Riesgos en la cadena de suministros

Because of the increasing early detection of oesophageal cancers and reflux-associated adenocarcinomas, obesity might be encountered in patients presenting for oesophagectomy. Commonly, patients will be underweight as a consequence of the dysphagia, poor socioeconomic status and cachexia associated with malignancy. Nutritional support should be considered in the malnourished and a multidisciplinary approach, including dieticians, cannot be overemphasised. Parenteral or enteral feeding through a nasogastric or jejunostomy tube should be initiated preoperatively where it is deemed necessary. Nevertheless, delaying surgery for the treatment of nutritional deficiencies by feeding has not been shown to improve outcome.4 Haematinics should also be given to treat preoperative anaemia. Dehydration should be corrected with fluid therapy which will also unmask the haemoconcentration.

Smoking cessation is advised to minimise respiratory complications perioperatively and also because of the poor wound healing that is associated with it. Chest imaging is useful in detecting hyperinflation which will suggest obstructive airway disease, and any pulmonary infiltrates from either an infective process or aspiration as a result of the oesophageal cancer. Some centres routinely do a lung function test to risk-stratify patients preoperatively and for comparisons at the postoperative period with the preoperative baseline.

Neoadjuvant chemotherapy, with or without radiation, is used increasingly to improve curative resection rate.1,7 _{There is a delay} of four to six weeks before surgery after the chemoradiation to minimise complications like bleeding, poor wound healing and postoperative infection. Commonly used chemotherapeutic agents are cisplastin, and 5-fluorouracil at times as a combination therapy which can increase the associated complications.1

Effort tolerance needs to be established preoperatively. Anaerobic threshold of less than 11 mls/kg/min is associated with poor outcome.4 _{Cardiopulmonary exercise testing is ideal} where available. Other means of assessing effort tolerance like shuttle walk test, stair test and six minutes’ walk test should be used where cardiopulmonary exercise testing cannot be done.8

Intraoperative

As previously mentioned, the Mckeown technique involves a laparotomy, right-sided thoracotomy and a left-sided neck incision.2 _{Common challenges faced by the anaesthetist include} positioning, long duration of surgery, blood loss and one lung ventilation (OLV).

Oesophageal surgery is a relative indication for OLV, but because of the ease of surgical access, it is almost always done during the oesophageal resection. Any method or device could be used for lung isolation depending on familiarity. In our setting a left-sided double lumen tube is used because of availability and a preference of intubating the bronchus of the ventilated lung. Lung protective ventilation has to be adhered to in order to minimise respiratory complications postoperatively which account for the highest morbidity at quoted rates between 17.7–38%.9 _{The pulmonary morbidity could either be pneumonia} or pulmonary insufficiency requiring ventilation including ARDS. Fluid therapy is important with excess fluids leading to pulmonary morbidity9 _{and a high likelihood of anastomotic leak.} Inadequate fluids will also compromise haemodynamics with hypotension and a need for vasopressors which both can lead to poor capillary perfusion, poor wound healing and anastomotic leaks.2 _{Goal-directed fluid therapy could help in striking a good} balance.

Adequate pain control perioperatively reduces the incidence of pulmonary complications.10 _{Thoracic epidural is considered} a gold standard in most centres. Some literature suggests that paravertebral blocks are as efficacious as an epidural with fewer side-effects.2

Hypotension can occur as a consequence of blood loss or compression of major vessels and the heart during thoracic dissection and also as a result of dehydration from the preoperative period unmasked by the anaesthetic agents.

Compression of the heart can also result in arrhythmias. Good communication between the surgical team and the anaesthetist is important to recognise and deal with the complication timeously and appropriately.

Postoperative

Patients are cared for in a high dependency unit. With the advent of fast-track surgery, minimally invasive oesophagectomy and adequate pain control with thoracic epidural analgesia, some authors suggest that patients can be cared for in the ward unless there is a need for ventilation postoperatively which is currently uncommon with most patients being extubated in theatre.

Conclusion

Success for oncological surgery should not only be limited to 30-day morbidity or mortality, but should also include recurrence of the cancer. Anaesthetists, as the perioperative physicians, can have an influence on morbidity, mortality and cancer recurrence, a concept called “onco-anaesthesia”.

References

1. Blank RS, Huffmyer JL, Jaeger JM. Anesthesia for esophageal surgery. Principles and practice of anesthesia for thoracic surgery: Springer; 2011. p. 415-43. 2. Howells P, Bieker M, Yeung J. Oesophageal cancer and the anaesthetist. BJA

Education. 2016:mkw037.

3. Mu J, Gao S, Mao Y, et al. Open three-stage transthoracic oesophagectomy versus minimally invasive thoraco-laparoscopic oesophagectomy for oesophageal cancer: protocol for a multicentre prospective, open and parallel, randomised controlled trial. BMJ open. 2015;5(11):e008328.

4. Sherry KM, Smith FG. Anaesthesia for oesophagectomy. Bja Cepd Reviews. 2003;3(3):87-90.

5. Doherty GM, Way LW. Current surgical diagnosis and treatment: Lange Medical Books/McGraw-Hill; 2006.

6. Park DP, Welch CA, Harrison DA, et al. Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database. Critical Care. 2009;13(2):S1.

7. Huitink JM, Teoh WH. Current cancer therapies–A guide for perioperative physicians. Best Practice and Research Clinical Anaesthesiology. 2013;27(4):481-92.

8. Murray P, Whiting P, Hutchinson SP, et al. Preoperative shuttle walking testing and outcome after oesophagogastrectomy. BJA: British Journal of Anaesthesia. 2007;99(6):809-11.

9. Xing X, Gao Y, Wang H, et al. Correlation of fluid balance and postoperative pulmonary complications in patients after esophagectomy for cancer. Journal of Thoracic Disease. 2015;7(11):1986-93.

10. Li W, Li Y, Huang Q, et al. Short and long-term outcomes of epidural or intravenous analgesia after esophagectomy: a propensity-matched cohort study. PloS one. 2016;11(4):e0154380.

South Afr J Anaesth Analg

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FCA 2 REFRESHER COURSE

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