manejo intraoperatorio del paciente sometido a esofagectomia

8/13/2019 Manejo Intraoperatorio Del Paciente Sometido a Esofagectomia

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Intraoperative Management ofthe Patient Undergoing

Esophagectomy

Javier H. Campos, M.D.Professor

Vice Chair for Clinical Affairs

Director of Cardiothoracic Anesthesia

Executive Medical Director of Operating Rooms

Department of Anesthesia

Disclosure Advisory board member of the ET View

Medical, Ltd.

Paid consultant ET View Medical, Ltd.

R L


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A B

Esophageal Cancer

n=17,000 cases per year U.S.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (NIH)

Fiscal Year

$21.6 M $22.3 M $22.4 M

$28.8 M$30.5 M

NCI Esophageal Cancer Research Investment

$4.75B$4.79B

$4.83B

$4.97B$5.12B

General Facts

Esophagectomy is associated with a significant risk of: Morbidity of 50% and Mortality of 10%Bailey SH, et al: Ann Thorac Surg 2003; 75: 217-222

High rates of post-operative morbidity

Anastomotic leaks Tachyarrhythmias Pneumonia

Orringer MB, et al. Ann Surg 2007; 246: 363-72

Pulmonary complications 50%


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Outline

Perioperative risk factors

Airway management Intubation Lung isolation Extubation

Inflammatory response to one-lung ventilation (OLV)

Fluid management

Vasoactive agents

Summary

Perioperative Risk Factors After Esophagectomy

Retrospective study in 168 patients ALI 23.8%, ARDS 14.5% Mortality in the ARDS patient was 50%

hx smoking Experience of surgeon Duration of operation and OLV Anastomotic leak

Tandom S, et al: Br J Anaesth 2001; 86: 633-6 38

Comparison of Hospitals with More Than 20 Esophageal ResectionsPer Year Versus Hospitals with Lower Case Loads

Metzger R, et al: Dis Esophagus 2004;17:310-314

Citation Year

EffectOdds-Ratio

Lower UpperConfidence Interval

P -Valu e N T ot al

Begg 1998 .23 .03 1.74 .12 503

Van Lanscht 2001 .43 .30 .64 .00 1892

Kuo 2001 .25 14 .45 .00 1193

Dimick 2001 .16 .09 .31 .00 1136

Gilison 2002 .99 .67 1.47 ..95 1076

Birkmeyer 2002 .42 .34 .53 .00 6337

Urbach 2003 .66 .38 1.15 .14 613

Finlayson 2003 .41 .34 .51 .00 5282

Random Combined (8) .42 .31 .58 .00 18032

Favors Vol>20 OP/yr Favors Vol< 20 Op/yr


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(< 5 per year) (5-10) (11-20) (>20)

Volume Hospital Esophagectomies (results of 13 publications)

Metzger R, et al: Dis Esophagus 2004;17:310-314

Surgical Approaches to Esophagectomy

Transhiatal esophagectomy Abdominal Cervical esophagogastric anastomosis

Trans-thoracic Thoracoabdominal +/- neck Ivor Lewis (R-thoracotomy + abdominal) McKeown (3-hole) in block

Minimal invasive esophagectomy

A

B

C

Transhiatal Dissection

Orringer MG, et al: OP Tech Thorac Cardiovasc Surg 2005: 63-83


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A B

Transhiatal Dissection

Orringer MG, et al: OP Tech Thorac Cardiovasc Surg 2005: 63-83

Transhiatal Esophagectomy withoutThoracotomy

n=1,950 transhiatal esophagectomies

n=4 intraoperative deaths (


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Radical En Bloc EsophagectomyA

B

C

Altork NK, et al:OP Tech Thorac Cardiovasc Su rg 2005: 84-98

A

B

C

Esophageal Cancer

Esophagectomy

Need for rapid sequence induction

Frequent need for postop ventilation Non-pulmonary surgery

Usually R-sided lung collapse


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Inflammatory Response in Esophagectomy

Author N SurgicalApproach InflammatoryResponse Outcome

Zingg UDur CytNtw2010; 21: 50-57

29 Transthoracicesophagectomy

IL-6, IL-IRA inleft ventilated lungand peripheral blood

cytokine in vent. lung No correlation with pulmonarycomplications

DJourno XEur J Cardiothorac Surg2010; 37: 1144-1151

97Group I pulmGroup II non-pulm

Transthoracicesophagectomy

IL-6, IL-8,IiL-10,TNF

4th day increasedcytokineCorrelate pulmonarycomplications

Conno ED, et al: Anesthesiology 2009;110:131626Propofol Sevoflurane Propofol Sevoflurane

Inflammatory Response to One-Lung Ventilation

Bundgaard-Nielsen M, et al: Acta Anaesthesiol Scand 2009; 53: 843-851

Intraoperative Fluids Administration and Esophagectomy


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Restrictive Fluids Pro:

RCT, 156 pts (Israel)

Elective bowel resections Liberal: 12ml/kg/hr (LR) Restrictive: 4ml/kg/hr (LR) Fluid challenges for bleeding or hypotension

Nisanevich V, et al: Anesthesiology 2005; 103: 25-32

Restrictive Fluids Pro:

Outcomes Significantly less fluid (3.6 vs 1.2) l and < weight gain Less patients with complications Earlier return of bowel function Earlier hospital discharge (8 vs 9 days)

Nisanevich V, et al: Anesthesiology 2005; 103: 25-32

Restrictive Fluids Con:

Prospective, randomized study, France

n=70 pts (gastric, hepatic, pancreas, resection)

Goal directed therapy(esophageal doppler probe) blood flow velocity

6ml/kg/hr vs 12ml/kg/hr Fluid challenge for P V >13%

Outcome

Futier E, et al: Arch Surg 2010; 145: 1193-1200


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1

Restrictive Fluid Con:

Statistically significant outcomes in restrictive

group More hypovolemic episodes (3.8 vs 1.2) Less overall fluid (3040 vs 5266) mL Lower venous saturation (intraop and postop) More anastomotic leaks (12 vs 4 cases) More sepsis (16 vs 5 cases) More ALI/ARDS

Futier E, et al: Arch Surg 2010; 145: 1193-1200

Perioperative Fluid Management and PulmonaryComplications after Esophagectomy (Lewis Tanner)

n=45 patients (divided according to complications)

Pulmonary complications group n=9 intraop fluids 5415 810 cc balance

No pulmonary complications n=36

intraop fluids 4174 1033 cc balance

Outcomes: > pneumonia, ALI and ARDS

Casado D, et al: Dis Esoph 2010; 23: 523-528

Preoperative Deficits

Fasting Does NOT change intravascular volume

Bowel preparation Can induce intravascular deficit However not routinely used for esophagectomy

patient, unless colon interposition is planned


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Intraoperative Deficits

Evaporative losses

Third spacing/edema

Bleeding

Vasodilation

Fluid and Weight Gain

Chappel D, et al: Anesthesiology 2008; 109: 723-740


Perioperative Weight Gain (%)

O v e r a

l l M o r

t a l i t y

( % )

Perioperative Weight Gain and Mortality of Patients.


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1


Volume Effect of Colloid is Context Sensitive

Normovolemic hemodilution

Volume loading

120

100

80

60

40

20

06% HES 200/0.5 32 5% human albumin 32 6 % H ES 1 30 /0 .4 31 6 % H ES 2 00 /0 .5 33 5% human albumin 33

V o l u m e

E f f e c

t ( %

)

Pulmonary Morbidity Following Esophagectomy isDecreased with a Multimodal Anesthetic Regimen

Restrictive strategy (not fluid balance 0.5 ml/kg/h Colloid 1:1 with blood loss Norepinephrine to maintain MAP?65 mmHg

SICU Crystalloid 150 ml/h

Pulmonary complications 26% vs 42%

Buise M, et al: Acta Anaesth Belg 2008; 59: 257-261

SR (n=84)

NR (n=83)

Fluids in

Crystalloids (ml) 5630 189 3670 266*

Colloids (ml) 1917 94 460 77

Packet cells (ml) 589 43 600 133

Fluids out

Blood loss (ml) 1432 92 1129 115

Urine production (ml/kg/hr) 1.77 0.15 1.17 0.10

Total fluid balance ( ml) + 5100 277 + 3 683 241*

Preoperative Fluid Therapy

Buise M, et al: Acta Anaesth Belg 2008; 59: 257-261


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Fluid Management in Esophagectomy

Baseline crystalloid sol. to replace insensible

perspiration and urine output Replace initial blood loss with crystalloid or

colloid to maintain euvolemic Albumin if risk of renal injury or hypoalbuminemia

Blood transfusion of threshold reacher


Hemodynamic Goal TherapyMeta Analysis

RCT adult surgical pts: 26 trials/4188 pts

Manipulation of hemodynamics with fluids and/orinotropes within 8 hrs after surgery (optimizationoxygen delivery)

Reduction on: - infection rates- pneumonia- urinary tract infection

Dalfino L, et al: Critical Care 2011; 15: 1-14

Norepinephrine

Inotropes associated with higher mortality afteresophagectomyFerguson MK, et al: World J Surg 1997; 21: 1599: 664

Inotropes correlate with leak-related mortality afteresophagectomyWhooley BP, et al: Am J Surg 2001; 181: 198-203

Inotropic support associated with development ofARDSTandon S, et al: BR J Anaesth 2001, 86: 633-638


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Early Extubation and Outcomes AfterEsophagectomy

Author N Operation OutcomeChandrashekar MVBr J Anaesth2003; 90: 474-9

76 retrospective(UK)

Ivor-Lewis Two stage with field

lymphadenectomy

73 extubated in OR 3 remain intubated 7 reintubation (10%)

Lanuti M:Ann Thorac Surg2006; 82: 2037-41

102 retrospective(MGH)

Transthoracicor

Thoraco-abdominalesophagectomy

92 extubate in OR 2 emergent intubation 3 delayed reintubation

for ARDS

n=43

n=6

n=34

n=11

n=4

n=1

n=0n=3

Lanuti M, et al: Ann Thorac Surg 2006; 82: 2037-2041

Summary

Aspiration risk (pre and post) OLV and lung protection

Fluid management crystalloids/ colloids Maintain hemodynamic stability (inotropes ??) Early extubation desirable Outcomes worst for postop pulmonary

complications

[email protected] http://www.anesth.uiowa.edu/

manejo intraoperatorio del paciente sometido a esofagectomia

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