WikiAnesthesia - User contributions [en]

Endoscopic retrograde cholangiopancreatography

2023-12-08T21:29:39Z

Nquach:

{{Infobox surgical procedure
| anesthesia_type = GETA vs deep sedation (risk stratify based on procedure and patient)
| airway = ETT vs native airway (risk stratify based on procedure and patient)
| lines_access = 1 PIV sufficient for most procedure, consider extra if unstable or complex procedure
| monitors = Standard ASA monitors, +/- A line depending on hemodynamic instability
| considerations_preoperative = Consider aspiration precautions in patient with risk factors. May be asked to give glucagon 0.25-2mg IV 10min prior to procedure to reduce duodenal motility.
| considerations_intraoperative = Consider RSI for pt at high risk of aspiration. Intubation increases likelihood of procedural success.
| considerations_postoperative = Pain from procedure is typically minimal. Pancreatitis from ERCP most common complication (1-40% quoted)
}}

Endoscopic retrograde cholangiopancreatography (ERCP) was originally designed as a purely diagnostic modality, but modern usage is typically for therapeutic purposes. Indications for ERCP include pancreatic or common bile duct obstruction and evaluation of pancreatic malignancy. Success, complication rate and speed of the procedure depends on significantly on operator experience.

ERCP consists of passing an endoscope from the mouth through the upper GI tract and into the duodenum, where the papilla of Vater is located. The endoscopist may request glucagon and/or secretin at this time to reduce duodenal motility. A guide wire is passed through the sphincter of Oddi into the common bile duct or pancreatic duct. Contrast is then injected to image the common bile duct and pancreatic duct via fluoroscopy. Brushings, samples, stenting, sphincterotomy and/or stone extraction may then proceed. Overall complication rate ranges widely based off of the final procedures and instrumentation of the common bile and pancreatic ducts, with <5% quoted for simple stone extraction and 20% or more with sphincterotomy.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedure|last2=Schmiesing|first2=Clifford|last3=Golianu|first3=Brenda|publisher=Wolters Kluwer|year=2014|isbn=9781451176605|edition=2nd|pages=1512-1515}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Cardiovascular
|Elderly patients may have comorbid CAD or CHF, screen appropriately in preop H&P
|-
|Pulmonary
|Evaluate aspiration risk and ability to protect airway. Airway evaluation should focus on the need for GETA vs MAC.
|-
|Gastrointestinal
|Patients often present with ileus or obstruction due to underlying pathology causing biliary or pancreatic obstruction. This makes them high aspiration risk.
|-
|Hematologic
|Underlying malignancy increases the risk of VTE and may cause comorbid anemia
|-
|Renal
|Many patients presenting for ERCP may have prerenal AKI from severe vomiting and dehydration
|-
|Endocrine
|Glucagon administration may be requested, which is contraindicated in certain rare endocrine tumors such as pheochromocytoma and insulinomas.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
* At a minimum, all patients should have a preoperative CBC and CMP prior to case start
* in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation

=== Operating room setup ===

* Standard monitors and setup
*Fluoroscopy will be used, ensure adequate radiation safety equipment available (lead apron, lead glasses, lead shield)
*Positioning (lateral vs prone) will depend on proceduralist preference and patient factors, have equipment for prone positioning availabe (prone pillow)
* Endoscopy will require bite block to facilitate scope passage

=== Patient preparation and premedication ===

* Endoscopist may request glucagon (0.25-2mg IV) 10 min and/or secretin (0.2mcg/kg IV over 1min) prior to procedure to reduce duodenal motility
* consider aspiration precautions

=== Regional and neuraxial techniques ===

* Not typically necessary

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
*+/- invasive arterial access for hemodynamic monitoring, based off of history and physical
*+/- addition IV access based on current access, though bleeding is typically minimal and operative time is short.
*consider glucose checks if glucagon is administered

=== Induction and airway management ===

* If GETA is chosen, RSI induction is often necessary in patient with inadequate NPO time, current abdominal distension/nausea/vomiting, or other risk factors for aspiration. otherwise standard induction
*If GETA is avoided, induction of deep sedation with propofol and topicalization of the airway to facilitate tolerance of endoscope passage in the pharynx can be sufficient
*Consider etomidate induction for hemodynamically unstable patients

=== Positioning ===

*Most patients will be prone for this procedure to aid in manipulation of scope into proper placement.
*If patient cannot tolerate the prone position, lateral or supine positioning can be done (increases difficulty for proceduralist).

=== Maintenance and surgical considerations ===

* If deep sedation is used, propofol infusion should be titrated to effect, avoiding respiratory depression and loss of protective airway reflexes
* If GETA is used, normal maintenance with volatile or intravenous agents or balanced approach can be used.
* GETA is associated with higher procedure success rate, consider intubation if the procedure is anticipated to be difficult or complex.

=== Emergence ===

* The duodenum and stomach are usually decompressed by the endoscopist prior to scope removal
*If obstruction in bile duct is removed, there is a high risk of bile aspiration. Have suction readily available.

== Postoperative management ==

=== Disposition ===

* ERCP can be done as an outpatient surgical procedure, with disposition PACU -> home
* however with more complex ERCP procedures or with comorbid conditions, patients will typically go PACU -> medicine/surgical ward.

=== Pain management ===

* Not typically a very painful procedure postop since ERCP is an endoscopic method.
* multimodal analgesia with oral regimen

=== Potential complications ===

* post-ERCP pancreatitis (most common complication, up to 40%), more common in young patients with preexisting sphincter of Oddi dysfunction
* bowel or duct perforation (rare)
* hemorrhage (rare)
* cholangitis/cholecystitis
* aspiration
* cardiopulmonary complications (MI, PE, respiratory arrest)

== References ==

[[Category:Surgical procedures]]

Endoscopic retrograde cholangiopancreatography

2023-12-08T21:27:37Z

Nquach: Filled in article

{{Infobox surgical procedure
| anesthesia_type = GETA vs deep sedation (risk stratify based on procedure and patient)
| airway = ETT vs native airway (risk stratify based on procedure and patient)
| lines_access = 1 PIV sufficient for most procedure, consider extra if unstable or complex procedure
| monitors = Standard ASA monitors, +/- A line depending on hemodynamic instability
| considerations_preoperative = Consider aspiration precautions in patient with risk factors. May be asked to give glucagon 0.25-2mg IV 10min prior to procedure to reduce duodenal motility.
| considerations_intraoperative = Consider RSI for pt at high risk of aspiration. Intubation increases likelihood of procedural success.
| considerations_postoperative = Pain from procedure is typically minimal. Pancreatitis from ERCP most common complication (1-40% quoted)
}}

Endoscopic retrograde cholangiopancreatography (ERCP) was originally designed as a purely diagnostic modality, but modern usage is typically for therapeutic purposes. Indications for ERCP include pancreatic or common bile duct obstruction and evaluation of pancreatic malignancy. Success, complication rate and speed of the procedure depends on significantly on operator experience.

ERCP consists of passing an endoscope from the mouth through the upper GI tract and into the duodenum, where the papilla of Vater is located. The endoscopist may request glucagon and/or secretin at this time to reduce duodenal motility. A guide wire is passed through the sphincter of Oddi into the common bile duct or pancreatic duct. Contrast is then injected to image the common bile duct and pancreatic duct via fluoroscopy. Brushings, samples, stenting, sphincterotomy and/or stone extraction may then proceed. Overall complication rate ranges widely based off of the final procedures and instrumentation of the common bile and pancreatic ducts, with <5% quoted for simple stone extraction and 20% or more with sphincterotomy.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedure|last2=Schmiesing|first2=Clifford|last3=Golianu|first3=Brenda|publisher=Wolters Kluwer|year=2014|isbn=9781451176605|edition=2nd|pages=1512-1515}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|ETT required, bite block
|-
|Cardiovascular
|Elderly patients may have comorbid CAD or CHF, screen appropriately in preop H&P
|-
|Pulmonary
|Evaluate aspiration risk and ability to protect airway. Airway evaluation should focus on the need for GETA vs MAC.
|-
|Gastrointestinal
|Patients often present with ileus or obstruction due to underlying pathology causing biliary or pancreatic obstruction. This makes them high aspiration risk.
|-
|Hematologic
|Underlying malignancy increases the risk of VTE and may cause comorbid anemia
|-
|Renal
|Many patients presenting for ERCP may have prerenal AKI from severe vomiting and dehydration
|-
|Endocrine
|Glucagon administration may be requested, which is contraindicated in certain rare endocrine tumors such as pheochromocytoma and insulinomas.
|-
|Other
|Check cervical ROM
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
* At a minimum, all patients should have a preoperative CBC and CMP prior to case start
* in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation

=== Operating room setup ===

* Standard monitors and setup
*Fluoroscopy will be used, ensure adequate radiation safety equipment available (lead apron, lead glasses, lead shield)
*Positioning (lateral vs prone) will depending on proceduralist preference and patient factors, have equipment for prone positioning availabe (prone pillow)
* Endoscopy will require bite block to facilitate scope passage

=== Patient preparation and premedication ===

* Endoscopist may request glucagon (0.25-2mg IV) 10 min and/or secretin (0.2mcg/kg IV over 1min) prior to procedure to reduce duodenal motility
* consider aspiration precautions

=== Regional and neuraxial techniques ===

* Not typically necessary

== Intraoperative management ==

=== Monitoring and access ===

* Standard ASA monitors
*+/- invasive arterial access for hemodynamic monitoring, based off of history and physical
*+/- addition IV access based on current access, though bleeding is typically minimal and operative time is short.
*consider glucose checks if glucagon is administered

=== Induction and airway management ===

* If GETA is chosen, RSI induction is often necessary in patient with inadequate NPO time, current abdominal distension/nausea/vomiting, or other risk factors for aspiration. otherwise standard induction
*If GETA is avoided, induction of deep sedation with propofol and topicalization of the airway to facilitate tolerance of endoscope passage in the pharynx can be sufficient
*Consider etomidate induction for hemodynamically unstable patients

=== Positioning ===

*Most patients will be prone for this procedure to aid in manipulation of scope into proper placement.
*If patient cannot tolerate position, lateral or supine positioning can be done (increases difficulty for proceduralist).

=== Maintenance and surgical considerations ===

* If deep sedation is used, propofol infusion should be titrated to effect, avoiding respiratory depression and loss of protective airway reflexes
* If GETA is used, normal maintenance with volatile or intravenous agents or balanced approach can be used.
* GETA is associated with higher procedure success rate, consider intubation if the procedure is anticipated to be difficult or complex.

=== Emergence ===

* The duodenum and stomach are usually decompressed by the endoscopist prior to scope removal
*If obstruction in bile duct is removed, there is a high risk of bile aspiration. Have suction readily available.

== Postoperative management ==

=== Disposition ===

* ERCP can be done as an outpatient surgical procedure, with disposition PACU -> home
* however with more complex ERCP procedures or with comorbid conditions, patients will typically go PACU -> medicine/surgical ward.

=== Pain management ===

* Not typically a very painful procedure postop since ERCP is an endoscopic method.
* multimodal analgesia with oral regimen

=== Potential complications ===

* post-ERCP pancreatitis (most common complication, up to 40%), more common in young patients with preexisting sphincter of Oddi dysfunction
* bowel or duct perforation (rare)
* hemorrhage (rare)
* cholangitis/cholecystitis
* aspiration
* cardiopulmonary complications (MI, PE, respiratory arrest)

== References ==

[[Category:Surgical procedures]]

Lung volume reduction surgery

2023-12-08T19:35:33Z

Nquach: Filled article in

{{Infobox surgical procedure
| anesthesia_type = GETA
| airway = DLT vs SLT w/ bronchial blocker
| lines_access = large bore PIV x2, A line, +/- central access/PA catheter
| monitors = Standard, 5 lead ECG, A line, +/- PA catheter
| considerations_preoperative = Medical optimization and strict patient selection is essential to prevent poor surgical outcomes
| considerations_intraoperative = Maintenance of physiologic parameters in the normal range may be very challenging due to poor reserve and synergistic interactions of comorbities
| considerations_postoperative = Extubation is anticipated, aggressive optimization prior to extubation in OR is necessary. Reduce coughing and bucking as much as possible to prevent worsening of air leaks. Tube exchange to SLT if mechanical ventilation is needed.
}}

Lung Volume Reduction Surgery (LVRS) is a surgical technique to help improve normal breathing in patients with emphysema by removing hyperinflated lung parenchyma. Up to 15-30% of lung parenchyma can be removed to achieve the desired results.<ref name=":0">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|last2=Schmiesing|first2=Clifford|last3=Golianu|first3=Brenda|publisher=Wolters Kluwer|year=2014|isbn=9781451176605|pages=336-340}}</ref> Initially developed to help palliate the symptoms of end-stage emphysema, the technique initially showed promising results as well as severe operative morbidity and mortality. The National Emphysema Treatment Trial currently represents the best evidence supporting LVRS and provides basis for its approved indications. LVRS is a palliative procedure and does not reverse the disease process. It has been shown to improve FEV1, exercise tolerance, 6 minute walk test, and overall quality of life. These benefits are most significant in the first year postop, and return to preop baseline in 5 years.<ref name=":1">{{Cite book|last=LaPar|first=Damien|title=Review of Cardiothoracic Surgery|last2=Mery|first2=Carlos|last3=Turek|first3=Joseph|publisher=Thoracic Surgery Resident Association|year=2015|isbn=9781523217168|location=Chicago|pages=70-74}}</ref>

Patients considered for this procedure with end stage emphysema will display decreased FEV1/FVC, absolute decrease in FEV1, hyperinflation, diaphragmatic flattening, and worsening work of breathing despite maximal medical therapy. Prior to surgery, preoperative pulmonary rehabilitation and smoking cessation are essential for a good surgical outcome. High resolution chest CT and V/Q scans can help with initial surgical evaluation by determining if a patient has upper lobe predominant, lower lobe predominant or homogeneous disease. From the NETT trial, patients with heterogenous upper lobe predominant disease demonstrated the most benefit from LVRS.<ref name=":1" />

The selection criteria for LVRS is traditionally quite strict, with upwards of 80% of patients referred for LVRS rejected as surgical candidates. Preoperative screening is extremely important to optimize surgical outcome.

<u>Inclusion Criteria:</u><ref name=":0" />

Medical Hx:

* severe emphysema
* age < 75
* smoking cessation > 6mo
* lowest effective prednisone dose
* no prior thoracic surgery

Pulmonary function

* FEV1 < 30-35% predicted
* PaCO2 < 50mmHg
* TLC > 120% predicted

Cardiac function:

* mPAP < 35mmHg if pulm HTN suspected
* no evidence of LV dysfunction on stress testing if CAD suspected

Radiographic:

* hyperinflation w/ flattened diaphragm on CXR
* decreased upper lobe perfusion on V/Q scan
* emphysema with upper lobe predominance

<u>Exclusion Criteria:</u><ref name=":0" />

* continued smoking
* severe malnutrition
* other severe cardiopulmonary disease causing dyspnea (CAD, CHF, cancer, ILD, bronchiectasis)
* severe obesity or malnutrition
* previous thoracic surgery
* severe pulmonary hypertension (mPAP > 35)
* chest wall deformities with restrictive physiology

The surgical procedure entails the following steps:<ref name=":1" />

# Inspection/palpation of the entire lung with observation of the areas with most rapid deflation for preservation.
# Mobilization of the entire lung
# Resection of target areas with reinforced stapler. Reinforce staple lines with PTFE or bovine pericardium
# Aggressive treatment of airleaks with sealants, pleural tents, or pleurodesis.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Cardiovascular
|Elderly patients with longstanding COPD often have comorbid CAD, pulmonary HTN, and ischemic heart disease.
|-
|Pulmonary
|Lung isolation is required for the procedure, and patients should have a thorough pulmonary evaluation to ensure that they will be able to tolerate at least some time on one lung ventilation. Smoking cessation and medical optimization of emphysema is a must prior to surgery.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
* All patients should have a preoperative hemoglobin and type and screen on file prior to case start
* In patients with a history of cardiac disease or low functional status (most patients with end stage emphysema will qualify), consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation
* Prior to surgery, high resolution CT, V/Q scan, PFTs, ABG and/or flow/volume loops will likely have been completed by the surgical team. Evaluation for tolerance of one lung ventilation is necessary.

=== Operating room setup ===

* Standard OR setup
* A-line
* Double lumen tube (left) vs bronchial blocker with SLT
* flexible bronchoscope for DLT placement
* fluid warmer in case transfusion is needed
* forced air warmer

=== Patient preparation and premedication ===

* ensure smoking cessation preop
* ensure all preop inhalers have been continued on the day of surgery.
* epidural or ESP catheter should be placed preoperatively for intraop and postop analgesia. Aggressive postop analgesia is extremely important to facilitate a favorable surgical outcome.

=== Regional and neuraxial techniques ===

* thoracic epidural is the preferred technique for intraop and postop analgesia, in patients without contraindications
* ESP catheters can also be placed for postop analgesia as an alternative to epidural technique.

== Intraoperative management ==

=== Monitoring and access ===

* standard ASA monitors
* 5 lead EKG
* invasive hemodynamic monitoring with arterial line for BP and ABG monitoring
* 2 large bore PIV
* central access/PA catheter as indicated by history and physical (presence and degree of pulmonary HTN and RV dysfunction) and surgeon preference.

=== Induction and airway management ===

* Standard induction in patients with low aspiration risk.
* Lung isolation is required, and left double lumen tube is the preferred option for optimal isolation. Patients will often have very little pulmonary reserve and if placement of a DLT cannot be achieved swiftly, intubation with SLT with BB or subsequent tube exchange are also viable options.

=== Positioning ===

* The traditional open approach is typically taken through a median sternotomy in the supine position
* With thoracoscopic approaches (VATS-LVRS), patients are often placed in lateral decubitus, and flipped to address the other side.

=== Maintenance and surgical considerations ===

* patients are often quite chronically ill and often present a great challenge intraop to maintain normal physiologic parameters.
* standard maintenance with volatile or intravenous agents or balanced technique, along with administration of bolus/infusions through epidural.
* Avoid opioids if possible to reduce the risk of respiratory depression during emergence.

=== Emergence ===

* this is one of the most critical times during the surgery, optimize all physiologic parameters as much as possible. Early extubation is important for a good surgical outcome as prolonged mechanical ventilation will worsen air leaks.
* Optimize respiratory mechanics by sitting patient upright, maintaining good analgesia, deep suctioning prior to extubation
* Chest tubes are typically only kept on water seal because suction will maintain or worsen air leaks.
* coughing and straining on the ETT is undesirable as they may worsen air leaks, consider deep extubation techniques, bridging to other non-invasive ventilatory support until patients are wide awake, maintaining respirations with minimal support.
* If extubation is impossible or anticipated to be delayed, tube exchange to a SLT should be performed while the patient is well anesthetized and prior to transport to ICU.

== Postoperative management ==

=== Disposition ===

* typically patients will recover in ICU even after extubation
* if postop mechanical ventilation is necessary, pressure support with low levels of CPAP may help with inspiratory work of breathing while controlling PaCO2 and airway pressure.

=== Pain management ===

* excellent postop analgesia is critical for good surgical outcome, as patients need early and aggressive pulmonary toilet and pulmonary rehabilitation
* epidural PCEA or ESP nerve catheters are typically used

=== Potential complications ===

* perioperative mortality is quite high, and is quoted at 5-15% in some series. No significant difference in outcomes have been shown between VATS vs median sternotomy approaches though patients operated with VATS approach have shorter recovery periods.
* virtually all patients will have air leaks, and may persist for longer than 7 days. Pleural pressure and pneumothoraces are manages with chest tubes that are kept on water seal. The chest tubes should NOT be placed on suction as they may worsen air leaks.
* Cardiac arrhythmias

== Procedure variants ==
New bronchoscopic approaches with one-way endobronchial valves have been developed and are currently being studied for the palliation of end stage emphysema.

== References ==
<references />
[[Category:Surgical procedures]]

Mediastinal tumor resection

2023-12-08T18:22:09Z

Nquach: Filled in article

{{Infobox surgical procedure
| anesthesia_type = GETA
| airway = DLT vs SLT w/ bronchial blocker
| lines_access = large bore PIV x2, A line
| monitors = Standard, 5 lead ECG, A line
| considerations_preoperative = Airway may be compressed by mediastinal mass
| considerations_intraoperative = Lung isolation required in most cases
| considerations_postoperative = Epidural analgesia is recommended with open thoracotomy for postop analgesia
}}

Mediastinal tumors are characterized by their location in the mediastinum: anterior, posterior, middle. The common anterior mediastinal masses can be remembered by the "Terrible T's": thyroid (substernal goiters), thymoma, teratoma (germ cell tumors) and "terrible" lymphoma. Common masses of the middle mediastinal compartment include bronchogenic cysts, pericardial cysts, lymphomas. Common masses of the posterior compartment primarily consist of neurogenic tumors, esophageal tumors and lymphoma. The approach to resection depends on the tumor location and extent of invasion. Substernal goiters can often be removed from a superior approach from the neck. Tumors of the anterior compartment are typically handled via median sternotomy. Tumors of the middle and posterior compartment are approached best via lateral thoracotomy or VATS approaches.<ref>{{Cite book|last=LaPar|first=Damien|title=Review of Cardiothoracic Surgery|last2=Mery|first2=Carlos|last3=Turek|first3=Joseph|publisher=Thoracic Surgery Resident Association|year=2015|isbn=9781523217168|location=Chicago|pages=183-192}}</ref>

Resection approaches also have to consider the invasion extent of the primary tumor and whether attached structures can be safely dissected away or sacrificed. Tumors with vascular invasion may require multidisciplinary approach with a cardiac surgeon and the use of cardiopulmonary bypass. In addition to posing tricky surgical considerations, large anterior mediastinal masses may also present significant anesthetic challenges. In particular, large bulky masses may compress the airway and induction of anesthesia may cause critical intrathoracic airway obstruction. Although rigid bronchoscopy may sometimes be able to bypass the obstruction and allow ventilation, often times the only safe method for ensuring ventilation on induction of anesthesia is preinduction peripheral VV-ECMO cannulation.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedure|last2=Schmiesing|first2=Clifford|last3=Golianu|first3=Brenda|publisher=Wolters Kluwer|year=2014|isbn=9781451176605|pages=308-309}}</ref>

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|Patients with lung cancer may develop Lambert-Eaton myasthenic syndrome, quantitative monitoring of neuromuscular blockade is recommended.
|-
|Cardiovascular
|Elderly patients may have comorbid CAD, preop testing to risk stratify is recommended if indicated by history. Tumors with invasion and compression of the great vessels and/or chambers of the heart may cause cardiovascular compromise with induction of anesthesia
|-
|Pulmonary
|Bulky mediastinal lymphadenopathy may make airway management in the anesthetized patient precarious. Ensure that the pt can lie flat without significant airway compression. Patients treated with bleomycin should have FiO2 < 40% intraop to prevent hyperoxic lung injury.
|-
|Gastrointestinal
|Bulky mediastinal lymphadenopathy can cause partial esophageal obstruction, increasing the risk of aspiration
|-
|Hematologic
|Malignant processes may induce comorbid anemia
|-
|Endocrine
|Depending on the exact pathology of the anterior mediastinal mass/lymphadenopathy, there may be underlying comorbid thyroid or paraneoplastic syndromes.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start
* in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation
* in patients with a history of pulmonary disease, consider further testing with PFTs, ABG and/or flow/volume loops.

=== Operating room setup ===

* Standard OR setup
* A-line
* Double lumen tube (left) vs bronchial blocker with SLT
* flexible bronchoscope for DLT placement vs bronchial blocker placement
* fluid warmer in case transfusion is needed
* forced air warmer

=== Patient preparation and premedication ===

* multimodal analgesic technique is recommended.
* thoracic epidural vs ESP block
* consider H2 antagonist and sodium citrate in patients with reflux or partial obstruction to esophagus

=== Regional and neuraxial techniques ===

* especially if an open thoracotomy approach is utilized, epidural placement for intraop/postop analgesia is recommended in patients without contraindications.
* ESP catheter placement can also be a viable option for postop analgesia

== Intraoperative management ==

=== Monitoring and access ===

* standard ASA monitors
* 5 lead EKG
* invasive hemodynamic monitoring with arterial line
* 2 large bore PIV
* central access as indicated by history and physical and surgeon preference, though uncommon for this type of procedure

=== Induction and airway management ===

* patients with mediastinal disease with compression of the esophagus are often at high risk of aspiration, RSI induction with cricoid pressure in these patients is recommended
* Lung isolation is necessary, placement of a (left) double lumen tube is recommended though other techniques may be used.
* In patients with a difficult airway and high aspiration risk, intubation with a single lumen tube followed by tube exchange vs bronchial blocker can be a viable strategy
* It is highly recommended that the surgeon be in the room or immediately available at induction should rigid bronchoscopy or ECMO be necessary.
* if there is high suspicion that the mediastinal mass will critically compress the airway on induction (eg. critical tracheal/bronchial compression at rest, stridor, dyspnea, imaging with critical stenosis etc...) creating an emergency cannot-ventilate-cannot-intubate scenario that can neither be solved with surgical airway, discuss with primary surgeon about potential pre-induction VV-ECMO cannulation.

=== Positioning ===
Positioning will depend on the location of the mass and the approach taken (median sternotomy vs open thoracotomy vs VATS).

* resection via median sternotomy: typically supine
* resection via lateral thoracotomy or VATS: lateral decubitus vs supine

=== Maintenance and surgical considerations ===

* standard maintenance with volatile or intravenous anesthetics, or balanced technique. Avoid nitrous given one lung ventilation
* if epidural was placed preoperatively, bolus or continuous infusion of local anesthetic with or without additional epidural opiate can provide intraop analgesia. If epidural opiate loading dose is used to enhance analgesia, administer early during the surgery and at least 1h prior to end of case.
* Lung isolation will be necessary, communicate with surgeon should the patient not tolerate one lung ventilation
* In patients treated with bleomycin, ensure the FiO2 remains <40% to prevent hyperoxic lung injury

=== Emergence ===

* extubation is anticipated in most cases
* major fluid shifts may occur during surgery which may cause significant airway edema. If extubation is contraindicated, tube exchange to a single lumen tube should be performed prior to transport to ICU.

== Postoperative management ==

=== Disposition ===

* PACU then step down surgical unit if extubated
* ICU disposition if postop mechanical ventilation is indicated

=== Pain management ===

* epidural postop analgesia with PCEA is preferred vs nerve block (ESP) catheters
* multimodal analgesia with opioids and/or NSAIDs

=== Potential complications ===

* major bleeding: tumor invading vascular structures can massive hemorrhage during dissection.
* chyle leak from thoracic duct injury: initially treated with bowel rest but may need duct ligation or embolization of the cisterna chyli
* recurrent laryngeal nerve/phrenic nerve injury
* SVT/afib
* thermal injury to membranous bronchus during dissection of subcarinal nodes
* DVT/PE: malignant disease will predispose patients to VTE.
* pulmonary complications (atelectasis, aspiration, pneumonia, pneumothorax)

== References ==
<references />
[[Category:Surgical procedures]]

Mediastinoscopy

2023-12-07T23:53:16Z

Nquach: Added content to page

{{Infobox surgical procedure
| anesthesia_type = GETA
| airway = ETT
| lines_access = large bore PIV x1, +/- A line
| monitors = Standard, BP cuff on left arm, +/- A line
| considerations_preoperative = Evaluate for degree of airway compression by mediastinal mass
| considerations_intraoperative = Be prepared for major bleeding. Compression to innominate artery may cause R arm BP or A line to falsely display hypotension or cardiac arrest.
| considerations_postoperative =
}}

Mediastinoscopy is a procedure that involves a cervical incision and placements of a rigid scope to view and instrument certain structures of the mediastinum. The most common indication for mediastinoscopy is biopsy of mediastinal lymph nodes in N2 or N3 NSCLC, though any indication for biopsy of mediastinal lymph nodes at stations 2, 4 or 7 is possible with this procedure.<ref name=":0">{{Cite book|last=LaPar|first=Damian|title=Review of Cardiothoracic Surgery|last2=Mery|first2=Carlos|last3=Turek|first3=Joseph|publisher=Thoracic Surgery Resident Association|year=2015|isbn=9781523217168|location=Chicago|pages=184-185}}</ref> Mediastinoscopy may also be performed at the thoracic level to access mediastinal lymph nodes at stations 5 and 6 (transthoracic mediastinoscopy, also known as the Chamberlain procedure). Previous mediastinoscopy, innominante or aortic arch aneurysms, and prior chest radiation are relative contraindications to the procedure.<ref name=":1">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|last2=Schmiesing|first2=Clifford|last3=Golianu|first3=Brendo|publisher=Wolters Kluwer|year=2014|isbn=9781451176605|edition=2nd|pages=309-315}}</ref>

In the more common cervical mediastinoscopy procedure, a cervical incision is made above the sternal notch and a mediastinoscopy is use to bluntly enter and instrument the middle mediastinum. Care is taken to avoid puncturing the numerous vulnerable neurovascular structures in the area (namely the aorta, innominate artery, innominate vein, azygous vein, recurrent laryngeal nerve, right pulmonary artery)<ref name=":1" />. Meanwhile, in the classic Chamberlain procedure (transthoracic mediastinoscopy), the 3rd costal cartilage is resected through an incision placed in the left 2nd and 3rd intercostal space, taking care not to injure the internal mammary artery or phrenic nerve, and the mediastinum explored without entering the pleura.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Cardiovascular
|Elderly patients may have comorbid CAD, preop testing to risk stratify is recommended if indicated by history
|-
|Pulmonary
|Bulky mediastinal lymphadenopathy may make airway management in the anesthetized patient precarious. Ensure that the pt can lie flat without significant airway compression. Patients with lung cancer may develop Lambert-Eaton myasthenic syndrome, quantitative monitoring of neuromuscular blockade is recommended.
|-
|Gastrointestinal
|Bulky mediastinal lymphadenopathy can cause partial esophageal obstruction, increasing the risk of aspiration
|-
|Hematologic
|Malignant processes may induce comorbid anemia
|-
|Endocrine
|Depending on the exact pathology of the anterior mediastinal mass/lymphadenopathy, there may be underlying comorbid thyroid or paraneoplastic syndromes.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start
* in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation

=== Operating room setup ===

* Standard GETA setup
* Risk stratify airway technique to the degree of anticipated airway difficulty and airway compression from mediastinal mass/lymphadenopathy.
* BP cuff on left arm, pulse oximeter on the right arm. The mediastinoscopy may compress the innominate artery which results in reduced/absent right sided upper extremity pulses.
* Arterial line as indicated by history and physical. If placed, it should be right sided, correlating carefully with the left arm BP cuff as right sided pressures may be inaccurate due to great vessel compression by surgeon.
* If CVP/PA catheter are desired, they should be placed through femoral access if SVC syndrome is present.

=== Patient preparation and premedication ===

* Avoid premedicating with sedating medications if airway compromise from mass compression is a concern
* If awake fiberoptic intubation is planned, ample time should be allocated for administration of antisialogogue and topicalization of the airway

=== Regional and neuraxial techniques ===

* Epidural placement for postop analgesia is typically not indicated given small incision. Epidurals or peripheral nerve blocks may be placed post op if there is catastrophic conversion to median sternotomy or thoracotomy.

== Intraoperative management ==

=== Monitoring and access ===

* standard ASA monitors
* 5 lead EKG

* 1 large bore IV (14-16g)
* +/- arterial line
* ensure blood in OR in case of severe bleeding

=== Induction and airway management ===

* Standard induction if there are no risk factors for aspiration, otherwise RSI w/ cricoid pressure
* Airway management based off of anticipated risk of difficult intubation based off of patient's pathology, history and physical, and imaging.

=== Positioning ===

* Supine, 180˚ degree flip, head toward surgeon.
* often some degree of reverse Trendelenburg (head up) is requested

=== Maintenance and surgical considerations ===

* standard maintenance with volatile and/or intravenous agents

=== Emergence ===

* extubation is anticipated, extubation strategy based off of difficulty of airway and degree of mediastinal mass airway obstruction.
* normal PONV prophylaxis based off of Apfel score.

== Postoperative management ==

=== Disposition ===

* PACU -> home vs surgical ward
* cervical mediastinoscopy is typically an outpatient surgical procedure
* transthoracic mediastinoscopy without violation of the pleura can be same-day discharge; if the pleura is entered a chest tube is placed and the patient is typically observed overnight.

=== Pain management ===

* Significant pain is not anticipated: multimodal pain control, typically with short course of oral opioids

=== Potential complications ===

* Major bleeding is the most common complication (0.1-0.6%), though most bleeding can be dealt with packing. Instrumentation near lymph node station 4R is the most common site of major bleeding due to injury to the azygous vien. In severe instances, median sternotomy with possible CPB may be necessary to achieve hemostasis and repair vascular injuries.<ref name=":0" />
* pneumothorax
* phrenic or recurrent laryngeal nerve damage (occurs most commonly with manipulation at station 4L)<ref name=":0" />
* tracheomalacia (more often seen in patients with longstanding mediastinal masses)
* esophageal perforation (near lymph node station 7)<ref name=":0" />

== References ==
<references />
[[Category:Surgical procedures]]

McKeown esophagectomy

2023-12-07T20:06:28Z

Nquach: Filled in all major areas in article

{{Infobox surgical procedure
| anesthesia_type = General
| airway = DLT vs SLT w/ bronchial blocker
| lines_access = 2 large bore IV, A line
| monitors = Standard ASA monitors, A line
| considerations_preoperative = Consider epidural placement for intra/postop analgesia
| considerations_intraoperative = RSI induction often necessary, lung isolation
| considerations_postoperative = Epidural postop analgesia preferred
}}

== Overview ==
The Mckeown esophagectomy, also known as the 3-incision or 3-field esophagectomy, is another established method for resection of the esophagus. As with all esophagectomy, indications include treatment of malignant disease in the middle and lower 3rd of the esophagus as well as benign disease such as intractable benign strictures and end stage achalasia. It involves 3 incisions as the name suggests: laparotomy, thoracotomy, and cervical incision. A Mckeown esophagectomy involves thoracic esophageal mobilization and lymph node dissection (either through right open thoracotomy or VATS approach), stomach mobilization and feeding jejunostomy placement (most commonly through laparoscopic methods), and finally left cervical incision for anastomosis.<ref>{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|last2=Schmiesing|first2=Clifford|last3=Golianu|last4=Brenda|publisher=Wolter Kluwer|year=2014|isbn=9781451176605|pages=493-498}}</ref><ref name=":0">{{Cite book|last=LaPar|first=Damian|title=Review of Cardiothoracic Surgery|last2=Mery|first2=Carlos|last3=Turek|first3=Joseph|publisher=Thoracic Surgery Resident Association|year=2015|isbn=9781523217168|edition=2nd|pages=137-140}}</ref>

The Siewert tumor type is assessed to determine the best surgical approach to an esophageal tumor. Siewert type I is defined as tumor located in the lower esophagus within 1cm above and 5cm above the gastroesophageal (GE) junction. Siewert type II involves tumor located within 1cm above and 2cm below the GE junction. Siewert type III tumors are located between 2 and 5cm below the GE junction. Mckeown esophagectomies are best for resecting Siewert type I and II tumors. Although the Ivor Lewis approach is still appropriate for some Siewert type I tumors, tumors located above the carina should only be approached via the Mckeown method due to higher risk of positive margins with the Ivor Lewis approach.

Compared to the more popular Ivor-Lewis approach to esophagectomy, the Mckeown esophagectomy has several advantages, namely lower chance of local recurrence and anastomotic leak is easier to manage and less morbid as the connection is in the neck. The disadvantage is the need for 3 incisions compared to the 2 needed for a traditional Ivor Lewis approach.<ref name=":0" />

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Malignant lympadenopathy may compress and distort tracheal and bronchial anatomy making placement of DLT more difficult.
|-
|Cardiovascular
|Elderly patients may have coexisting CAD, preexisting use of antiplatelets or anticoagulants may prevent epidural placement
|-
|Pulmonary
|atients with esophageal cancer often have a long smoking history and have comorbid COPD. Because this technique uses thoracotomy, evaluate patient for the ability to tolerate one lung ventilation.
|-
|Gastrointestinal
|Patients with esophageal disease are often at higher risk for aspiration.
|-
|Hematologic
|Patients with malignant disease may have comorbid anemia
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start
* in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation
* in patients with a history of pulmonary disease, consider further testing with PFTs, ABG and/or flow/volume loops.

=== Operating room setup ===

* Standard OR setup
* A-line
* Double lumen tube (left) vs bronchial blocker with SLT
* flexible bronchoscope for DLT placement
* fluid warmer in case transfusion is needed
* forced air warmer

=== Patient preparation and premedication ===

* multimodal analgesic technique is recommended.
* thoracic epidural vs ESP block
* consider H2 antagonist and sodium citrate in patients with reflux or partial obstruction

=== Regional and neuraxial techniques ===

* because a thoracic approach is utilized, epidural placement for intraop/postop analgesia is recommended in patients without contraindications.

== Intraoperative management ==

=== Monitoring and access ===

* standard ASA monitors
* 5 lead EKG
* invasive hemodynamic monitoring with arterial line
* 2 large bore PIV should be
* Central access is often unnecessary

=== Induction and airway management ===

* patients with esophageal disease are often at high risk of aspiration, RSI induction with cricoid pressure is usually recommended
* Lung isolation is necessary, placement of a (left) double lumen tube is recommended though other techniques may be used.
* In patients with a difficult airway and high aspiration risk, intubation with a single lumen tube followed by tube exchange vs bronchial blocker can be a viable strategy

=== Positioning ===

* patient is positioned in left lateral decubitus for the initial thoracic component
* after completing the thoracic portion of the operation, the patient is repositioned supine with a shoulder roll to allow for the neck to be mildly hyperextended and turned to the right.<ref name=":1">{{Cite web|last=Asharva|first=Evgeny|title=Esophagectomy: Three-field (McKeown) - Laparotomy and Right Thoracoscopy (Thoracotomy) with Cervical Anastomosis|url=https://medicine.uiowa.edu/iowaprotocols/esophagectomy-three-field-mckeown-laparotomy-and-right-thoracoscopy-thoracotomy-cervical-anastomosis|url-status=live}}</ref>

=== Maintenance and surgical considerations ===

* standard maintenance with volatile or intravenous anesthetics, or balanced technique.
* some surgeons prefer to be involved in the decision to begin vasopressor infusions and may ask for fluid resuscitation prior to initiation of pressors.<ref name=":1" />
* if epidural was placed preoperatively, bolus or continuous infusion of local anesthetic with or without additional epidural opiate can provide intraop analgesia. If epidural opiate loading dose is used to enhance analgesia, administer early during the surgery and at least 1h prior to end of case.

=== Emergence ===

* extubation is anticipated in most cases
* aggressive PONV prophylaxis is preferred
* major fluid shifts may occur during surgery which may cause significant airway edema. If extubation is contraindicated, tube exchange to a single lumen tube should be performed prior to transport to ICU.

== Postoperative management ==

=== Disposition ===

* PACU then step down unit if extubated
* ICU disposition if postop mechanical ventilation is indicated

=== Pain management ===

* epidural postop analgesia with PCEA is preferred
* multimodal analgesia with opioids and/or NSAIDs

=== Potential complications ===

* anastomotic leak: less devastating in the 3 hole approach given the cervical location
* chyle leak from thoracic duct injury: initially treated with bowel rest but may need duct ligation or embolization of the cisterna chyli
* recurrent laryngeal nerve injury
* SVT/afib
* thermal injury to membranous bronchus during dissection of subcarinal nodes
* DVT/PE: malignant disease will predispose patients to VTE.
* pulmonary complications (atelectasis, aspiration, pneumonia, pneumothorax)

== Procedure variants ==

=== Choice of conduit: ===
There are several choice of conduits to bridge the cervical esophagus to the duodenum to reestablish gastrointestinal continuity.

* Stomach: Most commonly used due to good blood supply and preexisting correct peristaltic direction and orientation. Blood supply to the prepared stomach conduit is from the right epiploic artery and the gastric tip is the most ischemic area especially when under tension. Most centers perform some sort of gastric drainage procedure to prevent delayed gastric emptying (Botox injection, pyloromyotomy or pyloroplasty)
* Jejunum: Given the cervical position of the anastomosis, if jejunum is used, it is typically used as a jejunal free flap can reach from the abdomen to the neck ("supercharged interposition graft"), with microvascular anastomosis performed by plastic surgery. In Ivor Lewis and transhiatal approaches where the anastomosis is in the thorax, Roux-en-Y and pedicled jejunal grafts can be used instead.
* Colon: typically used when stomach is not an option. Either side colon can be used but the left is more commonly used due to smaller caliber, longer length, and fewer vascular variations.

== References ==
<references />
[[Category:Surgical procedures]]