Letters to the Editor: Letters & Announcements
To the Editor:
A 59-yr-old patient required general anesthesia for extensive dental extractions. Six weeks earlier he had undergone Ivor Lewis esophagectomy and was currently tolerating multiple small meals. The patient was appropriately nulla per os and full stomach precautions were not felt necessary. Immediately after induction there was a large volume bilious regurgitation and aspiration. The patient developed a right upper lobe consolidation and acute respiratory distress syndrome. After a period of mechanical ventilation, the lung injury resolved and he recovered fully.
Our literature search revealed only several letters describing the risk of aspiration in patients after esophagectomy.1,2 Standard textbooks include gastroparesis as a risk for aspiration but do not specifically mention prior esophagectomy.3,4 Esophagectomy results in excision of the lower esophageal sphincter and loss of vagal innervation of the stomach. The new gastroesophageal anastomosis is made in the midesophagus (Ivor Lewis) or cervical esophagus (transhiatal). The denervated stomach requires a pyloroplasty to prevent gastric outlet obstruction. The flaccid stomach, draining only by gravity, is in a thoracic position without the protection of a lower esophageal sphincter.
Options for management include preinduction placement of a nasogastric tube to decompress the stomach, induction with the patient in the head-up position, rapid sequence induction with cricoid pressure, and awake tracheal intubation. Insertion of a nasogastric tube carries a risk of anastomotic disruption but can be safely placed 2–3 wk postoperatively if the patient is tolerating oral feeding. Although used routinely, cricoid pressure has never been definitively shown to decrease aspiration.5 The stated goal of cricoid pressure is to occlude the cervical esophagus by compressing it between the cricoid ring and vertebral bodies. Radiologic studies in normal volunteers have demonstrated that this does not reliably occur.6 Furthermore, in patients with a cervical anastomosis, the esophagus may be lateral rather than posterior to the cricoid cartilage. Survival is improving for patients with esophageal cancer and anesthesiologists can expect to encounter more patients with prior esophagectomy.
Duncan G. de Souza, MD, FRCPC
Cheryl L. Gaughen, MD
Department of Anesthesiology
University of Virginia
1.Black DR, Thangathurai D, Senthilkumar N, Roffey P, Mikhail M. High risk of aspiration and difficult intubation in post-esophagectomy patients. Acta Anaesthesiol Scand 1999;43:687
2.Jankovic ZB, Milosavljevic S, Stamenkovic D, Stojakov D, Sabljak P, Pesko P. High risk of aspiration and difficult intubation in post-esophagectomy patients. Acta Anaesthesiol Scand 2000;44:899–900
3.Gal TJ, Airway management. In: Miller RD, ed. Miller’s anesthesia. 6th ed. Philadelphia, PA: Elsevier Churchill Livingstone, 2005:1617–52
4.Tasch MD, Stoelting RK. Aspiration prevention and prophylaxis: preoperative considerations. In: Hagberg CA, ed. Benumof’s airway management. 2nd ed. Philadelphia, PA: Elsevier 2007:281–302
5.Brimacombe JR, Berry AM. Cricoid pressure. Can J Anaesth 1997;44:414–25
6.Smith KJ, Dobranowski J, Yip G, Dauphin A, Choi PT. Cricoid pressure displaces the esophagus: an observational study using magnetic resonance imaging. Anesthesiology 2003;99:60–4