Title: Gastric Resection: General Surgical and Anesthetic Considerations
1Gastric Resection General Surgical and
Anesthetic Considerations
Natalya Hasan, MD
2Gastric Resections
- Indicated for Gastric CA (Adenocarcinoma - 95
Gastrointestinal Stromal Tumors, lymphomas,
leiomyosarcomas, carcinoids, or sarcomas -5) - 21,000 diagnosed annually -gt 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
GIST
Gastric Adenocarcinoma
3Who 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.
4Surgical Considerations Pre-Op Eval
- Pre-Op Eval is aimed at staging
- Physical exam - specifically lymphadenopathy
(e.g. Virchows 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
5Intraoperative 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.
6Intraoperative 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.
7Approaches
- 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
8Overview of Open Gastric Resection
9Overview of Open Gastric Resections
- Midline incision
- Lateral segment of liver is retracted to
patients 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
10Roux 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
11Mortality in the Paleolithic Era 100 Current
Mortality Total gastrectomy 2 Partial
gastrectomy 1
12Anesthetic ConsiderationsPRE-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 gt
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.
13Anesthesia 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.
14Anesthetic ConsiderationsINTRAOPERATIVE
- 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 lt1L - 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.
15Anesthetic 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 theyll ask you many times if EVERYTHING has
been removed from the mouth (OG/NG, temp probe,
bite block). - Technically, its not okay to say yes (since
hopefully your orotracheal tube is still in
place). Preferably, youll 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 - thats one of the temp probes
favorite hiding places!
16Speaking of Oro- and Naso-gastric Tubes
17Why 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 patients nose (even
the mannequin looks uncomfortable).
18Besides the right-main stem intubation, what else
is wrong with this picture?
19Oops! This can happen to you. Watch your tidal
volumes when you place the NGT (or temp probe).
If youre unsure, use a laryngoscope.
20Complications of NGT
- Epistaxis
- Sinusitis
- Nasal alar ulceration/necrosis
- Gastritis
- Perforation
- Aspiration (by preventing lower esophageal
sphincter from closing entirely) - Intracranial placement!
21Nasogastric 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 - 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
22Prophylactic nasogastric decompression after
abdominal surgery. Cochrane Database Syst Rev.
2007
- Systematic review of 33 trials (5240 patients)
- Patients randomly assigned to no nasogastric tube
(early removal lt24 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 (plt0.00001), a
- decrease in pulmonary complications (p0.09) and
an - Insignificant trend toward increase in risk of
wound infection (p0.22) 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
- Reviewers remark that the heterogeneity
encountered in these analyses make rigorous
conclusion difficult to draw for this outcome. - Laparoscopic abdominal surgeries excluded
- .
23Meta-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.
24Assessment 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
Roux-en-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.
25Nasogastric Tubes Conclusions
- Were no longer in the 1800s (or the 1900s 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!!!
26References
- 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
132844-848. - Jaffe Richard and Stanley Samuels.
Anesthesiologists 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 Jul95(7)809-16.