食道癌手术的麻醉管理课件

Anesthesia for esophageal cancer Part I Reporter R2 藍正妍 Supervisor VS 趙安怡 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 Racial groups:African Americans Caucasians MF(3-4 times) Age 40 y/o Geographic and cultural variations Carcinogens: Tabacco, Alcohol, Nitrosamines, Furacin c, Opiates, Fungal toxins, Spices Nutritional deficiencies: Vit A, riboflavin, Trace elements, zinc Physical factors:thermal trauma, hot food or drinks, abrasive material (soil) and food, Lye Predisposing factors:Tylosis, Plummer-Vinson syndrome, Achalasia, Celiac sprue SCC- Pathology and pathogenesis 50% in middle third 30-40 % in lower third 10-20 % in upper third Macroscopic vs microscopic features Metastases:60% lymphatic Distant meta: lungs, liver, bone Adenocarcinoma- Epidemiology and etiology Age:68 y/o MF Caucasian African Americans Barretts metaplasia is the precursor lesion to esophageal adenocarcinoma(7-20%ca) (GERchronic inflammationBarretts) Other risk factors: Obesity Ectopic gastric mucosa Esophageal diverticula Iron overload Alcohol use Polysaturated fats Diets high in red meat 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,endoscopic ultrasound, thoracoscopy and laparoscopy Laboratory examinations Anemia Hypoproteinemia Hypercalcemia Abnormal liver function tests TPN associated abnormally Staging Accurate staging is essential for treatment selection and prognosis. Treatment 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 Indications:any 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 Contraindications:fusion of Rt pleural space or inability to support ventilation with Lt lung Technique 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 Technique Abdominal incision:dissection of the mediastinum and lower esophagus bluntly into the upper chest through hiatus Cervical incision:dissection of the esophagus Gastric tube was drawn to neck Ivor Lewis esophagectomy Indications:similar to triincisional approach Contraindications(不適合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: Technique Supine position Abdomen incision:mobilize stomach, pyloroplasty,create gastric tube, placement of a J- tubeconduit 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 Indications:distal esophageal tumor beyond 30-35 cm with compromised physiological status Contraindications: above 30cm distal esophageal peptic stricture 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 Alternate conduits Colon-right or left colon Jejeunum 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 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 Colon Jejeunum Indications: stomach is not available Limited distal esophagectomy is planned Contraindications: Intrinsic dx of small bowel Total esophageal replacement Perioperative mortality Mortality rates:6-10% Intrathoracic sepsis: anastomotic or conduit leak Pulmonary etiology: respiratory insufficiency,pneumonia,pulmonary embolus Perioperative complications Anastomotic leak Albumin intrathoracic anstomosisinjection or prosthesis implantation Complications:effective cough , secretions Perioperative complications Respiratory complications: pneumonia , atelectasis, respiratory failure Muscle-sparing, limited thoracotomy, epidural anesthesia, early ambulation Bleeding: transthoracic transhiatal approach Chyle leakligation 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 tx:1-,2-, and 5-year survival rates:18,8,6% Dose:55-65Gy High surgical risk patient Advanced or metastatic dx cannot op Post-op R/T:decrease local recurrence rates , not improve survival rates Chemotherapy Neoadjuvant C/T:down-staging of dx in 50% pt, pathologic complete response rate 80% after op in early identified lesions and invasion limited to mucosa Poor prognosis:increase age, African- American race, length of lesion, lower esophageal tumors, depth of invasion, metastatic spread 5 lymph nodes 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 Anesthesia for esophageal cancer Part II Reporter R2 藍正妍 Supervisor VS 趙安怡 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 Surgical exploration No distant metastases Surgical resection with lymph node dissection as possible Pathologic staging completed Biopsy area of suspicion Negative Positive R/T or R/T +C/T; surgical palliation Distant metastases No dysphagia Dysphagia (enteral feeding tube, esoophageal intubation laser, or stent) Surgery concluded R/T or R/T+ C/T 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: Doxorubicinmyelosuppression, cardiomyopathy Bleomycinpulmonary 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/T:pneumonitis, 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 phasePFTIncreased operative risk result Whole-lung tests ABGHypercapnia on room air SpirometryFEV150% Single-lung tests R-L split-function testsPredicted postop FEV170% blood flow to diseased lung Mimic postop condition Temporary unilateral balloon occlusion of R or L main stem bronchus or PA Mean PAP40mmHg, PaCO2 60mmHg, or PaO2 univent suction, CPAP, convert from two-lung to one-lung Univent DLT 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 signsfiberoptic bronchoscopy may reveal malpositioning: 38-78% Difficult intubation:standard single-lumen tube+Fogarty 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太大, 28F太小) 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) SurgeryIncisions 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 Surgical approaches Intraoperative considerations and management Hypotension:blood loss, IVC compression, manipulation of heart Surgical trauma to tracheaventilating 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 opened Dependent dung FiO2=1 TV=10 ml/kg RR=so that PaCO2=40mmHg PEEP=0-5 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 TPNhypoglycemia, hyperosmolar coma Respiratory complications:obesity, coexisting lung dx Incisional pain:hypoventilation, hypoxemia, atelectasis Postoperative complications Pneumothorax: retrosternal approach Postoperative pain Patient comfort, minimize pulmonary complications, ambulate Thoracic epidural analgesiagold 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 TEA-adverse effects Technique-related 3%:dural perforation, postop radicular pain, transient peripheral n lesions Neuraxial blocks and anticoagulation Hemorrhagic complications:1/150000 Risk factor:impaired hemostasi