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Gastric Resection: General Surgical and Anesthetic Considerations
Gastric Resection: General Surgical and Anesthetic Considerations
Natalya Hasan, MD
Gastric Resections
Indicated for Gastric CA (Adenocarcinoma - 95%; Gastrointestinal
Stromal Tumors, lymphomas, leiomyosarcomas, carcinoids, or sarcomas
-5%)
21,000 diagnosed annually -> 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
Who gets operated on?
• For localized cancers:
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
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.
Current Mortality:
Total gastrectomy: 2%
Partial gastrectomy: 1%
Anesthetic Considerations
PRE-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 > 50 years
old. Pre-op EKG is generally indicated. Pts with poor PO
intake may be hypovolemic, and potentially more unstable
intraoperatively.
Contrary to what the patient on the left would make you think,
a nasogastric tube is more than just a little tube in your
patient’s nose (even the mannequin looks uncomfortable).
Besides the right-main stem intubation, what
else is wrong with this picture?
Oops! This can happen to you. Watch your tidal
volumes when you place the NGT (or temp probe). If
you’re unsure, use a laryngoscope.
Complications of NGT
Epistaxis
Sinusitis
Nasal alar ulceration/necrosis
Gastritis
Perforation
Aspiration (by preventing lower esophageal sphincter
from closing entirely)
Intracranial placement!
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.
.
Meta-analysis of the need for nasogastric
or nasojejunal decompression after
gastrectomy for gastric cancer.
• Five randomized-controlled trials, 717 patients
• 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.