat
them with neoadjuvant therapy, so that time is not lost in wait-
ing for an optimal time for surgery post-coronary stenting.
●● In patients with high-grade esophageal tumor stenosis, a fine-
bore nasogastric tube can be placed for nutritional support
while workup is performed and is preferable over parenteral
nutrition, gastrostomy, or jejunostomy feeding. Oral nutri-
tional supplementation is given [ 9 ].
●● Diabetic control should be optimized.
●● Immediate preoperative preparations include prophylactic
antibiotics to be given at anesthesia induction and deep vein
thrombosis prophylaxis. Bowel preparation is not necessary,
unless a colonic interposition is intended.
●● Increasingly patients who undergo esophagectomy would go
through an enhanced recovery after surgery (ERAS) protocol
[ 10 , 11 ]. This differs depending on institutions and detailed
discussion is beyond the scope of this chapter. At the author’s
institution, preoperatively it involves preoperative patient edu-
cation, pre-habilitation exercises, nutritional support in those
who are deemed to have nutritional risk, and carbohydrate
loading before surgery (see Note 1).3 Methods
The patient is first placed in the supine position for the abdominal
part of the surgery. To prepare for the subsequent right thoracot-
omy, a double-lumen endotracheal tube is usually positioned. At
the author’s institution, it is routine practice to place a single-
lumen endotracheal tube, and during the thoracotomy phase, a
right bronchial blocker is placed. This results in less airway trauma,
and the more flexible tube allows better exposure of areas behind
the trachea and also around the left main bronchus. In the thoracic
phase of surgery, the patient is placed in a full lateral decubitus
position with the right arm approximately at a right angle at the
shoulder.
Judicious use of intravenous fluid is important to avoid over-
hydration, epidural analgesia is standard practice, avoidance of
hypothermia, meticulous surgical technique to avoid blood loss are
all crucial to enhance postoperative outcome.3.1 Positioning
and Anesthetic
Technique
Simon Law