Transcript Surgical considerations- summary of procedure including

Esophagogastric Fundoplasty
Natalya Hasan, MD
Esophagogastric Fundoplasty
• Performed with intent to prevent
esophageal reflux in the
following:
– Persistent or recurrent symptoms
despite maximizing medical therapy
– Noncompliance
– Severe esophagitis by endoscopy
– Benign stricture
– Barrett's columnar-lined epithelium
(without severe dysplasia or
carcinoma)
– Recurrent pulmonary symptoms (eg,
aspiration, pneumonia) in
association with GERD
– Laryngeal symptoms
– Asthma
Surgical Considerations
Pre-operative evaluation of surgical candidates
is not standardized. Generally, pts will have
undergone at least one of the following:
– Endoscopy - possibly one of the only preoperative tests if esophagitis is evident
– Esophageal manometry - highly valuable
as it can reveal disease states in which
fundoplication would be contraindicated
(e.g. achalasia or scleroderma). In
addition, there is evidence, albeit
inconclusive, that certain surgical
approaches may be more efficacious if
dysmotility is present
Surgical Considerations: Pre-op Eval Cont’d
– Esophageal pH monitoring - not
highly specific as it generally will
reveal increased acid exposure
– Gastric emptying - of questionable
value. It may reveal other etiologies
of dyspepsia, but generally is done
before surgery is even considered
– Esophageal length — usually
assessed by a set of plain films. If a
markedly shortened esophagus or a
large hiatal hernia that does not
reduce in the upright position,
surgeons may be inclined to perform
a transthoracic approach
Approaches
• Transabdominal
(open or laparoscopic)
• Left Transthoracic
Types of Fundoplasty
Toupet
Hill
Belsey Mark IV
Nissen
http://www.nature.com/gimo/contents/pt1/images/gimo56-f8.jpg
https://www.hon.ch/OESO/books/Vol_5_Eso_Junction/Articles/Images/2772f1.jpg
Approaches
• Most common - Nissen Fundoplication: anterior and posterior walls
of stomach are sutured together around the lower esophagus with
nonabsorbable sutures
– Laparoscopic (LNF)
• Initially met with skepticism
• One RCT was prematurely terminated as it revealed that LNF
was associated with a higher risk of developing dysphagia (and
subsequent reoperation) than conventional Nissen (this criticism
was later theorized to be attributable to surgeon’s experience).
• More recent RCTs have shown that the LNF is not inferior, and
may even be superior, to the open approach in that it is
associated with fewer in-hospital complications and shorter
hospitalization when performed by experienced surgeons.
– Open - can be performed via transthoracic or transabdominal
approach
Anesthetic Considerations
PRE-OP
• Respiratory: Identify pts with hx of smoking, aspiration or asthma.
Ordering a CXR prior to the case is not likely to change your
management unless you think the pt has a current aspiration
pneumonitis or asthma exacerbation.
• Hematologic: Though EBL is usually <300, a pre-op CBC is often
ordered.
• GI: Obviously these patients have severe GERD. Pts should be
encouraged to take their usual dose of PPI or H2 blocker on the AM
of surgery.
Pre-op (continued)
•
Cardiovascular: Patients presenting for an
esophagogastric fundoplasty will be a
variety of ages and possibly with multiple
comorbidities.
– The concept of “linked angina” describes the
cardio-oesophageal reflex in pts with CAD.
Studies have revealed that esophageal acid
stimulation can reduce coronary blood flow in
pts with CAD (i.e. non-cardiac chest pain can
invoke cardiac chest pain). It is theorized that
vagal tone plays a role, though neither the
concept of linked angina nor the mechanism
has been proven with certainty.
– ASK about exercise tolerance
Anesthetic Considerations
INTRAOPERATIVE
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Induction: Modified RSI with cricoid (please refer to lecture slides
dedicated to cricoid pressure for an evidence-based discussion). Pts with
concomitant reactive airway disease may need beta-agonists following
intubation.
Maintenance: Standard inhalational or IV. Ongoing muscle relaxation or
deepening of the anesthetic during certain times (e.g. trocar insertion or
abdominal closure) will optimize surgical conditions. Nitrous should be
avoided (increases volume of pneumoperitoneum, implicated in PONV).
Emergence: Anticipate extubation. These patients are not ideal candidates
for deep extubation given their hx of GERD and aspiration risk. As with
induction, pts with reactive airway disease may have bronchospasm on
emergence. Consider nebulizer treatment in PACU.
Access: 1-2 IV
Monitoring: Standard +/- arterial line if indicated by pt history +/- CVP in
pts with difficult access
Positioning: Laparoscopic - supine, Transthoracic - lateral decubitus.
Clinical Scenario
Pt is a 75 yo M, DM, HTN, COPD, former skin popper with esophagitis refractory
to medical management who presents for a laparoscopic Nissen. After
several attempts by you and your attending, the patient is getting quite upset
and suggests that you just use a mask to put him to sleep.
What do you do?
Clinical Scenario
You decide that he is not a good candidate for a mask induction given his GERD
and decide to place a central line. You consent the patient, citing the risks of
a central venous catheter as:
1.
2.
3.
4.
5.
(try to fill in the blanks…answers will be revealed in later slide)
Clinical Scenario
You masterfully catheterize the right internal jugular vein using ultrasound
guidance (and the needle-guide, of course, since you attended the central
line placement workshop as a CA-1) in the OR. After placing standard
monitors, you proceed with a rapid sequence induction with cricoid pressure.
During direct laryngoscopy, you can’t see anything but the epiglottis. You’re
surprised because the patient had been a Grade I view during a prior
laryngoscopy.
WHAT MIGHT BE THE PROBLEM?
Clinical Scenario
You suspect that the cricoid pressure of your very heavy-handed circulator might
be the problem. After readjusting your assistant’s hand, the patients vocal
cords come into view and you intubate the trachea. You secure the tube,
hand off to the surgeons, and get started on charting.
You check the schedule for tomorrow and see that you’re doing a hepatic
resection. You call your anesthesia buddy who tells you to plan for an arterial
line and central line because “that’s what we usually do.” So, you think to
yourself, when should I place a central line?
Central Lines:
Common Indications
* Hemodynamic monitoring - CVP via standard central venous
catheters (vs. PCWP, CO, et al. via Swan-Ganz)
* Administration of medications - e.g. infusions of pressors, TPN,
chemotherapy
* Transvenous cardiac pacing
* Plasmapheresis, apheresis, hemodialysis, or continuous renal
replacement therapy (requires special catheters that allow for
high-flow - e.g. Quinton catheter, Trialysis catheter)
* Poor peripheral venous access
Central Lines:
Complications
•Infection (subclavian < internal jugular <<< femoral)
•Arrhythmias
•Vascular injury
•Pneumothorax
•Venous air embolism (on removal or with large
boluses of air)
•Bleeding
Review: The Tracing
Clinical Scenario
You place a central line for the hepatic resection.
The surgical attending says he needs you to
keep the CVP low especially during the
Pringle maneuver…
1) Why?
2) Is this a surgical myth or evidence-based?
The role of central venous pressure and type of vascular
control in blood loss during major liver resections
 Compares CVP ≤ 5 vs. ≥ 6 as well as method of vascular control (Pringle
vs. Selective Hepatic Vascular Exclusion) in peri-operative bleeding and
other outcomes (ICU stay, Hospital stay, Infection, et al.)
 Significant differences:
– Blood loss with CVP ≥ 6 + Pringle = 1250 [250 to 2,850]
– Blood loss with CVP ≤ 5 + Pringle = 780 [150 to 3,100]
– Blood loss between the Pringle maneuver and SHVE was observed,
only when CVP ≥ 6
– Hospital stay was also significantly longer in patients operated on
with CVP ≥ 6 than in patients with CVP ≤ 5
– Authors’ Conclusions: Elevated CVP during major liver resections
results in greater blood loss and a longer hospital stay. SHVEhas
been shown not to be affected by CVP levels and should be used
whenever CVP remains high despite adequate anesthetic
management.
Issues?
• Authors make no mention of CVP trends. The only
value considered was the CVP at time of
commencement of liver resection.
• The authors attribute the differences in post-op
hospital stay to increased transfusion in the higher
CVP group due to increased blood loss…but, those
pts might have had higher CVPs due to comorbidities not present in the low CVP group (e.g.
right heart failure) or elevated CVP as a result of
ventilatory strategy (e.g. lung disease necessitating
higher PEEP)
Related article (same conclusion, similar
shortcomings)
• Wang WD, Liang LJ, Huang XQ, Yin XY. Low
central venous pressure reduces blood loss
in hepatectomy. World J Gastroenterol. 2006
Feb 14;12(6)
What about CVP and fluid
management?
• Fact or fiction? Intraoperative CVP is a good
indicator of fluid status.
Intraoperative CVP is probably NOT a good
indicator of fluid status.
– Marik PE, Baram M, Vahid B. Does central venous pressure
predict fluid responsiveness? Chest 2008 (134): 172-178.
– Gelman S. Venous function and central venous pressure: A
physiologic story. Anesthesiology 2008 (108): 735-748.
– Magder S. Central venous pressure monitoring. Current opinion in
critical care 2006.
Board Review
Methods to decrease the incidence of central venous
catheter infections inculde all of the following
EXCEPT:
A. Using chlorhexidine over povidone-iodine for skin
decontamination
B. Unsing minocycline/rifampin impregnated catheters
for suspected long term use
C. Using the subclavian over the internal jugular route
for access
D. Using a single lumen over a multi-lumen catheter
E. Changing the central catheter every 3 to 4 days
over a guidewire.
Board Review
Methods to decrease the incidence of central venous
catheter infections include all of the following
EXCEPT:
E. Changing the central catheter every 3 to 4 days over
a guidewire.
From Hall: Bloodstream infectious complications with central venous
catheters are the most common late complication seen with central
catheters (>5%). Current CDC guidelines do not recommend
replacing central venous catheters. In addition, evidence is
suggesting that the use of ultrasound may decrease the time needed
to place catheters and the number of skin punctures needed for
central vein access and may also decrease infections.
Additional References
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Bais JE, Bartelsman JF, Bonjer HJ; et al, The Netherlands
Antireflux Surgery Study Group. Laparoscopic or conventional
Nissen fundoplication for gastro-oesophageal reflux disease:
randomised clinical trial. Lancet. 2000;355(9199):170-174
Broeders JA, Draaisma WA, Rijnhart-de Jong HG, Smout AJ,
van Lanschot JJ, Broeders IA, Gooszen HG. Impact of
surgeon experience on 5-year outcome of laparoscopic Nissen
fundoplication. Arch Surg. 2011 Mar;146(3):340-6.
Hall Brian and Robert Chantigian. Anesthesia: A
comprehensive review. Philadelphia: Mosby, 2010.
Jaffe Richard and Stanley Samuels. Anesthesiologist’s manual
of surgical procedures. Philadelphia: Lippincott Williams and
Williams, 2004.
Surgical management of gastroesophageal reflux in adults. In
UpToDate, Friedberg JS and Talley NJ (Eds), UpToDate,
Waltham, MA 2011.