Oesophageal cancer for Ivor Lewis oesophagectomy61-year-old man, 60 kg, for elective Ivor Lewis oesophagectomy: laparotomy

The patient

The examiner asks

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1. Consider

   What are your concerns?

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   • A 61-year-old, malnourished after chemotherapy, for elective two-stage Ivor Lewis oesophagectomy. Patient
   • High-morbidity surgery; the serious complications are mostly cardiovascular, and lung injury is common. Surgery
   • 5-fluorouracil can cause myocardial ischaemia; cisplatin damages kidneys and wastes magnesium. Disease
   • He regurgitates, so aspiration at induction is a real risk. Airway
   • Alcohol until 2 days ago: withdrawal peaks at 24–36 hours, delirium tremens at 2–4 days. Disease

2. Prepare

   What do you check and arrange before his surgery?

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   • He is malnourished after losing 9 kg; dietitian involved and feeding planned. Disease
   • ECG and echo for 5-fluorouracil effects; kidney function for cisplatin.
   • Magnesium replaced: 1–2 g IV over 15 minutes.
   • Withdrawal watched with a CIWA-Ar score; benzodiazepines given for symptoms.
   • Thoracic epidural: fewer lung complications and earlier gut function. Surgery
   • Epidural uses a hydrophilic opioid with local, to cover both incisions.

3. Plan

   Describe your anaesthetic.

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   • Arterial line and right internal jugular line; his left neck stays free for the surgeon. Surgery
   • His reflux means rapid sequence induction, with an assistant applying cricoid pressure. Airway
   • Left double-lumen tube or a right-sided blocker for the thoracic phase.
   • One-lung: 5 mL/kg with 5 cmH2O PEEP to limit the inflammatory response. Disease
   • Goal-directed, restrictive fluids; extra fluid brings lung complications.
   • Once he's filled, vasopressor keeps the conduit perfused; hypotension starves the anastomosis. Surgery
   • Extubated in theatre if he meets the usual criteria. After surgery

4. Crisis

   During thoracic mobilisation BP drops to 64/40, HR 104, while the surgeon retracts near the heart. What do you do?

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   • Compression of his heart and venous return: ask the surgeon to release now. (Crisis)
   • Phenylephrine 50–100 mcg while the pressure comes back.
   • If it recovers at once, we agree on shorter, gentler retraction.
   • If not: look for bleeding, arrhythmia and a moved tube.
   • Fluid only if he's truly empty, given his lung risk.

5. Crisis

   On day 4 he develops AF at 150/min, BP 104/62, temperature 38.4°C, and needs more oxygen. What do you do?

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   • Tachycardia algorithm: irregular narrow complex at 150, and he is stable. Crisis
   • Stable branch: slow the rate with metoprolol 2.5–5 mg over 2 minutes, or esmolol 500 mcg/kg over 1 minute.
   • Diltiazem 0.25 mg/kg over 2 minutes is the alternative; if these fail, amiodarone 300 mg over 1 hour.
   • Synchronised cardioversion at 200 J or more if he becomes unstable; potassium and magnesium corrected.
   • Fever and a rising oxygen need on day 4: I exclude an anastomotic leak.
   • Antibiotics within the hour, imaging, and early surgery if a leak is confirmed.
   • Late withdrawal is less likely by day 4, but I still screen him with CIWA-Ar. After surgery