What is the recommended anesthesia technique for a patient with carcinoma of the stomach undergoing surgery?

Anesthesia for Gastric Carcinoma Surgery

For patients undergoing surgery for gastric carcinoma, general anesthesia using short-acting agents (propofol with remifentanil or other short-acting opioids) combined with epidural analgesia is recommended, with epidural placement performed only by experienced anesthesiologists familiar with this technique. 1

Anesthetic Technique Selection

General Anesthesia Protocol

Use short-acting induction and maintenance agents to facilitate rapid recovery:

• Induction: Propofol combined with short-acting opioids (fentanyl, alfentanil, or remifentanil infusion) 1
• Muscle relaxation: Short-acting relaxants titrated with neuromuscular monitoring, maintaining deep block to facilitate surgical access 1
• Maintenance: Sevoflurane or desflurane in oxygen-enriched air, or total intravenous anesthesia (TIVA) using target-controlled infusion pumps (particularly beneficial for patients prone to postoperative nausea/vomiting) 1

Regional Anesthesia Considerations

Epidural analgesia combined with general anesthesia provides superior outcomes for open gastric surgery:

• Epidural placement should only be performed by anesthesiologists experienced with one-lung ventilation and epidural techniques 1
• In open surgery, epidural analgesia is superior to opioid-based alternatives for pain control, reducing postoperative nausea/vomiting, and decreasing complications 1
• Epidural reduces the surgical stress response and insulin resistance, helping prevent perioperative hyperglycemia 1

Important caveat: For laparoscopic gastric surgery, alternative methods (spinal anesthesia, intravenous lidocaine, or patient-controlled analgesia) may be equally effective to epidural 1

Oncologic Considerations for Anesthetic Choice

The choice of anesthetic technique may influence long-term cancer outcomes, though evidence remains conflicting:

• Regional anesthesia (particularly epidural) combined with general anesthesia has been associated with better oncologic outcomes in some retrospective studies, potentially through reduced immunosuppression 1, 2
• Volatile anesthetics may suppress immune function and affect cancer cell behavior, though prospective data are lacking 1
• Practical approach: Propofol-based TIVA with regional analgesia is theoretically preferable to volatile-only techniques, though this should not override patient safety considerations 2

Specific Anesthetic Management

Preoperative Assessment

Focus on cancer treatment effects on organ systems:

• Chemotherapy effects: Bleomycin causes pulmonary damage, anthracyclines are cardiotoxic, platinum agents are nephrotoxic 2
• Nutritional status: Many gastric cancer patients have compromised nutrition requiring optimization 1
• Coagulation: Check coagulation profile if neuroaxial block planned 1

Intraoperative Management

Fluid therapy should be goal-directed to avoid overload:

• Target fluid delivery against physiological measures 1
• Maintain mean arterial pressure with vasopressors once normovolemia established, especially important with epidural use 1
• Avoid salt and water overload 1

Depth of anesthesia monitoring:

• In elderly patients, use bispectral index (BIS) monitoring to avoid excessive anesthetic depth, which increases postoperative confusion risk 1

Antibiotic prophylaxis:

• Administer intravenous antibiotics covering aerobic and anaerobic bacteria 30-60 minutes before incision 1
• Repeat doses during prolonged procedures according to drug half-life 1

Pain Management Strategy

Multimodal analgesia reduces opioid requirements and improves recovery:

• Primary: Epidural analgesia for open surgery (local anesthetics ± low-dose opioids) 1
• Alternative for laparoscopic: Spinal anesthesia, IV lidocaine infusion, or PCA 1
• Adjuncts: NSAIDs (with caution for renal/GI/cardiac risks), acetaminophen 1
• Postoperative: Transition to extended-release oral formulations when stable 1

Critical pitfall: Avoid excessive opioid use, as opioids inhibit natural killer cell function and may stimulate cancer cell proliferation 3

Special Considerations

For High-Risk Patients

Segmental thoracic spinal anesthesia (T9-T10) may be considered for ASA III patients unable to tolerate general anesthesia:

• Use 2 mL hyperbaric bupivacaine 0.5% (10 mg) plus 20 mcg fentanyl intrathecally 4
• This technique shows shorter recovery time and better postoperative pain relief than general anesthesia 4
• Should only be performed by experienced anesthesiologists 4

Postoperative Care

Plan for adequate postoperative analgesia before emergence:

• Administer morphine 0.15 mg/kg IV 20 minutes before anticipated end of surgery if using remifentanil-based technique 5
• This does not delay respiratory recovery 5
• Monitor for pain using standardized assessment tools 1

Procedure-Related Pain Management

For biopsies, line placements, or other procedures:

• Use local anesthetics (lidocaine, prilocaine, tetracaine) with adequate time for effectiveness 1
• Consider sedation for anxious patients, but deep sedation/general anesthesia requires trained professionals 1
• Provide preprocedure patient education on pain management strategies 1

Common Pitfalls to Avoid

• Do not use neuroaxial blocks without checking coagulation status in patients receiving chemotherapy 1
• Do not use ester-type local anesthetics if patient has received organophosphate-based chemotherapy (use amides instead) 1
• Do not extubate until fully reversed from neuromuscular blockade and adequate respiratory drive confirmed 1
• Do not neglect glucose monitoring, as hyperglycemia increases postoperative complications 1
• Do not perform epidural placement unless experienced with the technique 1

1, 5, 2, 4, 3