What the Anesthesiologist Should Know before the Operative Procedure
Antireflux surgery: Laparoscopic and open Nissen fundoplications and partial fundoplications
Gastroeosophageal reflux disease (GERD) is an extremely common ailment in Western societies. Approximately half of all adult populations in the developed world suffer from it. Despite broadening indications for surgical intervention, only a very small subset are good candidates for antireflux surgery.
These patients are at exceptional risk for pulmonary aspiration of gastric contents, and it is of critical importance that their complaints of reflux be taken very seriously. Specifically, it is imperative to closely observe preoperative fasting guidelines, to continue all acid suppressive medication preoperatively, and to faithfully and flawlessly secure the patient’s airway using a rapid sequence induction. Also, airway changes secondary to chronic exposure to refluxate may make intubation challenging. The anesthesiologist should assume a higher likelihood of a difficult intubation.
1. What is the urgency of the surgery?
What is the risk of delay in order to obtain additional preoperative information?
Antireflux surgery is an elective procedure.
Gastric fundoplications are performed electively for symptomatic relief in patients with objectively defined GERD. In addition to relief from typical symptoms, the successful postoperative patient may also enjoy (1) freedom from life-long acid suppression therapy, (2) alleviation of respiratory symptoms if secondary to reflux, and (3) regression of Barrett’s metaplasia.
You will not encounter an urgent or emergent indication for any primary antireflux repair.
2. Preoperative evaluation
Cardiac disease: Patients with GERD will present, almost categorically, with some element of heartburn. Many patients will, in fact, describe their heartburn as a burning, substernal, radiating type chest pain. These descriptions should necessarily invoke a cardiac work-up for an ischemic cause of this chest pain. This is true especially in patients who are epidemiologically at risk for cardiac disease. An electrocardiogram should be obtained at the very least. If you have a higher index of suspicion for cardiac disease, it is prudent to pursue a more involved cardiac workup including stress tests and tests of myocardial perfusion.
Pulmonary disease: Reflux can also lead to respiratory symptoms. Sometimes, cough or asthma are the predominant findings in patients with GERD. Poorly controlled or profound reflux can even lead to laryngitis and recurrent pneumonia. In exceptional cases, pulmonary fibrosis can develop after repeated episodes of aspiration pneumonitis. It is important that the GERD patient with respiratory symptoms be properly optimized prior to surgery. Bronchodilator therapy, if needed, should be continued. Chest x-rays should demonstrate clear lung fields and the patient should be absent signs of pneumonia. Finally, pulmonary function tests should be obtained for the severe asthmatic or if pulmonary fibrosis is suspected.
Coronary artery disease: If suspicion exists that they are ischemic in origin, then the patient’s complaints of “heart burn” should be more fully investigated. Appropriate work-up under the guidance of a cardiologist is recommended.
Aspiration pneumonia:Aspiration pneumonia should be suspected in the patient with fever, productive cough, and findings of consolidation on chest x-ray. Suspicion for aspiration pneumonia should be greater still if these findings present in the context of a longer, more cyclic pattern of recurrent pneumonia. Surgery should be delayed pending resolution of symptoms following an appropriate course of antibiotics.
Bronchoconstriction: For the asthmatic patient who is dyspneic or having ongoing wheezing, surgery should be delayed, and the patient should be reevaluated and optimized on bronchodilating therapy. Also, consideration should be given for an infectious cause of the asthma exacerbation.
3. What are the implications of co-existing disease on perioperative care?
Perioperative evaluation: Co-existing diseases should be optimized prior to undergoing elective antireflux surgery. However, it is necessary to remember that many diseases are themselves sequelae of the reflux and cannot be ameliorated without surgery. These may include cough, bronchospasm, laryngitis, dental erosions, aspiration pneumonia, chronic pneumonitis, and pulmonary fibrosis.
Perioperative risk reduction strategies: The design of all perioperative risk reduction strategies should be to decrease the incidence or severity of pulmonary aspiration of gastric contents. 1) Continue acid suppressive medication. 2) Observe fasting guidelines. 3) Perform strict and proper rapid sequence inductions. 4) Employ lung-protective ventilation strategies. 5) Verify the patient’s ability to protect his or her airway prior to extubation.
b. Cardiovascular system
Acute/unstable conditions: Antireflux surgery is an elective procedure. Any acute or unstable cardiovascular issue demands full workup and cancellation of the surgery.
Baseline coronary artery disease or cardiac dysfunction – goals of management: Prudent hemodynamic management with attention to reduction in myocardial workload is the standard of care. The patient should continue with his or her current regimen of beta-blockers, statins, and afterload reducers (with the possible exception of angiotensin converting enzyme [ACE] inhibitors and angiotensin receptor blockers [ARBs]). Diuretics should be held the day of surgery. For laparoscopic procedures, special care should be exercised to avoid excessive hypercarbia and acidosis in patients with history of right heart failure. Euvolemia, as always, is important in patients with history of left heart failure.
Chronic obstructive pulmonary disease (COPD)/asthma: Continuation of bronchodilatory treatment is the standard of care.
History of pulmonary aspiration: As mentioned above, it is imperative to closely observe preoperative fasting guidelines, to continue all acid-suppressive medication preoperatively, and to faithfully and flawlessly secure the patient’s airway using a rapid sequence induction. Furthermore, upon emergence from anesthesia, the patient must demonstrate wakefulness and the ability to protect his or her airway prior to extubation.
Pulmonary fibrosis/chronic pneumonitis: GERD patients with these serious sequelae may not be able to tolerate the physiologic changes in respiratory mechanics that accompany laparoscopic surgery. In such cases, an open fundoplication may be the only feasible approach.
Continue the acid-suppressive regimen that symptomatically works best for the patient. These medications will be discussed in detail later.
Acute issues: Acute neurological issues are not a factor in elective antireflux surgery.
Chronic disease: Chronic neurological diseases are not a factor in elective antireflux surgery.
There is a strong link between obesity and GERD; body mass index (BMI) has a direct effect on the severity of reflux. It is not, therefore, surprising that many patients undergoing antireflux surgery are morbidly obese. The anesthesiologist must take into consideration the well-known anesthetic concerns of caring for this population: securing an intravenous (IV) line, managing the airway, proper positioning, and maintaining adequate ventilation, among many others.
g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (eg. musculoskeletal in orthopedic procedures, hematologic in a cancer patient)
4. What are the patient's medications and how should they be managed in the perioperative period?
There are a host of antireflux medications that a patient may be taking. These include antacids, histamine2-receptor antagonists, prokinetics, and proton pump inhibitors.
Antacids: Preoperatively, nonparticulate antacids may be administered to neutralize the acidity of gastric contents and thus help reduce the risk of aspiration. It should be remembered that antacids have a short duration of action and must be administered every 1 to 2 hours to achieve and maintain effective pH levels. It is reasonable to continue sodium citrate use well into the preoperative period. However, particulate antacids should be avoided for greater than 6 hours in accordance with standard npo guidelines. Also, it should be remembered that magnesium-based antacids may result in hypermagnesemia and diarrhea. Aluminum-containing antacids may cause hypophophotemia and constipation. Calcium-based antacids may cause hypercalcemia and constipation.
Histamine2-receptor antagonists:This class of drugs has been shown to reduce gastric acidity as well as decreasing gastric volume. Common H2 antagonists include ranitidine, famotidine, and cimetidine. There are several drawbacks to the use of these drugs preoperatively for the purposes of mitigating aspiration risk. High doses and continuous infusion are required, and sometimes fail, to maintain target pH levels above 4.0. Also, tolerance to H2-receptor antagonists can develop, and this may limit their effectiveness.
Prokinetics: Metoclopramide is sometimes used by these patients, espeically those with a concurrent diagnosis of gastroparesis. If a patient is using metoclopramide chronically for this purpose, then it is reasonable to administer this drug again preoperatively. However, there is little convincing data to suggest that the prokinetic effect of metoclopramide does much to decrease the incidence of clinically significant aspiration. Furthermore, its theoretical benefit must be balanced against the risk of extrapyramidal symptoms.
Proton pump inhibitors (PPIs): PPIs act directly at the final site of gastric acid secretion, and as such, provide a more targeted and potent suppression than that obtained with H2-blockers. In contradistinction to H2-blockers, PPIs are not associated with tolerance and consistently and dependably maintain gastric pH>4 throughout treatment. IV formulations are also readily available. This class of drugs is considered the gold standard for treatment of patients with GERD. Unless contraindicated due to allergy or drug intolerance, a PPI should without doubt be administered to these patients prior to their anesthetic. This may take the form of a po medication taken both the evening before and the morning of surgery. The PPI may also be given as an IV medication administered preoperatively. IV pantoprazole, administered as an 80 mg bolus over 2 minutes, achieves the desired pH within 20 minutes.
h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?
For medications specific to patients having antireflux surgery:
Particulate antacids should be considered a solid food and as such should be completely avoided for at least 6 hours preoperatively.
Cimetidine (Tagamet) causes inhibition of the cytochrome P450 system. This may cause increased concentrations of a multitude of drugs, including many anesthesia-relevant medications such as codeine, haloperidol, imipramine and nortriptyline, methadone, warfarin, metoprolol, labetalol, and propranolol.
Metoclopramide (Reglan) can cause extrapyramidal symptoms in some patients. This side effect may run the spectrum from simple restlessness to severe dystonia.
PPIs are generally well tolerated. It should be remembered, however, that omeprazole may inhibit metabolism of diazepam, phenytoin, and warfarin.
i. What should be recommended with regard to continuation of medications taken chronically?
Cardiac: Continue the current regimen of beta-blockers, statins, and afterload reducers. ACE inhibitors and ARBs, however, may be held on the morning of surgery, as they may contribute to intraoperative hypotension. Diuretics should also be held on the morning of surgery.
Pulmonary: Continue with the current regimen of brochodilators.
Renal: May continue all.
Neurologic: May continue all.
Antiplatelet: The decision to discontinue anti-platelet medications should be made in conjunction with the surgeon and other involved physicians. It is, however, common practice to hold aspirin and clopidogrel for at least 7 days. Other NSAIDs are commonly held for at least 3 days.
Psychiatric: May continue all.
j. How To modify care for patients with known allergies –
Avoid medications to which the patient is allergic, as you would with any anesthetic.
k. Latex allergy- If the patient has a sensitivity to latex (eg. rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.
l. Does the patient have any antibiotic allergies- – Common antibiotic allergies and alternative antibiotics]
The most common antibiotic administered for antireflux surgery is cefazolin. It provides coverage against gram-positive cocci of the skin as well as gram-negative enteric aerobes. In cases of cephalosporin allergy, clindamycin or vancomycin may be substituted. (Current recommendations for antibiotic prophylaxis of surgical wound infections will be discussed in detail below.)
m. Does the patient have a history of allergy to anesthesia?
5. What laboratory tests should be obtained and has everything been reviewed?
It is prudent to have a recent complete blood count (CBC) and basic metabolic panel prior to this elective surgery.
If concern exists over liver function or undiagnosed coagulopathy, it is also very reasonable to obtain a coagulation panel.
A blood type and screen should be done.
As discussed above, GERD patients who complain of heart burn should have an electrocardiogram done. If true concern exists for myocardial disease, then an echocardiogram and/or a myocardial perfusion study should be performed.
Also as summarized above, if pulmonary pathology exists, then a chest radiograph at the very least should be reviewed. The rare patient with pulmonary fibrosis secondary to recurrent aspiration deserves pulmonary function tests to quantify the extent of his/her disease.
Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
Fundoplication involves dissection of the diaphragmatic crura and significant mobilization of the esophagus and gastric fundus. In the case of laparoscopic procedures, instruments are often advanced into the mediastinum to mobilize the esophagus. When reapproximating the crura, the inferior vena cava is millimeters away from the ideal suturing site. Patient movement cannot be tolerated during these maneuvers.
While other modalities may be employed for pain control, it is not safe to perform such a case without a general anesthetic. In the event of a planned open fundoplication, epidural analgesia may be employed in conjunction with general anesthesia, however, this is not the common course. If the open procedure is planned, an upper midline incision is the normal approach. The transthoracic approach is rarely seen.
Patient positioning is low lithotomy for laparoscopic procedures, allowing the surgeon to operate from between the patient’s legs. The arms may or may not be tucked, thus reliable access is crucial.
Regional anesthesia (in conjunction with general anesthesia [GA]) would be most appropriate in an open fundoplication. As the anticipated incision would extend from the T6 to T10 dermatomes, a low thoracic epidural is most appropriate.
Awareness of any contraindication (patient refusal, coagulopathy, thombocytopenia, site infection, etc.) must be ensured prior to performing any neuraxial block.
Benefits: Epidural analgesia minimizes use of narcotics. Less narcotics mean less postoperative nausea and earlier return of bowel function. Epidural analgesia functions independent of patient input, and greatly increases respiratory function in the setting of upper midline incision.
Drawbacks: Epidural analgesia may be of use in the instance of an open fundoplication, but much of the discomfort (especially after the laparoscopic approach) may be due to diaphragmatic manipulation and irritation, which would not be covered neuraxially.
The possibility of dural puncture, nerve injury, post dural puncture headache, and significant hypotension cannot be ignored
Peripheral nerve block
A transversus abdominis plane (TAP) block may be performed postoperatively if conversion to open procedure occurs.
Benefits: TAP blocks increase patient comfort in the short term and are not very difficult to perform.
Drawbacks: Short to intermediate duration, the TAP block can be most useful as a bridge to improved pain control.
Issues:Familiarity with ultrasound guidance is crucial for safe performance of a TAP block. Care must be taken not to violate the peritoneum and perforate the bowel.
General anesthesia via endotracheal intubation is the only safe manner in which to anesthetize a patient for a fundoplication. With endotracheal intubation, the airway is secured while preparing for fundoplication. The entire purpose for this procedure is gastric reflux that is unresponsive to medical therapy. These patients are at a greatly increased risk of aspiration.
During the procedure, a nasogastric tube (NG) should be inserted to decompress the stomach. The NG tube is later removed, and at the point of fundoplication, the surgeon will ask for a bougie to be placed in the esophagus. This helps ensure that the fundoplication wrap is not so tight as to hinder passage of food boluses. Careful advancement of the large bougie is key to avoid esophageal perforation.
Benefits: General anesthesia via endotracheal intubation provides a secure airway, the ability to control minute ventilation to minimize hypercapnia during laparoscopic procedures, the ability to paralyze the patient, and the ability to rapidly convert to an open procedure if necessary.
Airway concerns:A secured airway does not negate the risk of aspiration, but can certainly minimize soilage. Any worsening of oxygenation must heighten suspicion.
Monitored anesthesia care
Monitored anesthesia care (MAC) is not an option during this procedure.
6. What is the author's preferred method of anesthesia technique and why?
I prefer to perform these procedures under general anesthesia via endotracheal tube. If an open procedure is anticipated, an epidural catheter should be placed preoperatively if at all possible in order to maximize patient comfort and positioning. All patients should be intubated after a rapid sequence induction, either with succinylcholine or rocuronium to minimize the risk of pulmonary soilage. The patient should be relaxed. I prefer to keep the patient at no more than 1 or 2 twitches on train of four monitoring until reversal is administered after fascial closure.
If performed laparoscopically, pain control should not be difficult in the normal patient. I prefer to employ fentanyl for induction, then morphine or hydromorphone during the case. Antiemetics should be given liberally. Retching may lead to disruption of fundoplication sutures, or migration of the fundoplication into the thorax. Unless contraindicated, dexamethasone, haloperidol, and ondansetron are quite useful.
What prophylactic antibiotics should be administered?
As an intraabdominal procedure which does not violate the gastrointestinal tract, cefazolin 2 grams IV is the recommended antibiotic regimen according to SCIP guidelines. Vancomycin or clindamycin may be substituted in the setting of life-threatening allergy.
What do I need to know about the surgical technique to optimize my anesthetic care?
After entry into the abdomen, the liver is retracted and the gastrohepatic ligament is divided. This is a point of importance as there may be an aberrant left hepatic artery, which, if divided, may lead to significant hepatic necrosis. The crura are then dissected and the esophagus mobilized. The short gastric arteries are ligated, then the gastric fundus is brought behind the esophagus and the fundoplication sutured in place. A bougie is normally placed in the esophagus in order to avoid a restrictively tight fundoplication. The diaphragmatic crura are then reapproximated and the wrap is often sutured to the right crus. Trocars are then removed, and fascia and skin are then closed.
What can I do intraoperatively to assist the surgeon and optimize patient care?
It is important to maintain deep paralysis throughout the surgery, as patient movement or sudden contraction of the diaphragm may lead to serious injuries.
What are the most common intraoperative complications and how can they be avoided/treated?
Many complications in this type of surgery involve pneumoperitoneum or extension of insufflated carbon dioxide into other compartments (subcutaneous, pleural, mediastinal).
b. If the patient is intubated, are there any special criteria for extubation?
As with other laparoscopic procedures, if subcutaneous emphysema is present, especially if it extends into the neck or face, extubation should be delayed, and the patient should remain on mechanical ventilation in either the Post-Anesthesia Care Unit (PACU) or Intensive Care Unit (ICU) until this resolves. Pneumomediastinum does occur with these procedures, but is usually not a significant issue.
c. Postoperative management
What analgesic modalities can I implement?
For laparoscopic procedures, much of the postoperative discomfort is secondary to diaphragmatic irritation. With good hemostasis, ketorolac may be dosed if no contraindications exist and with assent from the surgical team.
For open procedures, preemptive neuraxial analgesia is preferable, but postoperative epidural placement is also reasonable.
What level bed acuity is appropriate?
The patient’s preoperative conditions should determine the appropriate disposition of the patient. Many patients undergoing fundoplication are otherwise healthy, and a floor bed is appropriate. Any significant cardiac disease necessitates telemetry, and patients with critical pulmonary disease may require ICU level care prior to or immediately after extubation.
Cardiac: On insufflation of the abdomen for laparoscopic procedures, it is common to see significant bradycardia from vagal stimulation. This can be significant enough to cause a large drop in cardiac output.
Pulmonary:Pneumoperitoneum often leads to hypercapnia requiring hyperventilation. In susceptible patients, allowing the end-tidal carbon dioxide to rise may cause pulmonary vasoconstriction and right ventricle strain. It is possible to create a rent in the pleura during the esophageal dissection. This can lead to a pneumothorax from extension of the pneumoperitoneum. As long as the lung parenchyma is not injured, this may be treated with increased positive end-expiratory pressure (PEEP) and decreased abdominal insufflation pressures.
Bleeding:The most significant bleeding risk in from the short gastric vessels and the potential for injuring the spleen. Normally, however, bleeding is expected to be minimal. When reapproximating the diaphragmatic crura, sutures are placed millimeters away from the inferior vena cava. This is performed most safely when the patient is paralyzed.
Esophageal/gastric rupture:It is of great importance to have very clear communication with the surgeon when advancing either the bougie or nasogastric tube so that the surgeon may offer guidance and avoid perforation or rupture of the esophagus or stomach.
What's the Evidence?
Zaninotto, G, Portale, G, Costantini, M, Rizzetto, C, Guirroli, E. “Long-term results (6-10 years) of laparoscopic fundoplication”. J Gastrointest Surg. vol. 11. 2007. pp. 1138-45. (A prospective study demonstrating the long-term effectiveness of Nissen fundoplication in controlling reflux symptoms. Also delineates the typical surgical work-up of GERD patients.)
Pisegna, JR, Martindale, RG. “Acid suppression in the perioperative period”. J Clin Gastroenterol. vol. 39. 2005. pp. 10-6. (Cites several studies showing the clinical superiority of PPIs for acid suppression in GERD patients.)
Fischer. Mastery of surgery. 2006. (Step-by-step explanation of the surgical procedure.)
Evans. Surgical pitfalls: prevention and management. 2008. (A systematic discussion of complications for surgical procedures.)
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- What the Anesthesiologist Should Know before the Operative Procedure
- 1. What is the urgency of the surgery?
- What is the risk of delay in order to obtain additional preoperative information?
- 2. Preoperative evaluation
- 3. What are the implications of co-existing disease on perioperative care?
- b. Cardiovascular system
- c. Pulmonary
- d. Renal-GI:
- e. Neurologic:
- f. Endocrine:
- 4. What are the patient's medications and how should they be managed in the perioperative period?
- i. What should be recommended with regard to continuation of medications taken chronically?
- j. How To modify care for patients with known allergies -
- l. Does the patient have any antibiotic allergies- - Common antibiotic allergies and alternative antibiotics]
- m. Does the patient have a history of allergy to anesthesia?
- 5. What laboratory tests should be obtained and has everything been reviewed?
- Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?
- 6. What is the author's preferred method of anesthesia technique and why?
- b. If the patient is intubated, are there any special criteria for extubation?
- c. Postoperative management