Timing of extubation is a crucial issue after esophagectomy. Basically there are two concepts of extubation after esophagectomy: prolonged ventilation and early extubation. Before the introduction of thoracic epidural analgesia, studies suggested prolonged postoperative ventilation up to 2 days. However, prolonged ventilation has not been shown to decrease incidence of postoperative pulmonary complications. Moreover, there are disadvantages of this approach: sedation-related side effects, risk of aspiration, and weaning problems.

The use of thoracic epidural and shorter operative time, early extubation has been advocated to reduce mortality, morbidity, and cost after esophagectomy. Early extubation may reduce intensive stay and cost, decreases postoperative respiratory complications, and does not increase the risk of reintubation.

However, there are conditions that could require prolonged ventilation: bleeding, hemodynamic instability, respiratory insufficiency, and neurologic impairment.

After extubation supplemental oxygen administration should be used either by face mask or nasal cannula (1–6 l/min) for maintaining of oxygen saturation above 90 %. Supplemental oxygen has advantages after esophagectomy: decreased incidence of postoperative nausea and vomiting, improved wound healing, maintenance of adequate cardiac and central nervous function, and decreased incidence of arrhythmias. There are data that low oxygen delivery after esophagectomy is associated with the risk of complications [30–32].

Effective analgesia after esophagectomy is a challenging issue in anesthesia. As we noted above, this procedure often requires an abdominal, cervical incision and either thoracotomy as well.

Analgesia for thoracic procedures has been discussed extensively in another chapter of this book. However, it is important to remember that sympathetic activation caused by surgical procedure and pain manifests as tachycardia, hypertension, and increased contractility, all of which result in increased myocardial oxygen consumption. As it has been noted, most of the patients undergoing esophagectomy have cardiovascular coexisting diseases, especially ischemic heart disease (IHD). These patients’ response to surgical stress differs from that of healthy patients. Sympathetic stimulation caused by pain may constrict post-stenotic coronary arteries and reduce blood supply to the subendocardium. The difference in oxygen delivery and demand presents as postoperative myocardial ischemia. The selective sympathectomy using thoracic anesthesia in patients with IHD can dilate constricted coronary vessels, reduce heart rate, and improve cardiac function by reducing preload and afterload and optimizing myocardial oxygen delivery.

The sympathectomy of thoracic epidural analgesia causes vasodilatation in mesenteric vessels and has been shown to improve bowel function by reducing the duration of postoperative ileus, enhancing bowel blood. The increase in bowel motility from unopposed parasympathetic activity is not associated with any significant increase in anastomotic dehiscence.

In patients in whom thoracic epidural analgesia is contraindicated, there are several alternative methods. Using intercostal nerve block a catheter is placed in a paravertebral space just below the level of incision. Effectiveness of this method is mostly similar to epidural analgesia. Intravenous opioids and nonsteroid analgesics can work synergistically and can reduce postoperative pain [33–37].

Fluid management is also crucial for all thoracic surgeries including esophagectomy and has been discussed extensively in a separate chapter of this book. Anesthesiologists should consider a restrictive fluid administration in the first 24 h (<20 ml/kg, less than 2 L crystalloid and less than 1 L albumin intraoperatively with less than 3 L of total amount of crystalloids in the first 24 h).

Therefore, close monitoring of intravascular volume status is required, along with invasive hemodynamic monitoring (arterial blood pressure, central venous pressure, thermodilution techniques) and urine output [38–41].

Patients undergoing esophagectomy are frequently malnourished due to several reasons: stenosis of the esophagus by the tumor, systemic effects of the tumor, side effects of the chemotherapy, and surgery.

Most common problem in patients with esophageal cancer is difficult swallowing. These patients eat only soft, easy-to-swallow foods, primarily consume liquids. Therefore, patients with dysphagia are at risk for deficiencies in protein, fat, carbohydrate, vitamins, minerals, and total calorie.

Nutritional assessment helps to identify the nutritional status and risk of malnutrition. Nutritional history and anthropometric parameters can be inaccurate; however, assessment of the metabolically active body cells by bioelectrical impedance may solve as a better marker. Assessment of sarcopenia, defined as loss of skeletal mass and strength, helps to identify high-risk patients who require perioperative nutrition.

Biomarkers, such as albumin, transferrin, C-reactive protein, prealbumin, and retinol-binding protein, are also used in assessing nutritional condition (Table 9.2). However, in postoperative period, accuracy of these biomarkers is questionable. Medication, inflammation, changes in fluid shift and vascular permeability, and hepatic and renal function have influence on levels of biomarkers. However, data are showing that patients with hypoalbuminemia are at risk of postoperative complications compared with those who have normal albumin level.

There are several nutritional scoring systems for nutritional assessment. The Subjective Global Assessment (based on patient’s history, loss of subcutaneous fat, muscle wasting, and presence of edema or ascites) has high sensitivity and specificity. The prognostic nutritional index is focusing on serum albumin level and current and usual weight. The Nutritional Risk Screening Score is based on the severity of nutritional status. An accurate estimation of energy expenditure is important in patients with nutritional disorders. The traditionally used Harris-Benedict equation is inaccurate, and the indirect calorimetry is the gold standard method to measure caloric requirements.

It is known that malnutrition is associated with increased rate of postoperative complications (including impaired wound healing, loss of muscle tissue, reduced immunocompetence, depression, apathy, immobility, and increased frequency of decubitus and ulcer) and delayed recovery.

Benefits have been found when severely malnourished patients received nutrition support prior to surgery. There are different ways for preoperative nutrition support. Most physiological route is the enteral way. Dysphagic patients should be modifying the consistency of food. It can include normal food with accurate chewing and or soft, pureed and blenderized foods. Patients should learn to eat frequently and smaller portions, because pureed foods have larger volume than normal foods containing same calories.

If these modifications are insufficient, there are options for insertion of a nasogastric or nasojejunal tube, feeding jejunostomy, or percutaneous endoscopic gastrostomy (PEG). Nevertheless, most of the surgeons do not prefer the use of PEG because stomach is most frequently used as conduit that forms the new esophagus.

There are different methods for delivery. Continuous feeding is used if a patient is unable to tolerate large volumes of feed and usually refers to feeding over 16–20 h. In this case, feed is delivered by pump. Continuous feeding usually includes a break of at least 4 h in 24 h to allow the stomach to re-acidify. The second method is the intermittent feeding that involves periods of feeding using the pump with breaks. The third way is the bolus feeding involves the delivery of 100 mls to 300 mls over a period of 10–30 min and can be given four to six times a day depending on patients’ individual feeding regime.

There are several type of feeds is available. Standard whole-protein feeds provide 1 kcal/ml, while high-energy feeds provide 1.5 kcal/ml. High-energy feeds are useful when fluid is restricted or to reduce feeding time. Most feeds are lactose-, gluten-, and wheat-free and suitable for vegetarians.

There is no need to change the regime in diabetic patients, but blood glucose level should be monitored frequently.

Feeding tubes should be flushed with water before and after administration of feed and medication and in between medications.

It is known that enteral nutrition is cheaper than parenteral nutrition, and it is comfortable, because patients can be fed at home. Nevertheless, in severely undernourished patients who cannot be fed adequately orally or enterally, preoperative parenteral nutrition is indicated. Moreover, parenteral nutrition requires hospitalization and sophisticated nursing.

Surgical stress leads to insulin resistance and increases blood glucose levels. In diabetic patients, blood glucose should be monitored every 4–6 h. Guidelines suggest that blood glucose be maintained between 5.5 and 11 mmol/l in stressed patients and then tightened to 5.5–8.5 mmol/l once control is established.

Good oral hygiene is essential for patients receiving nutritional support or nil by mouth. Saliva is normally produced when eating and keeps the mouth clean. However, saliva production is often reduced during nutritional support and the oral mucosa can develop sores. Patients should be encouraged to brush their teeth regularly and use a suitable mouth rinse [42–52].

Regardless of the specific approach (transthoracic versus transhiatal), esophagectomy with lymphadenectomy represents a major operation with a mean operative blood loss of 3–500 ml approximately. The use of neoadjuvant chemotherapy can cause bone marrow suppression and anemia in patients undergoing esophagectomy. All of these factors require consideration of administration of blood transfusion in the perioperative period. Nevertheless, there are evidences that blood transfusion may worsen the oncologic outcome, though these reports were uncontrolled. Patients who received blood transfusion have had larger tumors, more sever medical conditions. Therefore, the relationship between cancer recurrence and death has not been clearly proven.

The ideal perioperative hemoglobin level is not clear. Keeping the hemoglobin level above 100 g/l is poorly supported with evidences. Recently, in hemodynamically stable patients, the transfusion trigger is 70 g/l.

There are evidences that the use of allogenic blood transfusion decreases survival and increases the incidence of cancer recurrence, compared with the use of autologous transfusion [53, 54].

Postoperatively, a majority of thoracic surgery patients are not able to move because of pain, respiratory distress, and age. The lack of ambulation can result in a blood stasis in lower extremities; this increases the contact time between blood and vein wall irregularities, helping a blood clot formation. The incidence of deep venous thrombosis in patients in medical and surgical intensive care units is about 10 % to 30 %. Prophylaxis with mechanical (compression stockings are applied to both lower extremities) and pharmacological methods (heparin shots are given subcutaneously twice a day) has been shown to be effective and safe in most types of surgery and should be routinely implemented. Both subcutaneous, low-dose unfractionated heparin (LDUH) and low-molecular-weight heparin (LMWH) have been shown to reduce the risk of venous thrombosis. Low-dose unfractionated heparin use does not interfere with epidural catheter placement or removal. However, LMWH should be held for 12–24 h before epidural placement or removal, to decrease the risk of hematoma formation. The use of LMWH for 2–3 weeks after hospital discharge in patients undergoing major cancer surgery may reduce the incidence of asymptomatic deep venous thrombosis.

Until patients are ambulating independently, they should keep the stockings on when in bed. Encourage early ambulation as well as leg and ankle exercises. Early mobilization of patients includes getting them out of bed to a chair the first postoperative day and three times each day thereafter [54, 55].

Chest tubes are indwelling catheters placed into the pleural space to evacuate air and fluids and maintain a physiological negative pleural pressure. Air collects at the less dependent part (apically or retrosternal, depending on patient’s position), and fluid collects at the lower part of the chest cavity. That’s why most guideline recommends the use of two chest tubes.

In the absence of air leak (50 ml/min in 12 h or less than 20 ml/min in 8 h), most postoperative chest tube removal protocol is based on quantity and quality of secretions. If bleeding, chylothorax, or empyema does not exist, the normal daily pleural secretion is about 350 ml. Most surgeons remove chest drains if the daily secretion is less than 300 ml.

If an air leak exists, a digital drainage system with continuous suction with (minus15 cmH2O) is recommended. If air leak reach less than 50 ml/min in 12 or 20 ml/min in 8 h, chest tubes are removable.

As chest tubes are playing major role in postoperative pain, their early removal appears to accelerate postoperative recovery [56, 57].

Respiratory complications are frequent after esophagectomy. The benefits of physiotherapy in the perioperative period have been shown by numerous studies.

It has been showed that preoperative physiotherapy (e.g., inspiratory muscle training) for two or more weeks before cardiac surgery reduced the incidence of pulmonary complications. Preoperative physiotherapy is also feasible for patients undergoing esophagectomy to preserve respiratory muscle strength.

There are two main types of breathing exercises: active cycles of breathing and using incentive spirometry. Both techniques aim to re-expand the lung with maximum sustained and fractional inspiration and clear airways with assisted cough.

For both types of exercises, patients must be in upright position either in bed or chair. During active cycle of breathing, patients must place hand over upper abdomen and take slow deep breaths and hold for 3–5 s and repeat four to five times. After this cycle, the patient has to huff as this maneuver helps move phlegm to clear.

Using incentive spirometer, patient inhales from the spirometer and holds breath as long as it is possible. This should be practiced up to ten breaths per hour. It is important to mobilize patients as soon as possible after esophagectomy to prevent postoperative complications such as pneumonia and deep vein thrombosis. At the first day, the aim is to sit in chair that can help to improve lungs by increasing the depth of each breath. By the second postoperative day, patients should aim to walk with assistance on the ward and increase gradually the exercise tolerance.

Due to the wound and chest drains, patients may be reluctant to move arm on the operated side. It is important to practice shoulder mobility to prevent joint stiffness [24, 58–61].

Esophageal anastomotic leak is a serious complication after esophageal surgery. Incidence is about 14 %, and the associated mortality is between 5 % and 35 %. Anastomotic leak or perforation occurs because of several conditions (ischemia or distention of conduit, poor nutrition, low serum albumin level, pressure at suture lines and anastomotic tension, intraoperative bleeding, tumor at resection margin, use of colon as conduit, drain contacts with the anastomosis). Leakage of digestive fluids, saliva, overgrowth of bacteria, and fungi in the perianastomotic tissues can lead to severe inflammation.