The surgeon considering a THE must be keenly aware of clinical “red flags” that may portend major intraoperative hemorrhage or injury to the adjacent airway. In the majority of patients requiring an esophageal resection and reconstruction, THE and a CEGA are applicable. In the last reported series of 2007 THEs by the author and his associates, there were 1525 (76 %) operations for carcinoma and 482 (24 %) for benign disease (Table 4.2) [9]. In patients with achalasia, the common indications for esophageal resection were a failed prior esophagomyotomy, often with a subsequent reflux stricture, and a tortuous megaesophagus (> 6 m) [10]. Technical features unique to achalasia and increasing the likelihood of bleeding during a THE include (1) adherence of the myotomized segment to the descending thoracic aorta; deviation of the megaesophagus into the right chest; (2) larger than usual aortic esophageal arteries; and (3) a wider than usual cervical esophagus, which is more difficult to mobilize and encircle. While the need for an esophagectomy for a reflux stricture has been dramatically reduced by the advent of proton pump inhibitors (PPIs), the number of failed laparoscopic antireflux operations is increasing, many after multiple procedures, or with perihiatal mesh, often with erosion into the esophagus. In the author’s experience, the likelihood of achieving long-term reflux control and/or relief of dysphagia after two or more prior antireflux operations is so low that esophageal resection and reconstruction are the “best” alternative if a reoperation is advised. However, the decision to resect the esophagus for benign disease should not be made lightly. Complaints of occasional reflux or intermittent dysphagia associated with a recurrent hiatal hernia, for example, may be less problematic in the long run than an esophageal anastomotic stricture or chronic dumping syndrome which may follow an esophagectomy. With mesh erosion into the esophagus, there is little option other than an esophageal resection. The distal periesophageal and esophagogastric junction inflammatory reaction associated with a mesh erosion may be extensive and result in bleeding as the inflammatory mass is mobilized away from the adjacent aorta. Parenthetically, although the mesh erosion is at the esophagogastric junction, a THE and CEGA is a better option than a limited distal esophagectomy and low intrathoracic esophagogastric anastomosis, particularly in an infected field due to local sepsis from the erosion. This latter operation insures lifelong gastroesophageal reflux and should never be done for benign disease. The author has recently learned of such a patient who developed a low esophagogastric anastomotic leak following a limited transabdominal resection for mesh erosion, survived this, and presented more than 2 years later with an aorto-esophageal fistula at the site of the prior anastomotic leak—an extremely rare cause of late major hemorrhage associated with an intrathoracic esophageal anastomosis. This was controlled with an endovascular aortic stent.

While it may seem obvious, a careful history to rule out bleeding tendencies or a family history of clotting disorders should always be obtained. The patient population requiring an esophagectomy is often older, and a number of conditions more common in this group result in the need for anticoagulation and platelet inhibitors, which may result in untoward bleeding with a THE unless carefully monitored and discontinued for an appropriate time before surgery. Three of the most frequent indications for anticoagulation among these patients are chronic atrial fibrillation, coronary artery stents, and prior thromboembolic disease, particularly that in association with neoadjuvant chemotherapy and radiation therapy for esophageal carcinoma [11–13].

Portal hypertension is a relative contraindication to esophagectomy and has been responsible twice for rare massive intraoperative abdominal bleeding in our patients. The author regards the presence of ascites from liver disease as an absolute contraindication to esophagectomy. Even if untoward bleeding does not occur, venous congestion of the mobilized stomach due to portal hypertension may have devastating consequences if an esophagogastric anastomosis is attempted.

Finally, it has been the personal observation of the author that obese, “soft,” often elderly women have experienced the preponderance of intraoperative massive bleeding during a THE, perhaps being more prone to an azygos vein tear because of general tissue laxity. Such a body habitus or tissue strength does not preclude a THE, but should alert the surgeon to the need to proceed cautiously.

An epidural catheter for postoperative analgesia, a standard endotracheal tube, and a Foley catheter are routinely used. As indicated above, the patient is positioned supine. Two large bore peripheral intravenous lines and a radial artery catheter for continuous monitoring of the blood pressure are placed and well secured, and the arms are padded and placed at the sides. Although the anesthetist may feel uncomfortable about not having direct access to the IVs intraoperatively, this positioning gives the surgeon and his assistant optimal access to the neck, chest, and abdomen from both sides of the table. To avoid prolonged hypotension from cardiac displacement, the surgeon and the anesthesiologist both watch the monitored blood pressure together while the surgeon’s hand is in the posterior mediastinum performing the transhiatal esophageal mobilization. Intraoperative monitoring of urinary output is important in these patients with impaired swallowing, many of whom have had preoperative bowel prep, as hypotension due to low intravascular volume is common.