What are the anesthetic considerations for a total gastrectomy?

Anesthetic Considerations for Total Gastrectomy

For total gastrectomy, thoracic epidural analgesia combined with general anesthesia using short-acting agents is the preferred anesthetic approach to optimize pain control, reduce opioid requirements, and minimize postoperative complications. 1

Preoperative Assessment and Preparation

• Evaluate for comorbidities with special attention to:

  • Nutritional status (often compromised in gastric cancer patients)
  • Cardiopulmonary status
  • Coagulation profile (if planning neuraxial techniques)
  • Airway assessment (potential difficult intubation)

• Aspiration prophylaxis:

  • Fasting period of 6-8 hours for solids 1
  • Consider proton pump inhibitors and non-particulate antacids

Intraoperative Management

Anesthetic Technique

1. General Anesthesia

   • Induction: Propofol (1-2.5 mg/kg based on patient status) 2
   • Maintenance: Short-acting inhalational agents (sevoflurane or desflurane) or TIVA 1, 3
   • Avoid nitrous oxide (increases PONV risk and delays return of bowel function) 1
   • Complete reversal of neuromuscular blockade with monitoring (TOF ≥0.9) 1

2. Regional Anesthesia

   • Mid-thoracic epidural (T7-T10) is strongly recommended for open gastrectomy 1
   • Insert before induction and continue intraoperatively and for 48-72h postoperatively 1
   • Use low-dose local anesthetic with short-acting opioid 1

Positioning

• For obese patients, 30° reverse Trendelenburg position with ramp elevation of head, neck, and shoulders improves intubation conditions 1
• Consider extended Mallampati score for predicting difficult intubation 1

Ventilation Strategy

• Lung-protective ventilation with low tidal volumes (6-8 ml/kg) and PEEP 6-8 cmH₂O 1
• Maintain normothermia throughout the procedure 1

Fluid Management

• Goal-directed fluid therapy to avoid overload
• Maintain mean arterial pressure with vasopressors once normovolemia established 1
• Consider minimally invasive cardiac output monitoring for high-risk patients

Postoperative Management

Pain Control

• First-line approach: Continue thoracic epidural analgesia for 48-72h 1, 4

  • Superior to IV PCA for pain control, earlier ambulation, and reduced pulmonary complications 4
  • Consider adding background infusion to patient-controlled epidural analgesia 5

• Alternative if epidural contraindicated: Multimodal analgesia

  • IV PCA with opioid-sparing adjuncts
  • Avoid continuous background opioid infusions in obese patients 1
  • Consider transversus abdominis plane (TAP) blocks 6

PONV Prevention and Treatment

• Multimodal PONV prophylaxis based on risk factors 1
• Consider dexamethasone, ondansetron, and other antiemetics

Early Recovery Measures

• Early mobilization (epidural facilitates this better than IV opioids) 7
• Early removal of nasogastric tube to promote return of bowel function 1
• Consider chewing gum to stimulate bowel function 1

Special Considerations

Laparoscopic vs. Open Approach

• Laparoscopic approach reduces pain and facilitates faster recovery 1, 7
• For laparoscopic gastrectomy, epidural still provides better bowel recovery than IV PCA 7

Obese Patients

• Higher risk of difficult airway and postoperative respiratory complications 1
• May require lower doses of anesthetic agents
• Increased risk of atelectasis; consider PEEP during induction 1

Elderly Patients

• Reduced anesthetic requirements
• Higher risk of postoperative delirium; consider BIS monitoring 1
• More susceptible to hypothermia and hemodynamic instability

Potential Complications and Management

• Respiratory: Atelectasis, pneumonia

  • Incentive spirometry, early mobilization, adequate pain control

• Cardiovascular: Hypotension with epidural

  • Treat with vasopressors if normovolemic 1

• Gastrointestinal: Delayed gastric emptying, ileus

  • Epidural analgesia reduces incidence compared to IV opioids 7

• Neurological: Post-dural puncture headache

  • Use pencil-point needles for spinal techniques 1

The evidence strongly supports thoracic epidural analgesia as the preferred analgesic technique for total gastrectomy, with demonstrated benefits for pain control, bowel function recovery, and reduced pulmonary complications compared to IV opioid-based analgesia 1, 4, 7.