What are the anesthetic considerations for a total gastrectomy?

Anesthetic Considerations for Total Gastrectomy

The optimal anesthetic management for total gastrectomy should include thoracic epidural analgesia, lung-protective ventilation strategies, and multimodal opioid-sparing techniques to reduce respiratory complications and promote early recovery. 1

Preoperative Assessment

Airway Evaluation

• Assess for difficult airway markers:
  • Mallampati score 3-4
  • Neck circumference ≥42 cm (especially in obese patients)
  • Thyromental distance <6 cm
  • Intact dentition
  • Age ≥46 years and male gender 2

Respiratory Assessment

• Evaluate for:
  • Arterial saturation <95% on air
  • Forced vital capacity <3L or FEV1 <1.5L
  • Respiratory wheeze at rest
  • Serum bicarbonate >27 mmol/L 2
• Consider arterial blood gas analysis if respiratory risk factors present

Cardiovascular Assessment

• Assess exercise tolerance
• Identify features of metabolic syndrome
• Consider cardiopulmonary exercise testing for high-risk patients 2

Anesthetic Technique

Induction

• Position patient in ramped position with tragus of ear level with sternum (especially important in obese patients) 2
• Consider video laryngoscopy for anticipated difficult airways 2
• Propofol is commonly used for induction 2, 3
• For target-controlled infusions in obese patients, be aware that Marsh and Schnider formulae become unreliable above 140-150kg 2

Maintenance

• Both inhalational anesthetics and total intravenous anesthesia (TIVA) are appropriate options with no difference in long-term mortality outcomes 4
• If using volatile agents, desflurane or sevoflurane are preferred due to faster onset/offset 2, 1
• Desflurane may offer faster wake-up times in patients with BMI ≥30 kg/m² 2
• Consider depth of anesthesia monitoring (BIS) to reduce risk of awareness and minimize anesthetic load 2

Ventilation Strategy

• Implement lung-protective ventilation:
  • Low tidal volumes (6-8 ml/kg ideal body weight)
  • PEEP 6-8 cmH₂O
  • Recruitment maneuvers to reduce atelectasis 2, 1
• For obese patients, consider slight sitting position during laparoscopy to allow increased abdominal excursion 2

Regional Anesthesia and Pain Management

Thoracic Epidural

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

Multimodal Analgesia

• Implement opioid-sparing techniques:
  • NSAIDs (unless contraindicated)
  • Paracetamol
  • Consider lidocaine, dexmedetomidine, ketamine, or magnesium as adjuncts 2
• Alternative regional techniques if epidural contraindicated:
  • Transversus abdominis plane (TAP) blocks 2, 1
  • Erector spinae plane blocks 2
  • Local anesthetic wound infiltration 2

Intraoperative Management

Fluid Management

• Implement goal-directed fluid therapy to avoid overload 1
• Maintain normothermia throughout procedure 1
• Ensure adequate intravenous access (consider two IV lines) 2

Neuromuscular Management

• Monitor neuromuscular function throughout
• Ensure complete reversal of neuromuscular blockade (TOF ≥0.9) before extubation 1
• Consider sugammadex for rapid and reliable reversal of rocuronium 3

Postoperative Considerations

Emergence and Extubation

• Extubate when fully awake with return of airway reflexes
• Position patient in sitting position for extubation 2
• Follow Difficult Airway Society extubation guidelines 2

PONV Management

• Implement multimodal PONV prophylaxis based on risk factors 1
• Avoid nitrous oxide due to increased PONV risk 1

Early Recovery

• Promote early mobilization
• Consider early removal of nasogastric tube
• Implement strategies to stimulate bowel function 1

Special Considerations

Obese Patients

• Higher risk of difficult ventilation and intubation
• Position in 30° reverse Trendelenburg with ramp elevation
• Consider high-flow nasal oxygen during induction to extend safe apnea time 2
• Monitor for sleep-disordered breathing postoperatively 2

Elderly Patients

• May have reduced anesthetic requirements
• Higher risk of postoperative delirium
• Consider BIS monitoring 1

Potential Complications

• Respiratory: atelectasis, pneumonia
• Cardiovascular: hypotension with epidural analgesia
• Gastrointestinal: anastomotic leaks, delayed gastric emptying
• Pain management challenges

By implementing these evidence-based anesthetic strategies for total gastrectomy, anesthesiologists can optimize patient outcomes by reducing respiratory complications, facilitating early recovery, and improving pain control.