Anesthesia for esophageal cancer Part I

1
Anesthesia for esophageal cancer Part I

• Reporter R2 ???
• Supervisor VS ???

2

• Carcinoma of the esophagus
• Epidemiology and etiology
• Pathology and pathogenesis
• Diagnostic evaluation
• Treatment
• Surgical approaches
• Perioperative mortality and complications
• Preoperative evaluation and preparation
• Monitoring
• Induction of anesthesia
• Choice of tracheal tube
• Intraoperative considerations and management
• Pain management

Part I
Part II
3
Carcinoma of the Esophagus

• Most tumor are malignant
• Most prognostic factor stage of disease
• Surgical therapy offers the best chance for cure
  with a complete resection
• Squamous cell carcinoma and adenocarcinoma

4
SCC- Epidemiology and etiology

• Carcinogens Tabacco, Alcohol, Nitrosamines,
  Furacin c, Opiates, Fungal toxins, Spices
• Nutritional deficiencies Vit A, riboflavin,
  Trace elements, zinc
• Physical factorsthermal trauma, hot food or
  drinks, abrasive material (soil) and food, Lye
• Predisposing factorsTylosis, Plummer-Vinson
  syndrome, Achalasia, Celiac sprue

• Racial groupsAfrican Americansgt Caucasians
• MgtF(3-4 times)
• Age gt40 y/o
• Geographic and cultural variations

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SCC- Pathology and pathogenesis

• 50 in middle third
• 30-40 in lower third
• 10-20 in upper third
• Macroscopic vs microscopic features
• Metastases60 lymphatic
• Distant meta lungs, liver, bone

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Adenocarcinoma- Epidemiology and etiology

• Barretts metaplasia is the precursor lesion to
  esophageal adenocarcinoma(7-20?ca) (GER?chronic
  inflammation?Barretts)
• Other risk factors
• Obesity
• Ectopic gastric mucosa
• Esophageal diverticula
• Iron overload
• Alcohol use
• Polysaturated fats
• Diets high in red meat

• Age68 y/o
• MgtF
• Caucasiangt African Americans

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Diagnostic evaluation

• Initial evaluation and clinical staging
• History dysphagia, pain, weight loss,
  hoarseness, dyspnea, cough
• Physical organomegaly supraclavicular or
  cervical LAP, SVC syndrome,
• Laboratory examination
• Radiology barium swallow with UGI series,
  CT,Bone scan
• Endoscopy esophagogastroscopy,bronchoscopy,endosc
  opic ultrasound, thoracoscopy and laparoscopy
  

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Laboratory examinations

• Anemia
• Hypoproteinemia
• Hypercalcemia
• Abnormal liver function tests
• TPN associated abnormally

9
Staging

• Accurate staging is essential for treatment
  selection and prognosis.

10
Treatment
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Surgical therapy

• The best chance for cure with a complete
  resection and also provides effective palliation
  with relief of dysphagia
• Approach depends on location , extent of
  lymphadenectomy, preference of the surgeon

12
Dr. Lewis the oesophagus is a difficult
surgical field for three reasons

• its inaccessibility
• its lack of a serous coat
• its enclosure in structures where infection is
  especially dangerous and rapid

13

• Modified McKeown or Triincisional Technique
• Transhiatal esophagectomy
• Ivor Lewis esophagectomy
• Left thoracoabdominal approach
• En Bloc Resection
• Three-Field Lymph Node Dissection
• Minimally invasive techniques
• Alternate conduits

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Modified McKeown or Triincisional Technique

• Indicationsany level, benign and malignant
  conditions
• Advantages
• complete lymph node dissection in the chest
• direct visualization of intrathoracic dissection
• avoidance intrathoracic anastomosis
• maximal margins
• ? postop GERD
• Contraindicationsfusion of Rt pleural space or
  inability to support ventilation with Lt lung
• Technique

15
Technique

• Double lumen tube
• Left lateral decubitus position
• Right posterolateral thoracotomy incision
• Dissect esophagus

16

• Supine position
• Single lumen tube
• Place transverse roll under scapula, head turned
  45o to the right
• Midline laparotomy
• Mobilize left lobe of the liver, stomach, spleen,
  pylorus , divide remaining ligament

17
Transhiatal esophagectomy

• Indication
• complete lymphadenectomy may not be necessary
• poor pulmonary function
• pleural symphasis
• Contraindications
• bulky tumors of midthoracic esophagus
• scarring after neoadjuvant tx
• complete lymphadenectomy
• severe CAD or valvular dx

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Technique

• Abdominal incisiondissection of the mediastinum
  and lower esophagus bluntly into the upper chest
  through hiatus
• Cervical incisiondissection of the esophagus
• Gastric tube was drawn to neck

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Ivor Lewis esophagectomy

• Indicationssimilar to triincisional approach
• Contraindications(???anastomosis in the right
  chest)
• tumor in upper third , above carina
• long segment Barretts esophagus with extension
  into the cervical esophagus
• fused pleural space
• severely compromised lung function
• Technique

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Technique

• Supine position
• Abdomen incisionmobilize stomach,
  pyloroplasty,create gastric tube, placement of a
  J-tube?conduit is advanced into the chest as far
  as possible prior to closing abdomen
• Double lumen endotracheal tube
• Left lateral decubitus position
• Right posterolateral thoracotomy
• Dissect intrathoracic esophagus
• Divide esophagus and fashion with gastric conduit

21
Left thoracoabdominal approach

• Indicationsdistal esophageal tumor beyond 30-35
  cm with compromised physiological status
• Contraindications
• above 30cm
• distal esophageal peptic stricture

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Technique

• Double lumen tube
• Variety ways
• Supine position-midline laparotomy
• Full lateral position thoracic incision,
  abdominal dissection
• Right lateral decubitus position with abdomen
  rolled back 45o

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Alternate conduits

• Colon-right or left colon
• Jejeunum

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Stomach

• Stomach is the preferred conduit because
• Reliable blood supply, usually free of
  atherosclerotic dx
• Low intraluminal bacterial burden
• Single anastomosis
• Not available because
• Gastric surgery
• Stomach with tumor

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Colon

• Left colon
• Longer
• Less vascular anatomical variation
• Caliber more similar to esophagus
• Midline laparotomy

• Right colon
• Left colon unusable
• Diverticular dx
• Stricture
• IMA oclusion
• IMV thrombosis

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Jejeunum

• Indications
• stomach is not available
• Limited distal esophagectomy is planned
• Contraindications
• Intrinsic dx of small bowel
• Total esophageal replacement

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Perioperative mortality

• Mortality rates6-10
• Intrathoracic sepsis
• anastomotic or conduit leak
• Pulmonary etiology
• respiratory insufficiency,pneumonia,pulmonary
  embolus

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Perioperative complications

• Anastomotic leak
• Albumin lt3g/dL, positive margins, cervical
  anastomosis
• Cervical anastomosis10-15
• Intrathoracic leaklife-threatening?immediate op
• Anastomotic stricture
• Never life threatening?repeat bougie dilation
• Cervical anastomosis28, Ivor Lewis
  resection16
• Transhiatal esophagectomy, use of a stapled
  anastomosis, anastomotic leak, cardiac disease
• Recurrent laryngeal nerve injury
• Cervical gt intrathoracic anstomosis?injection or
  prosthesis implantation
• Complicationseffective cough , secretions

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Perioperative complications

• Respiratory complications
• pneumonia , atelectasis, respiratory failure
• Muscle-sparing, limited thoracotomy, epidural
  anesthesia, early ambulation
• Bleeding transthoracic gt transhiatal approach
• Chyle leak?ligation of the duct
• Postresection reflux
• Impaired conduit emptying
• Truncal vagotomy, pyloric drainage procedure,
  swelling at the pyloroplasty site, kinking of
  redundant conduit , wide conduit

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Mucosal ablation

• Thermal heater probes and lasers
• Mucosal resection
• Photodynamic therapy

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Multimodality therapy

• Radiation therapy
• Chemotherapy
• Chemoradiation therapy

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Radiation therapy

• Alone to be only effective alternative to op
• As primary tx1-,2-, and 5-year survival
  rates18,8,6
• Dose55-65Gy
• High surgical risk patient
• Advanced or metastatic dx cannot op
• Post-op R/Tdecrease local recurrence rates , not
  improve survival rates

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Chemotherapy

• Neoadjuvant C/Tdown-staging of dx in 50 pt,
  pathologic complete response rate lt10
• Neoadjuvant C/T vs op aloneno survival benefit

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Chemoradiation therapy

• Standard for nonsurgical management of locally
  advanced dx
• 2- and 5-year survival rates36,72 better then
  R/T alone
• Reduction in local recurrence and distant dx
• Substantial toxicities
• Chemoradiation OP?down-staging, improve
  survival(?)
• Cisplatin based 5-fluorouracil

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• Surgery remains the standard treatment for
  resectable esophageal cancer.
• For patient with locally advanced disease and
  those unfit for surgery, chemoradiation therapy
  appears to be a reasonable alternative.

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Outcomes

• 5 year survival rates5-12, median survival is
  23 months
• 5 year survival ratesgt80 after op in early
  identified lesions and invasion limited to
  mucosa
• Poor prognosisincrease age, African-American
  race, length of lesion, lower esophageal tumors,
  depth of invasion, metastatic spread gt5 lymph
  nodes

37
Reference

• Thoracic anesthesia 3rd , James B.
  Eisenkraft,MD, Steven M. Neustein, MD Ch.13,
  P269-277
• General thoracic surgery 6th, Thomas W. Shields
  Ch.150, P2265-2293
• Sabisten and Spencer surgery of the chest 7th,
  Frank W.sellke,Pedro J. del Nido, Scott J.
  Swanson Ch. 37,P627-649

38
Anesthesia for esophageal cancer Part II

• Reporter R2 ???
• Supervisor VS ???

39

• Carcinoma of the esophagus
• Epidemiology and etiology
• Pathology and pathogenesis
• Diagnostic evaluation
• Treatment
• Surgical approaches
• Perioperative mortality and complications
• Preoperative evaluation and preparation
• Monitoring
• Induction of anesthesia
• Choice of tracheal tube
• Intraoperative considerations and management
• Pain management

Part I
Part II
40
Clinical staging complete
No distant metastases
Distant metastases suspected
Biopsy area of suspicion
Negative
Positive
Surgical exploration
R/T or R/T C/T surgical palliation
No distant metastases
Distant metastases
Dysphagia (enteral feeding tube, esoophageal
intubation laser, or stent)
No dysphagia
Surgical resection with lymph node dissection as
possible
Surgery concluded
R/T or R/T C/T
Pathologic staging completed
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Preop evaluation and preparation
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• Aspiration
• C/T, R/T
• Airway
• Lung function
• Cardiovascular system

43

• Aspiration
• C/T, R/T
• Airway
• Lung function
• Cardiovascular system

44

• C/T
• Doxorubicin?myelosuppression, cardiomyopathy
• Bleomycin?pulmonary toxicity(5-10)
• Cough, dyspnea, basilar rales
• Hypoxemia, interstitial pneumonia and fibrosis
• Increased A-a difference for oxygen and reduced
  diffusion capacity
• Risk for ARDS postop
• R/Tpneumonitis, pericarditis, bleeding,
  myelitis, tracheoesophgeal fistula

45

• Aspiration
• C/T, R/T
• Airway
• Lung function
• Cardiovascular system

46
Radiographic findings

• Tracheal deviation or obstruction
• Mediastinal mass
• Pleural effusions
• Cardiac enlargement
• Bullous cyst
• Air-fluid levels
• Parenchymal reticulation, consolidation,
  atelectasis, edema

47

• Aspiration
• C/T, R/T
• Airway
• Lung function
• Cardiovascular system

48
Pulmonary function test
Testing phase PFT Increased operative risk result
Whole-lung tests ABG Hypercapnia on room air
Whole-lung tests Spirometry FEV1lt50 of FVC or FEV1lt2L or MBClt50 predicted
Whole-lung tests Lung volume RV/TLC gt50
Single-lung tests R-L split-function tests Predicted postop FEV1lt0.85L or gt70 blood flow to diseased lung
Mimic postop condition Temporary unilateral balloon occlusion of R or L main stem bronchus or PA Mean PAPgt40mmHg, PaCO2 gt60mmHg, or PaO2lt45mmHg
49

• Aspiration
• C/T, R/T
• Airway
• Lung function
• Cardiovascular system

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Cardiovascular system

• Pulmonary vascular and RV function
• COPD?pulmonary hypertension, increased PVR, RV
  hypertrophy and dilation
• Inability to tolerate increased in blood
  flow?Postpneumonectomy pulmonary edema
• PE, CXR, Echo, EKG
• LV function
• CAD or valvular dx
• Systemic hypertension
• Systemic hypoxemia and acidosis
• RV dysfunction

51
Preoperative preparation

• Respiratory preparation
• Stop smoking
• Dilate airways
• Loosen secretions
• Remove secretions
• Adjunct medication
• Increase motivation and postop care
• Psychological preparation
• Preop pulmonary care training
• Preop exercise
• Weight loss/gain
• Stabilize other medical problems

• Prophylaxis against AF/Af(15)
• Diltiazem
• normalize serum K and Mg
• Improving the nutritional status
• Antiacids, H2-blockers, metoclopramide

52
Monitoring

• Routine monitors
• Arterial catheter
• Central venous access
• Pulmonary arterial catheter(cardiac status)
• PiCCO?

53
Induction of anesthesia

• Awake tracheal intubation or rapid-sequence
  induction
• muscle relaxation
• mediastinal lymphadenopathy might have tracheal
  compression and collapse of the airway with the
  onset of muscle relaxation

54
Choice of tracheal tube

• DLT gt univent
• suction, CPAP, convert from two-lung to one-lung
• Univent gtDLT
• Easier to inset, not to be changed intra-op or
  post-op, properly positioned during continuous
  ventilation, selective blockade of some lobes
• Contraindications to the use of L DLT carinal
  and proximal left main stem bronchial lesions
• DLT properly positioned by clinical
  signs?fiberoptic bronchoscopy may reveal
  malpositioning 38-78
• Difficult intubationstandard single-lumen
  tubeFogarty catheter(high P, low V cuff)

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Complications of DLT

• Disruption of tracheobronchial tree
• Choose appropriately sized tube
• Not malpositioned
• Prevent overinflation of cuff
• Deflating cuff during turning
• Inflating cuff slowly
• Prevent tube from moving during turning
• Traumatic laryngitis
• Suturing of a pulmonary vessel to DLT

56
Relative contraindications to use DLT

• Full stomach
• Lesion along pathway of DLT
• Small patients(35F??, 28F??)
• Upper airway anatomy preclude safe insertion
• Extremely critically ill patients(single-lumen in
  place and will not tolerate being taken off
  mechanical ventilation and PEEP for even a short
  time)

57
Surgical approaches
Surgery Incisions Anesthetic considerations
Modified McKeown or Triincisional Technique(upper /middle) R thoracotomy Laparotomy L neck One-lung ventilation Repositioning lateral to supine No vascular access in L neck
Transhiatal (lower/middle) Laparotomy L neck Hemodynamic instability cardiac compression Perforation or tracheobronchial tree No vascular access in L neck
Ivor Lewis (lower/middle) Laparotomy R thoracotomy One-lung ventilation Repositioning supine to R-lateral
L thoracoabdominal(lower) L lateral thoracotomy to LU abdominal One-lung ventilation
Thoracoscopy laparotomy or laparoscopy(upper/middle) Port access Neck incision One-lung ventilation Potentially prolonged surgery
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Intraoperative considerations and management

• Hypotensionblood loss, IVC compression,
  manipulation of heart
• Surgical trauma to trachea?ventilating through
  endobronchial tube, advancing a single-lumen
  endotracheal tube beyond the tracheal rupture
  into the bronchus
• Avoid high concentrations of nitrous oxide when
  bowel is present in the chest
• One-lung ventilation

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One-lung ventilation plan

• Maintain two-lung ventilation until pleura is
  opened
• Dependent dung
• FiO21
• TV10 ml/kg
• RRso that PaCO240mmHg
• PEEP0-5 mmHg

• If severe hypoxemia occurs
• Check position of DLT with fiber
• Check hemodynamic status
• Nondependent lung CPAP
• Dependent lung PEEP
• Intermittent two-lung ventilation
• Clamp PA (for pneumonectomy)

60
Postoperative considerations

• Hypotenstion hypovolemia or hemorrhage
• Delayed awakening due to TPN?hypoglycemia,
  hyperosmolar coma
• Respiratory complicationsobesity, coexisting
  lung dx
• Incisional painhypoventilation, hypoxemia,
  atelectasis
• Postoperative complications
• Pneumothorax retrosternal approach

61
Postoperative pain
62

• Patient comfort, minimize pulmonary
  complications, ambulate
• Thoracic epidural analgesia?gold standard
• Cryoanalgesia (intercostal n freezing)
• Degeneration of n axons without damage support
  structure of n
• 1-3 months fully restored
• Approach from within chest
• In thoracic pain that are expected to last a long
  time
• Interpleural regional analgesia
• Paravertebral nerve block
• Subarachoid injection

63
TEA-adverse effects

• Technique-related
• 3dural perforation, postop radicular pain,
  transient peripheral n lesions
• Neuraxial blocks and anticoagulation
• Hemorrhagic complications1/150000
• Risk factorimpaired hemostasis, difficult needle
  placement, multiple punctures
• Agent
• LAmotor blockade, sympathetic blockade,hemodynami
  c changes
• Opioidssystemic side effectssedation, N/V,
  changes in GI motility, pruritus, respiratory
  depression

64
TEA-advantages

• Pulmonary function
• Stress reduction
• Myocardial function
• Oxygen delivery
• Myocardial irritability
• Easily mobilized

65
Sample analgesic protocol

• Patient60y/o, 70kg
• Preopheparin 5000U, 2 hr before epidural
• Intraop
• Epidural catheter placed before induction at
  T4-T5
• Test doselidocaine 2, 3ml, test sensory level
  at 5min
• During chest incisionboluses Fentanyl
  10ug/mlbupivacaine 0.2in 2ml increments as
  tolerated to maximum total dose of 10ml
• Epidural infusion 1-2hr after inductionboluses
  of epidural solution 2-3ml during chest closure
  guided by BP
• Postop
• PCEA with infusion rate and prn
  bolusesbupivacaine 0.1fentanyl 4ug/ml at
  6ml/hr with boluses 3ml every 20minprn, 4 hr
  maximum dose limit 40ml
• Ketorolac 15-30 mg iv every 12hr
• Famotidine 10mg every 12hr

66
TEA-optimal combination of agents

• Bupivacaine 0.1
• Fentanyl 10ug/ml
• Infusion rate0.05-0.1 ml/kg/hr
• Max. rate10ml/hr

67
Reference

• Thoracic anesthesia 3rd , James B.
  Eisenkraft,MD, Steven M. Neustein, MD Ch.13,
  P269-277
• General thoracic surgery 6th, Thomas W. Shields
  Ch.150, P2265-2293
• Sabisten and Spencer surgery of the chest 7th,
  Frank W.sellke,Pedro J. del Nido, Scott J.
  Swanson Ch. 37,P627-649
• Millers anesthesia 6th, Ch. 49, P1847-1927