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Anesthesia for esophageal cancer Part I


Anesthesia for esophageal cancer Part I Reporter R2 Supervisor VS Carcinoma of the esophagus Epidemiology and etiology Pathology and pathogenesis ... – PowerPoint PPT presentation

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Title: Anesthesia for esophageal cancer Part I

Anesthesia for esophageal cancer Part I
  • Reporter R2 ???
  • Supervisor VS ???

  • 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
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

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

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

Adenocarcinoma- Epidemiology and etiology
  • Barretts metaplasia is the precursor lesion to
    esophageal adenocarcinoma(7-20?ca) (GER?chronic
  • 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

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

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

  • Accurate staging is essential for treatment
    selection and prognosis.

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

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

  • 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

Modified McKeown or Triincisional Technique
  • Indicationsany level, benign and malignant
  • 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

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

  • 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

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

  • 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

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

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

  • 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

Alternate conduits
  • Colon-right or left colon
  • Jejeunum

  • 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

  • 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

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

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

Perioperative complications
  • Anastomotic leak
  • Albumin lt3g/dL, positive margins, cervical
  • Cervical anastomosis10-15
  • Intrathoracic leaklife-threatening?immediate op
  • Anastomotic stricture
  • Never life threatening?repeat bougie dilation
  • Cervical anastomosis28, Ivor Lewis
  • 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

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

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

Multimodality therapy
  • Radiation therapy
  • Chemotherapy
  • Chemoradiation therapy

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

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

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
  • Cisplatin based 5-fluorouracil

  • 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.

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

  • Thoracic anesthesia 3rd , James B.
    Eisenkraft,MD, Steven M. Neustein, MD Ch.13,
  • 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

Anesthesia for esophageal cancer Part II
  • Reporter R2 ???
  • Supervisor VS ???

  • 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
Clinical staging complete
No distant metastases
Distant metastases suspected
Biopsy area of suspicion
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
Surgery concluded
R/T or R/T C/T
Pathologic staging completed
Preop evaluation and preparation
  • Aspiration
  • C/T, R/T
  • Airway
  • Lung function
  • Cardiovascular system

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

  • 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

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

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

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

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

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

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

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

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

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)

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

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

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
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

One-lung ventilation plan
  • Maintain two-lung ventilation until pleura is
  • 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)

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

Postoperative pain
  • 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
  • Interpleural regional analgesia
  • Paravertebral nerve block
  • Subarachoid injection

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

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

Sample analgesic protocol
  • Patient60y/o, 70kg
  • Preopheparin 5000U, 2 hr before epidural
  • Intraop
  • Epidural catheter placed before induction at
  • 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

TEA-optimal combination of agents
  • Bupivacaine 0.1
  • Fentanyl 10ug/ml
  • Infusion rate0.05-0.1 ml/kg/hr
  • Max. rate10ml/hr

  • Thoracic anesthesia 3rd , James B.
    Eisenkraft,MD, Steven M. Neustein, MD Ch.13,
  • 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