Gastric Resection: General Surgical and Anesthetic Considerations

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Gastric Resection General Surgical and
Anesthetic Considerations
Natalya Hasan, MD
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Gastric 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
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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.

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Surgical 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

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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.

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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.

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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

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Overview of Open Gastric Resection
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Overview 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

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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

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Mortality in the Paleolithic Era 100 Current
Mortality Total gastrectomy 2 Partial
gastrectomy 1
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Anesthetic 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.
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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.

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Anesthetic 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.

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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 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!

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Speaking of Oro- and Naso-gastric Tubes
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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 patients nose (even
the mannequin looks uncomfortable).
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Besides the right-main stem intubation, what else
is wrong with this picture?
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Oops! This can happen to you. Watch your tidal
volumes when you place the NGT (or temp probe).
If youre unsure, use a laryngoscope.
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Complications of NGT

• Epistaxis
• Sinusitis
• Nasal alar ulceration/necrosis
• Gastritis
• Perforation
• Aspiration (by preventing lower esophageal
  sphincter from closing entirely)
• Intracranial placement!

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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
• 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

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Prophylactic 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
• .

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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.

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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
  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.

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Nasogastric 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!!!

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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
  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.