Transcript Surgical considerations- summary of procedure including steps

Gastric Resection: General
Surgical and Anesthetic
Considerations
Natalya Hasan, MD
Gastric Resections
 Indicated for Gastric CA (Adenocarcinoma - 95%; Gastrointestinal
Stromal Tumors, lymphomas, leiomyosarcomas, carcinoids, or sarcomas
-5%)
 21,000 diagnosed annually -> 10,570 yearly mortality
 5-year survival 27% between 1995 and 2005 (vs. 16% between 1975
and 1977)
 Most cancers are diagnosed at an advanced stage
Gastric Adenocarcinoma
GIST
Who gets operated on?
• For localized cancers:
• Resection + adjuvant or perioperative chemotherapy or
chemoradiotherapy offers the best chance of survival
• Abdominal exploration with curative intent is undertaken
UNLESS:
• unequivocal evidence of disseminated disease
• major vascular invasion
• medical contraindications to surgery.
Surgical Considerations: Pre-Op Eval
 Pre-Op Eval is aimed at staging
 Physical exam - specifically lymphadenopathy (e.g. Virchow’s node), abdominal and
rectal exams
Computed tomography
Useful for identifying distal metastases, ascites, or carcinomatosis
Does not reliably assess the depth of tumor invasion of the stomach
wall or regional nodal involvement
Often underestimate the extent of disease, principally because of
radiographically undetectable metastases involving the liver and
peritoneum
Intraoperative Evaluations:
Endoscopic Ultrasound
• May provide more accurate staging
evaluation of the tumor (T) and
nodal (N) stage than CT and also
allows for preoperative biopsies.
• Identifies pts who will benefit from
neoadjuvant therapy (i.e. chemo
prior to surgical treatment)
• Identifies tumors that may be
amenable to endoscopic mucosal
resection.
Intraoperative Evaluations:
Staging Laparoscopy
• May identify radiographically occult metastases
• Allows for direct visualization of the liver surface,
peritoneum, and local lymph nodes, and permits biopsy of
any suspicious lesions.
• Identifies peritoneal metastases in up to 20 to 30% of
patients with a negative CT (e.g. those who would have
been considered as candidates for resection)
• Pts with positive peritoneal washings but without evidence of
intraperitoneal metastases can undergo neoadjuvant
therapy. Laparoscopy is repeated. If repeat peritoneal
washings show negative cytology, pts can then be
considered candidates for resection.
Approaches
Though some superficial cancers can be treated
endoscopically, gastrectomy is the most widely
used approach
Total gastrectomy - usually performed for lesions in the
upper third (proximal) stomach
Distal subtotal gastrectomy - performed for tumors in the
distal (lower two-thirds) of the stomach
Gastric resections are increasingly performed
laparoscopically
Overview of Open Gastric
Resection
Overview of Open Gastric Resections
 Midline incision
 Lateral segment of liver is retracted to patient’s right to expose the
esophagogastric junction
 Omentum is removed from the colon
 Vessels to the stomach are individually ligated and divided
 Short gastric vessels on the greater curvature are difficult to
reach
 Potential source of blood loss
 Splenic injury may occur at this time if the capsule is torn during
exposure to the short gastrics
 Left gastric artery ligation can be another potential source of
blood loss
 Antrum and pylorus are resected in both total and partial
gastrectomy
 Lymph node dissection is typically performed
Roux en what?
After gastric resection, intestinal
continuity is achieved:
 After total gastrectomy, a
Roux limb of jejunum is
brought up to the distal
esophagus
 After partial gastrectomy, a
Roux limb or loop of jejunum
is connected to the stomach
 Anastomosis is handsewn or
stapled
Mortality in the
Paleolithic Era:
100%
Current Mortality:
Total gastrectomy: 2%
Partial gastrectomy: 1%
Anesthetic Considerations
PRE-OP
 Respiratory: Identify pts with co-occurring diseases, such
as COPD or asthma. Smoking history should be obtained.
Review imaging (most patients should have XRAY or CT
as part of their staging workup).
 Cardiovascular: Most patients will be male and > 50 years
old. Pre-op EKG is generally indicated. Pts with poor PO
intake may be hypovolemic, and potentially more unstable
intraoperatively.
Probably not the best candidate for
surgery.
Anesthesia Pre-Op Continued
 Heme: Hypovolemia may mask anemia. CBC should be
checked pre-operatively.
 EBL is 100-500 for partial gastrectomy
 500 or more for total gastrectomy.
 GI: Some pts may have GERD, delayed gastric emptying, or
food contents in the lower part of their esophagus. Pre-op eval
should focus on PO intake, dysphagia, GERD, etc.
Anesthetic Considerations
INTRAOPERATIVE
 Consider thoracic epidural prior to induction.
 Induction: RSI with cricoid pressure (controversial - please refer to the
lecture slides dedicated to cricoid pressure)
 Maintenance: Standard. Ongoing muscle relaxation is often requested
by the surgeons, especially if they are having difficulty (e.g. during
exposure of the vessels or closing).
 Fluids: No consensus yet. However, running fluids in for the duration of
the case is unequivocally undesirable. Please refer to slides on fluid
management.
 Emergence: Anticipate extubation in most patients (except for those
with underlying medical issues - e.g. COPD with FEV <1L - or in pts
who have received significant volumes of IV fluids and blood products
intraoperatively)
 Access: 2 large IV
 Monitoring: Standard +/- arterial line (in total gastrectomy or if indicated
by pt history) +/- CVP in pts with difficult access
 Positioning: Laparoscopic - supine, Transthoracic - lateral decubitus.
Anesthetic Considerations:
Complications
• Make sure you are in communication with the surgeons
during stapling.
• It is quite undesirable to staple the NG/OG (or any foreign body
for that matter) into the anastomosis or within the stomach
closure.
• Some surgeons are so fearful of this complication that they’ll
ask you many times if EVERYTHING has been removed from
the mouth (OG/NG, temp probe, bite block).
• Technically, it’s not okay to say yes (since hopefully your
orotracheal tube is still in place). Preferably, you’ll state that
“Everything is out of the mouth except for the orotracheal
tube” after you have inspected the oral cavity with your eyes
and fingers. Make sure you check behind the ETT - that’s one
of the temp probe’s favorite hiding places!
Speaking of Oro- and Nasogastric Tubes…
Why do we place a NGT?
Contrary to what the patient on the left would make you think,
a nasogastric tube is more than just a little tube in your
patient’s nose (even the mannequin looks uncomfortable).
Besides the right-main stem intubation, what else is wrong
with this picture?
Oops! This can happen to you. Watch your tidal volumes when you place
the NGT (or temp probe). If you’re unsure, use a laryngoscope.
Complications of NGT
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Epistaxis
Sinusitis
Nasal alar ulceration/necrosis
Gastritis
Perforation
Aspiration (by preventing lower esophageal sphincter from
closing entirely)
 Intracranial placement!
Nasogastric tubes: A little
history
Nasogastric tubes have been used for over 200 years for
decompression of the bowel. Until the last decade, prophylactic
insertion had been considered the “standard of care” for
intraabdominal operations with the intended goals of:
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gastric decompression
decreased nausea and vomiting
decreased distension
decreased pulmonary aspiration
and pneumonia
decreased wound separation and infection
decreased fascial dehiscence and hernia
earlier return of bowel function
earlier discharge from hospital.
Sounds great! But, a little evidence would be nice…
Prophylactic nasogastric decompression after abdominal
surgery. Cochrane Database Syst Rev. 2007
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Systematic review of 33 trials (5240 patients)
Patients randomly assigned to no nasogastric tube (early removal <24
hours after surgery included in this group) vs. standard nasogastric tube
placement (up until the return of bowel function)
“No tube group”
• Earlier return of bowel function (p<0.00001), a
• decrease in pulmonary complications (p=0.09) and an
• Insignificant trend toward increase in risk of wound infection (p=0.22)
and ventral hernia (0.09).
• Decreased length of stay
• Increased vomiting
“Tube group”
• Less vomiting, but with increased patient discomfort
• No adverse events specifically related to tube insertion
Shortcomings:
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Reviewers remark that the “heterogeneity encountered in these analyses make
rigorous conclusion difficult to draw for this outcome.
Laparoscopic abdominal surgeries excluded
Meta-analysis of the need for nasogastric or nasojejunal
decompression after gastrectomy for gastric cancer.
• Five randomized-controlled trials, 717 patients
• Randomization to routine tube vs. no tube
• Findings
• Time to oral diet was significantly shorter in the latter group
(though, on average, only a half-day sooner)
• Time to flatus, anastomotic leakage, pulmonary complications,
length of hospital stay, morbidity and mortality were similar in
both groups.
• Authors Conclusion: “Routine nasogastric or nasojejunal
decompression is unnecessary after gastrectomy for gastric cancer.”
Assessment of routine elimination of postoperative
nasogastric decompression after Roux-en-Y gastric
bypass.
Background: Anastomotic disruption after surgical intervention is an
infrequent complication, but may lead to severe morbidity and
mortality when it occurs. Of the various gastric procedures, the Rouxen-Y gastric bypass (RYGB) has one of the highest risks for
anastomotic leakage. Consequently, a nasogastric tube (NGT) is
frequently placed when these operations are performed.
 Retrospective study 1067 patients, 56 had NGTs routinely placed
 No difference in the rate of leaks between the 2 groups
 Also found no increase risk of other complications (though the study
has questionable power)
 Conclusions. Our findings suggest that routine placement of an NGT
after RYGB is unnecessary.
Nasogastric Tubes:
Conclusions
 We’re no longer in the 1800’s (or the 1900’s for that
matter)
 Likely increase pulmonary complications
 Do not speed the return of gastrointestinal function
(and may actually delay the return of function)
 Should be removed within 24 hours post-operatively.
Per our Stanford surgeons, NGT is removed on POD
#1 after gastrectomy. Exception is esophageal
anastomsis (after total gastrectomy or Ivor Lewis); if
swallow is functional, NGT is removed on POD 5.
 Should not be left in during stapling - pay attention!!!
References
 Huerta S, Arteaga JR, Sawicki MP, Liu CD, Livingston EH. Assessment
of routine elimination of postoperative nasogastric decompression after
Roux-en-Y gastric bypass. Surgery 2002; 132:844-848.
 Jaffe Richard and Stanley Samuels. Anesthesiologist’s manual of
surgical procedures. Philadelphia: Lippincott Williams and Williams,
2004.
 Mansfield, PF. Clinical features, diagnosis, and staging of gastric
cancer. In: UpToDate, Tanabe, KK (Ed), UpToDage, Waltham, MA,
2011.
 Mansfield, PF. Invasive gastric cancer: Surgery and prognosis. In:
UpToDate, Tanabe, KK (Ed), UpToDage, Waltham, MA, 2011.
 Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression
after abdominal surgery. Cochrane Database Syst Rev. 2007 Jul
18;(3):CD004929.
 Yang Z, Zheng Q, Wang Z. Meta-analysis of the need for nasogastric or
nasojejunal decompression after gastrectomy for gastric cancer. Br J
Surg. 2008 Jul;95(7):809-16.