Ivor-Lewis

One of the bigger cases we have is the Ivor-Lewis esophagectomy for cancers of the lower esophagus. We begin by placing a thoracic epidural for post-operative pain control because the incision is quite large. Then after inducing anesthesia, we place a single lumen endotracheal tube and additional lines and monitors; we always have arterial access, and sometimes opt for central venous access as well. The general surgeons start with an upper endoscopy to look at the esophageal cancer and then perform a large abdominal laparotomy to mobilize the stomach and nearby structures. After they are done, we switch out the single lumen endotracheal tube to a double lumen tube. The thoracic surgeons then cut open the chest cavity. After resecting the cancer, they have to take the stomach, freed from its moorings, and pull it up into the chest to reform the gastrointestinal tract. Because all of this happens deep within the chest, we have to deflate a lung to give the surgeons space to work. They are quite close to critical vascular and nerve structures, making it a high risk surgery. The challenges for the anesthestic management include balancing fluid goals. An open abdomen and chest causes an enormous loss of insensible evaporation, but we try to keep patients dry in thoracic surgery because wet lungs can be hard to manage. Post-operative pain control is tricky because the incision extends all the way from the ribcage down to the bellybutton; a well-placed epidural will catch the area, but a poorly placed one will be patchy. Nevertheless, for some patients, this surgery is worth it if it means that the cancer is cured.