WikiAnesthesia - User contributions [en]

Heller Myotomy (Laparoscopic)

2022-12-13T17:39:55Z

Mabadir1:

'''Laparoscopic Heller Myotomy Wiki Page'''

PDF Version with Images --[https://drive.google.com/file/d/1l1LRSCW9XSp--_pQQ9_BH9MwzUZyIgRO/view?usp=sharing Heller Myotomy] (Laparoscopic)

* Objectives:
** Understand surgical indications for Heller myotomy and alternatives
** Understand relevant anatomy and physiology
** Describe the anesthetic management of Heller myotomy
* Indications and alternatives:
** Achalasia is the main indication for laparoscopic Heller myotomy. Achalasia is a disorder of esophageal motility of unknown etiology classically associated with increased tone of the lower esophageal sphincter (LES) and aperistalsis of the distal esophageal smooth muscle, possibly due to selective loss of inhibitory neurons in the myenteric plexus in the LES and distal esophagus.
** Achalasia affects ~2-13 per 100,000 persons per year, equally men and women with peak incidence around 30-60 years old. Typical symptoms of achalasia include progressively worsening dysphagia to solids and then liquids, burning chest pain, heartburn, and eventually weight loss and nutritional deficiency if left untreated.
** There are multiple treatment options for achalasia, ranging from pharmacologic therapy to endoscopic procedures to surgical myotomy.
** Surgical myotomy is one of the most effective and common definitive treatment options for achalasia. Initially myotomy was performed through a thoracotomy, however the current practice is the laparoscopic approach which has shown decreased mortality and faster recovery. Because there is an ~30% risk of developing GERD after a myotomy, a fundoplication (folding of fundus around LES to reduce distal esophageal acid exposure) is typically performed at the same time.
** Other treatment options include botulinum toxin injection into LES, PO pharmacotherapy with calcium channel blockers or nitrates, pneumatic esophageal dilation, and most recently, peroral endoscopic myotomy (POEM) that frequently eliminates the need for laparoscopy.

Relevant anatomy and physiology:

* The esophagus is a hollow muscular organ (cervical esophagus contains striated muscle, thoracic esophagus contains smooth muscle), it runs anterior to the aorta below T8 and enters the abdominal cavity through an opening of the diaphragm located anterior to the opening for descending aorta.
* LES tone affected by several medications commonly used in anesthesia practice:
** Drugs that decrease LES pressure: anticholinergics, nitroprusside, dopamine, beta agonists, TCAs, opioids.
** Drugs that increase LES pressure: anticholinesterases, metoclopramide, prochlorperazine, metoprolol.
* Blood supply to the thoracic esophagus comes from paired aortic esophageal arteries or terminal branches of bronchial arteries. The blood supply to LES and most distal part of the esophagus comes from the left gastric artery and a branch of the left phrenic artery.
* Vagal afferents coming from the esophageal smooth muscle layer and serosa are sensitive to stretch. Due to convergence of sensory afferents from the heart and esophagus on same dorsal spinal horn neuron in cervical and thoracic spinal cord, esophageal pain may present similarly to cardiac pain.

* Anesthetic management
** Preop evaluation
*** Perform a thorough history and physical focusing on signs/symptoms of esophageal obstruction, severity of dysphagia, signs/symptoms of active GERD and aspiration.
*** If patient reports chest pain/other symptoms that may be of cardiac etiology, even though these symptoms may be attributed to achalasia, it may be reasonable to obtain additional cardiac workup to assess for myocardial ischemia or arrythmias.
*** Ensure patient is appropriately NPO given high risk of aspiration in this patient population, longer NPO status may be beneficial. If the risk of aspiration is high, consider pretreating the patient with nonparticulate antacids or gastric acid secretion blockers (i.e H2 blockers) to decrease the risk and severity of pneumonitis if aspiration occurs.
** General case considerations
*** Anesthetic type: GETA with paralysis.
*** Airway management: Given high risk of aspiration in this patient population, RSI and intubation with head of the bed at 30 degrees is recommended if difficult airway is not anticipated. If there is a concern for difficult airway, consider awake intubation given high risk of aspiration with masking. Ensure airway is secure if intraoperative EGD is performed by the surgical team.
*** Access: one PIV is typically sufficient.
*** Monitors: standard ASA monitors +/- invasive monitors if guided by patient's comorbidities.
*** Positioning: reverse Trendelenberg.
*** Pain management considerations: typically post-procedure pain is not particularly severe.
*** Other considerations: Aggressive PONV prophylaxis is helpful. Esophageal perforation is a possible early complication of laparoscopic Heller's myotomy and can be detected intraoperatively, one review estimates the prevalence of this complication to be ~7%.
* Post-op considerations
** Most patients are extubated at the end of surgery. NGT typically not necessary.
* Resources used and links
** Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT. ACG clinical guidelines: diagnosis and management of achalasia. Official journal of the American College of Gastroenterology| ACG. 2020 Sep 1;115(9):1393-411.
** Yazaki E, Sifrim D. Anatomy and physiology of the esophageal body. Diseases of the Esophagus. 2012 May 1;25(4):292-8.
** Blank RS, Collins SR, Huffmyer JL, Jaeger JM. Anesthesia for esophageal surgery. InPrinciples and practice of anesthesia for thoracic surgery 2019 (pp. 609-649). Springer, Cham.
** AlHajjaj GM, AlTaweel FY, AlQunais RA, Alshammasi ZH, Alshomimi SJ. Iatrogenic Esophageal Perforation After Laparoscopic Heller’s Myotomy Treated Successfully with Endoscopic Stent: Case Report and Literature Review. The American Journal of Case Reports. 2021;22:e931677-1.
** Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: '''An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration'''. ''Anesthesiology'' 2017; 126:376–393
**
* Contributors
** Anastasia Piersa
** Diana Barragan Bradford

Open Retroperitoneal Lymph Node Dissection

2022-11-01T02:14:27Z

Mabadir1: Blanked the page

Open Retroperitoneal Lymph Node Dissection

2022-11-01T01:58:36Z

Mabadir1: Created page with " Link to PDF including Images -- [https://drive.google.com/file/d/1EIlvIxpoZJHnKP7O1kkTxafGogMNM6i6/view?usp=share_link Open Retroperitoneal Lymph Node Dissection] '''Open Retroperitoneal Lymph Node Dissection (RPLND)''' · Objectives 1. Understand the indication for RPLND 2. Review relevant surgical anatomy 3. Discuss anesthetic management details specific to RPLND · Indication and procedural goals RPLND is primarily indicated f..."

Link to PDF including Images -- [https://drive.google.com/file/d/1EIlvIxpoZJHnKP7O1kkTxafGogMNM6i6/view?usp=share_link Open Retroperitoneal Lymph Node Dissection]

'''Open Retroperitoneal Lymph Node Dissection (RPLND)'''

· Objectives

1. Understand the indication for RPLND

2. Review relevant surgical anatomy

3. Discuss anesthetic management details specific to RPLND

· Indication and procedural goals

RPLND is primarily indicated for suspected metastatic testicular cancer, especially early-stage, nonseminomatous germ cell tumors in which nodal micrometastases are currently only found via RPLND. The goal of the procedure is to provide accurate pathological staging and remove any disease from the retroperitoneal nodes [1,2].

· Relevant Anatomy and Surgical Approach

The retroperitoneal, pelvic and inguinal nodes should be removed for pathology. The right and left testes drain into different lymphatic regions: the right to the interaortocaval nodes at the second lumbar vertebral body (full right-sided dissection area outlined in Figure 1, Left) and the left to the paraaortic area that is defined by the renal vein superiorly, inferior mesenteric artery inferiorly, ureter laterally and the aorta medially (full left-sided dissection area outlined in Figure 1, Right). The spermatic cord’s lymphatic drainage is to the retroperitoneal lymph node chain while the epididymis drains to the external iliac and pelvic nodes [2,3]. Therefore, RPLND involves the surgeon operating near major vessels and the sympathetic chain.

The RPLND laparotomy incision is long—midline laparotomy from sternum to inches below the umbilicus. This has important implications for post-operative pain management, as outlined below.

AUA Video of RPLND Surgical Approach for Trainees [4]: <nowiki>https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0</nowiki>

· Anesthetic Management

1. General

§ Procedure is typically scheduled for the whole day.

· For Dr. Salari, one case took 8 hours.

§ These cases are almost always general anesthetics with a single-lumen endotracheal tube

§ Preop:

· Active type and screen without blood in the room. EBL is typically <500 cc, but possibility for large EBL exists given proximity of major vessels to target lymph nodes being resected.

· If surgeon agrees, place thoracic epidural. Most pain is from skin incision and muscle injury, less so from deep lymph node dissection.

· Obtain consent for: possible central and A-line access, blood products if necessary, and regional anesthesia, including post-op epidural if pre-op is not allowed by surgeon

· Anxiolytic may be needed given patients are typically otherwise healthy, young men.

§ Access:

· 2 PIVs – at least one large bore

· Consider central access for CVP monitoring if patient has a history of bleomycin-induced restrictive lung disease and close monitoring of fluid management is needed.

· Consider A-line if risk of large EBL or if there are significant cardiopulmonary comorbidities

· OGT placed after induction for stomach decompression; ask surgeon if the tube will be left for the post-operative period (rare), in which case an NG tube should be placed instead

§ Monitors:

· Given long length of case, consider rotating the blood cuff and pulse oximeter if using clip-on pulse oximeter probes to prevent pressure damage [5].

§ Fluid management:

· Foley will be in place intra-op and post-op. For most cases, EBL will be <500 cc and a volume neutral approach can be taken. Large insensible volume loss will be present due to large laparotomy and urine output may not be accurate if surgery applying pressure to ureters.

· Consider having albumin in room.

§ Pain Management:

· RCT on TEA vs rectus sheath catheters (RSCs) for midline laparotomy [6]:

o No difference was observed for time to first food intake, first bowel movement, postoperative morbidity, catheter failure rates, time in PACU and discharge from the hospital.

o TEA was shown to improve postoperative movement pain scores until 48hrs, at which time no difference was observed.

o While time to first opioid dose was much shorter for RSCs, the daily opioid usage was largely indifferent, except for less opioid consumption in the RSC group on postoperative day 3.

o Notes about study:

§ The population is not completely generalizable to this surgery as women were included and all participants were between 40-84.

§ The procedures included were major rectal and colonic resection and radical cystectomy, although the mean (SD) incision length in mm was 219.6 (68.5) for RSCs and 220 (95.6) for TEA.

§ The RSC group received fentanyl patches with morphine PCA as an alternative for visceral pain. The paper notes that the fentanyl patches are standard of care at the hospital and that similar systemic opioid is achieved with patch compared to the fentanyl in the TEA infusion.

§ The RSC group received doses of ropivacaine that were within the recommended FDA guideline of 770 mg/day. Patients received 20 cc bolus dose of 0.25% Ropivacaine on each side with intermittent blousing every 4 hrs of 20 cc of 0.2% Ropivacaine per side.

· Cochrane review of TEA vs IV analgesia for abdominal surgery in adults [7]:

o Pain benefit in first 24 hours with significant difference after 24 hrs. This benefit is thought to not likely be clinically important.

o Relative risk (RR) of TEA failure was 2.48 [1.13-5.43].

o RR of hypotension was 7.13 [2.87-17.75]. Of note, RSCs would not cause hypotension 2/2 sympathetic blockade.

o Generalizability difficult since a very broad range of abdominal surgeries are included in this review and open RPLND is relatively uncommon.

· As of 09/2022, Dr. Salari does not want epidural catheters due to his concern of distinguishing sympathetic blockade from epidural versus surgical resection near the sympathetic nervous system. He prefers post-op bilateral rectus sheath catheters placed. If plan for TEA, one could try to recommend epidural and wait to utilize the epidural catheter until post-op to allay surgeon concern.

· Since majority of pain is from midline laparotomy incision, RSCs may be a good option.

· Multimodal pain management is very important, as for any laparotomy (e.g., acetaminophen, ketorolac, ketamine and other opioid-sparing analgesics).

2. Clinical Pearls

§ Retrograde ejaculation and infertility is common from sympathetic/parasympathetic manipulation during dissection [8].

§ Acute Respiratory Distress Syndrome or prolonged ventilatory support can occur for those with bleomycin-induced lung toxicity or needing intrathoracic dissection. Bleomycin-induced lung toxicity is a restrictive disease that is sensitive to IVF volume and high FiO2 [2,5].

§ Chemotherapy-induced cardiotoxicity, including prolonged QT interval, and peripheral neuropathy can occur with chemotherapy regimens that include cisplatin [5].

· Resources and Links

1. Laguna, M. P. ''et al.'' Guidelines on testicular cancer. In ''EAU Guidelines'' vol. Edn. presented a the EAU Annual Congress Amsterdam 2020 (EAU Guidelines Office, 2020).

2. Steele, GS. Retroperitoneal lymph node dissection for early-stage testicular germ cell tumors. In: UpToDate, UpToDate, Waltham, MA. (Accessed on Sept. 26, 2022.)

3. Whitson, J.M. Retroperitoneal Lymph Node Dissection. Medscape. <nowiki>https://emedicine.medscape.com/article/449137-overview?reg=1#a9</nowiki>. Sept. 28, 2018. Accessed: Sept. 26, 2022.

4. AUA Video of RPLND Surgical Approach for Trainees: <nowiki>https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0</nowiki>

5. Stephens, M. & Murphy, T. & Hendry, David. (2019). Anaesthesia for retroperitoneal lymph node dissection in the treatment of testicular cancer. BJA Education. 19. 10.1016/j.bjae.2019.04.003.

6. Krige A, Brearley SG, Mateus C, Carlson GL, Lane S. A comparison between thoracic epidural analgesia and rectus sheath catheter analgesia after open midline major abdominal surgery: randomized clinical trial. BJS Open. 2022 May 2;6(3):zrac055. doi: 10.1093/bjsopen/zrac055. PMID: 35543263; PMCID: PMC9092444.

7. Salicath JH, Yeoh EC, Bennett MH. Epidural analgesia versus patient-controlled intravenous analgesia for pain following intra-abdominal surgery in adults. Cochrane Database Syst Rev. 2018 Aug 30;8(8):CD010434. doi: 10.1002/14651858.CD010434.pub2. PMID: 30161292; PMCID: PMC6513588.

8. Heidenreich A, Albers P, Hartmann M, Kliesch S, Kohrmann KU, Krege S, Lossin P, Weissbach L; German Testicular Cancer Study Group. Complications of primary nerve sparing retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell tumors of the testis: experience of the German Testicular Cancer Study Group. J Urol. 2003 May;169(5):1710-4. doi: 10.1097/01.ju.0000060960.18092.54. PMID: 12686815.

· Contributors

1. Brittani Bungart, MD PhD

2. Daniel Ankeny, MD PhD

Heller Myotomy (Laparoscopic)

2022-10-19T19:23:44Z

Mabadir1: Created page with "'''Laparoscopic Heller Myotomy Wiki Page''' PDF Version with Images --[https://drive.google.com/file/d/1l1LRSCW9XSp--_pQQ9_BH9MwzUZyIgRO/view?usp=sharing Heller Myotomy] (Laparoscopic) * Objectives: ** Understand surgical indications for Heller myotomy and alternatives ** Understand relevant anatomy and physiology ** Describe the anesthetic management of Heller myotomy * Indications and alternatives: ** Achalasia is the main indication for laparoscopic Heller myotomy...."

'''Laparoscopic Heller Myotomy Wiki Page'''

PDF Version with Images --[https://drive.google.com/file/d/1l1LRSCW9XSp--_pQQ9_BH9MwzUZyIgRO/view?usp=sharing Heller Myotomy] (Laparoscopic)

* Objectives:
** Understand surgical indications for Heller myotomy and alternatives
** Understand relevant anatomy and physiology
** Describe the anesthetic management of Heller myotomy
* Indications and alternatives:
** Achalasia is the main indication for laparoscopic Heller myotomy. Achalasia is a disorder of esophageal motility of unknown etiology classically associated with increased tone of the lower esophageal sphincter (LES) and aperistalsis of the distal esophageal smooth muscle, possibly due to selective loss of inhibitory neurons in the myenteric plexus in the LES and distal esophagus.
** Achalasia affects ~2-13 per 100,000 persons per year, equally men and women with peak incidence around 30-60 years old. Typical symptoms of achalasia include progressively worsening dysphagia to solids and then liquids, burning chest pain, heartburn, and eventually weight loss and nutritional deficiency if left untreated.
** There are multiple treatment options for achalasia, ranging from pharmacologic therapy to endoscopic procedures to surgical myotomy.
** Surgical myotomy is one of the most effective and common definitive treatment options for achalasia. Initially myotomy was performed through a thoracotomy, however the current practice is the laparoscopic approach which has shown decreased mortality and faster recovery. Because there is an ~30% risk of developing GERD after a myotomy, a fundoplication (folding of fundus around LES to reduce distal esophageal acid exposure) is typically performed at the same time.
** Other treatment options include botulinum toxin injection into LES, PO pharmacotherapy with calcium channel blockers or nitrates, pneumatic esophageal dilation, and most recently, peroral endoscopic myotomy (POEM) that frequently eliminates the need for laparoscopy.

Relevant anatomy and physiology:

* The esophagus is a hollow muscular organ (cervical esophagus contains striated muscle, thoracic esophagus contains smooth muscle), it runs anterior to the aorta below T8 and enters the abdominal cavity through an opening of the diaphragm located anterior to the opening for descending aorta.
* LES tone affected by several medications commonly used in anesthesia practice:
** Drugs that decrease LES pressure: anticholinergics, nitroprusside, dopamine, beta agonists, TCAs, opioids.
** Drugs that increase LES pressure: anticholinesterases, metoclopramide, prochlorperazine, metoprolol.
* Blood supply to the thoracic esophagus comes from paired aortic esophageal arteries or terminal branches of bronchial arteries. The blood supply to LES and most distal part of the esophagus comes from the left gastric artery and a branch of the left phrenic artery.
* Vagal afferents coming from the esophageal smooth muscle layer and serosa are sensitive to stretch. Due to convergence of sensory afferents from the heart and esophagus on same dorsal spinal horn neuron in cervical and thoracic spinal cord, esophageal pain may present similarly to cardiac pain.

* Anesthetic management
** Preop evaluation
*** Perform a thorough history and physical focusing on signs/symptoms of esophageal obstruction, severity of dysphagia, signs/symptoms of active GERD and aspiration.
*** If patient reports chest pain/other symptoms that may be of cardiac etiology, even though these symptoms may be attributed to achalasia, it may be reasonable to obtain additional cardiac workup to assess for myocardial ischemia or arrythmias.
*** Ensure patient is appropriately NPO given high risk of aspiration in this patient population, longer NPO status may be beneficial. If the risk of aspiration is high, consider pretreating the patient with nonparticulate antacids or gastric acid secretion blockers (i.e H2 blockers) to decrease the risk and severity of pneumonitis if aspiration occurs.
*** If there is a concern for aspiration pneumonia/pneumonitis, a CXR may be reasonable to obtain. [GA1]
** General case considerations
*** Anesthetic type: GETA with paralysis.
*** Airway management: Given high risk of aspiration in this patient population, RSI and intubation with head of the bed at 30 degrees is recommended if difficult airway is not anticipated. If there is a concern for difficult airway, consider awake intubation given high risk of aspiration with masking. Ensure airway is secure if intraoperative EGD is performed by the surgical team.
*** Access: one PIV is typically sufficient.
*** Monitors: standard ASA monitors +/- invasive monitors if guided by patient's comorbidities.
*** Positioning: reverse Trendelenberg.
*** Pain management considerations: typically post-procedure pain is not particularly severe.
*** Other considerations: Aggressive PONV prophylaxis is helpful. Esophageal perforation is a possible early complication of laparoscopic Heller's myotomy and can be detected intraoperatively, one review estimates the prevalence of this complication to be ~7%.
* Post-op considerations
** Most patients are extubated at the end of surgery. NGT typically not necessary.
* Resources used and links
** Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT. ACG clinical guidelines: diagnosis and management of achalasia. Official journal of the American College of Gastroenterology| ACG. 2020 Sep 1;115(9):1393-411.
** Yazaki E, Sifrim D. Anatomy and physiology of the esophageal body. Diseases of the Esophagus. 2012 May 1;25(4):292-8.
** Blank RS, Collins SR, Huffmyer JL, Jaeger JM. Anesthesia for esophageal surgery. InPrinciples and practice of anesthesia for thoracic surgery 2019 (pp. 609-649). Springer, Cham.
** AlHajjaj GM, AlTaweel FY, AlQunais RA, Alshammasi ZH, Alshomimi SJ. Iatrogenic Esophageal Perforation After Laparoscopic Heller’s Myotomy Treated Successfully with Endoscopic Stent: Case Report and Literature Review. The American Journal of Case Reports. 2021;22:e931677-1.
** Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: '''An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration'''. ''Anesthesiology'' 2017; 126:376–393
**
* Contributors
** Anastasia Piersa
** Diana Barragan Bradford

----[GA1]I would probably delete this sentence since if you are concerned about this you would cancel the case, since it’s elective surgery