ANESTHESIOLOGY FAST REVIEW

ANESTHESIOLOGY_FAST_REVIEWKAPAK1-0-25

GASTROINTESTINAL SYSTEM SURGERY ANESTHESIA

İpek Üçkan

Isparta City Hospital, Department of Anesthesiology and Reanimation, Isparta, Türkiye

Üçkan İ. Gastrointestinal System Surgery Anesthesia. In: Kazancı D, editor. Anesthesiology Fast Review. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.287-301.

ABSTRACT

  • Enhanced Recovery After Surgery (ERAS) protocols focuses on thorough evaluation, patient optimization, education, and minimizing the physiological impacts of fasting and bowel preparation.
  • General anesthesia suppresses pharyngeal reflexes, in emergency situations, gastric emptying may be altered; therefore, even after prolonged fasting, it cannot be assumed that the stomach is empty.
  • Certain cancers, particularly right-sided colonic and gastric tumors, are commonly associated with iron-deficiency anemia due to sustained low-grade bleeding.
  • Bowel preparation can cause significant fluid and electrolyte imbalances, especially in elderly patients.
  • The pH of the gastric contents, the presence of particulate matter, and the volume are the primary factors determining the severity of the pulmonary insult.
  • Under general anesthesia for abdominal procedures, patients are typically positioned supine, which can significantly reduce functional residual capacity (FRC) by 0.5 to 1.0 L.
  • Excessive intravenous fluid administration during the perioperative period can aggravate respiratory issues by promoting pulmonary edema, which increases arteriovenous shunting and leads to hypoxemia.
  • In the context of postoperative ileus, the use of nitrous oxide may exacerbate bowel distension due to its property of expanding gas-filled spaces.
  • Postoperative gastrointestinal dysfunction is characterized by symptoms such as nausea, vomiting, abdominal distension, intolerance to oral intake, and the absence of flatus or bowel movements.
  • Esophagectomy, regardless of the surgical approach, necessitates the use of general anesthesia. When feasible, combining general anesthesia with continuous neuraxial analgesia, such as thoracic epidural analgesia (TEA) or paravertebral block, is recommended for thoracotomy or laparotomy procedures.
  • The management of intraoperative hypotension during esophagectomy presents a complex challenge, balancing the risks associated with vasopressor use against those of fluid overload.
  • Malignant or benign growth of the colon and rectum and diverticular disease predominantly affect older adults, who often present with significant comorbidities including coronary artery disease, chronic pulmonary conditions, and diabetes mellitus.
  • The coexistence of general anesthesia and thoracic epidural anesthesia is widely regarded as the preferred technique for major abdominal surgery.
  • CRS and HIPEC are associated with significant fluid shifts due to prolonged surgery, peritoneal lavage, and hyperthermia.
  • Emergency abdominal surgeries are often performed under urgent and life-threatening conditions, which involve sepsis, hemorrhage, bowel obstruction, or perforation, leading to significant physiological derangements.

Keywords: Analgesia; Epidural; Rapid sequence induction and intubation; Colorectal surgery; Esophagectomy; Endoscopy; Gastrointestinal; Conscious sedation; Acute care surgery; One-lung ventilation

Referanslar

  1. Michał P, Judene, Jan W, Alexandros A, Piotr M, Michał N, et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol. 2018;35(6):95 [Crossref]  [PubMed]  [PMC]
  2. American Society of Anesthesiologists, ed. Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures: An Updated Report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology. 2017;126:376e393. [Crossref]  [PubMed]
  3. Warner MA, Warner ME, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology. 1993;78:56e62. [Crossref]  [PubMed]
  4. Jeremy D, Zaki-Udin H, Destiny C. Anesthetic implications of obesity in the surgical patient.Clin Colon Rectal Surg. 2011;24(4):222-8. [Crossref]  [PubMed]  [PMC]
  5. K Krishnaswamy. Drug metabolism and pharmacokinetics in malnourished children.Clin Pharmacokinet1989:17 Suppl 1:68-88. [Crossref]  [PubMed]
  6. Clarissa PS, Matthew CC, Julie H , Yosuf K, Lena N , Katerina P, et al. Preoperative Anemia and Iron Deficiency in Elective Gastrointestinal Cancer Surgery Patients. J Surg Oncol 2024. [Crossref]  [PubMed]
  7. Laura K, Pipsa L, Pirita V, Marja H, Reetta S , Carola Haapamäkiet al. Morbidity After Mechanical Bowel Preparation and Oral Antibiotics Prior to Rectal Resection. The MOBILE2 Randomized Clinical Trial.JAMA Surg. 2024;159(6):606-614. [Crossref]  [PubMed]  [PMC]
  8. Hongze Liu. Prospective study on the effects of mechanical bowel preparation under the enhanced recovery after surgery concept on electrolyte disturbances and functional recovery after robotic surgery for urologic tumors in older adults. BMC Urology , Article number: 2024;184:24. [Crossref]  [PubMed]  [PMC]
  9. J Savilampi, A Magnuson, R Ahlstrand. Effects of remifentanil on esophageal motility: a double-blind, randomized, cross-over study in healthy volunteers. Acta Anaesthesiol Scand. 2015;59(9):1126-36. [Crossref]  [PubMed]
  10. Michael R, -, Andrew D, -. Aspiration under anaesthesia: risk assessment and decision-making. Continuing Education in Anaesthesia Critical Care & Pain, 2014;4(15):171-175. [Crossref]
  11. Valérie A, Pierantonio L, Rémi V, Baptiste S , Christian S, Thomas S. Effects of Posture on the Inspiratory and Expiratory Components of Vital Capacity in Healthy Humans. Arch Bronconeumol. 2025;61(2):104-106. [Crossref]  [PubMed]
  12. Shengchen Liu, Per W Moller, Andreas Kohler, Anisa Hana , Guido Beldi , Dominik Obrist,et al. Effects of Trendelenburg position and increased airway pressure on hepatic regional blood flow of normal and resected liver. J Appl Physiol. 2020;128(3):667-680. [Crossref]  [PubMed]
  13. Lais Helena CN, Joshua AB, Jose Otavio Costa Auler Jr , Maxime Cannesson, Giorgio Della Rocca, et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioper Med (Lond). 2015;4:3. [Crossref]  [PubMed]  [PMC]
  14. Zubin M B, Liliana B. Perioperative Fluid Management.Clin Colon Rectal Surg. 2009;22(1):28-33. [Crossref]  [PubMed]  [PMC]
  15. Akça O , Lenhardt R, Fleischmann E, Treschan T, Greif R, Fleischhackl R, et al. Nitrous Oxide Increases the Incidence of Bowel Distension in Patients Undergoing Elective Colon Resection. Acta Anaesthesiol Scand. 2004;48(7):894-898. [Crossref]  [PubMed]  [PMC]
  16. MJ Scott, G Baldini, KCH Fearon, A Feldheiser, LS Feldman, T J Gan , et al. Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations. Acta Anaesthesiol Scand. 2015;59(10):1212-31. [Crossref]  [PubMed]  [PMC]
  17. Cheng-Cheng AZ, Aalok A, Xiaodong B. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clin Colon Rectal Surg. 2019;32(2):114-120. [Crossref]  [PubMed]  [PMC]
  18. Xiaozhuo Z, Ke W, Ling L, Jingyue M, Dan L, Jun Z. The Impact of Goal-Directed Fluid Therapy on Postoperative Nausea and Vomiting in High-Risk Patients Undergoing Laparoscopic Sleeve Gastrectomy. Obes Surg. 2022;32(11):3533-3540. [Crossref]  [PubMed]
  19. ASGE Standards of Practice Committee; Dayna S Early, Jenifer R Lightdale, John J Vargo 2nd, Ruben D Acosta, Vinay Chandrasekhara, et al. Guidelines for sedation and anesthesia in GI endoscopy. 2018;87(2):327-337. [Crossref]  [PubMed]
  20. Reena S, David T, Hasan H, et al. British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy. [Crossref]  [PubMed]  [PMC]
  21. Sadhvika R, .aats. tsra-primer-esophagectomy-basics [Link]
  22. Jessie AE, Emer G, John VR. Measurement and optimization of perioperative risk among patients undergoing surgery for esophageal cancer . Diseases of the Esophagus, 2024;3:37 [Crossref]  [PubMed]  [PMC]
  23. Randal S. Blank, Julie L. Huffmyer MD & J. Michael Jaeger PhD, MD, FCCP Anesthesia for Esophageal Surgery, In book: Principles and Practice of Anesthesia for Thoracic Surgery 2011;415-443: .DOI:10.1007/978-1-4419-0184-2_30. [Crossref]
  24. Peter G. Postthoracotomy pain management problems. Anesthesiol Clin 2008;26(2):355-67, vii. [Crossref]  [PubMed]  [PMC]
  25. Philip MH, Sergey K, Ritu RG, Ju-Mei Ng , Stephanie Y, Hisashi Tsukada, et al. Mediastinal Masses, Anesthetic Interventions, and Airway Compression in Adults: A Prospective Observational Study Anesthesiology 2022;136(1):104-114. [Crossref]  [PubMed]
  26. Mayank Mehrotra, Ankit Jain. Single-Lung Ventilation 2023. [PubMed]
  27. Akira M, Koichi S, Ryota W, Takashi J, Yasue H, Katsuaki T, et all. Impact of intraoperative goal-directed fluid therapy on major morbidity and mortality after transthoracic oesophagectomy: a multicentre, randomised controlled trial. Br J Anaesth. 2020;125(6):953-961 https://doi.org/10.1016/j.bja.2020.08.060 [Crossref]  [PubMed]  [PMC]
  28. Marc L, Frédéric T, Christoph E, Wolfram K. Fluid Therapy in Thoracic Surgery: A Zero-Balance Target is Always Best!. Turk J Anaesthesiol Reanim. 2016;44(5):227-229. [Crossref]  [PubMed]  [PMC]
  29. Maria Carolina AS, Marina Feliciano Orlandini, Letícia Nogueira Datrino , Guilherme Tavares , Luca Schiliró Tristão, Clara Lucato Dos Santos, et all. Is early extubation after esophagectomy safe? A systematic review and meta-analysis. J Surg Oncol. 2022;126(1):68-75. [Crossref]  [PubMed]
  30. Yuki Ho, Takaaki K, Hidehiro K, Hidetaka I, Satoru M, Hirofumi K, et al. Proportion of early extubation and short-term outcomes after esophagectomy: a retrospective cohort study. Int J Surg. 2023;109(10):3097-3106. [Crossref]  [PMC]
  31. Duncan G de Souza, Cheryl L Gaughen. Aspiration risk after esophagectomy. Anesth Analg. 2009;109(4):1352. [Crossref]  [PubMed]
  32. Miller's Anesthesia (10th Edition), Chapter 34: Aspiration risk and premedication strategies. [Link]
  33. NP van Orshoven , PL Oey, LJ van Schelven, JMM Roelofs, PAF Jansen, LMA Akkermans. Effect of gastric distension on cardiovascular parameters: gastrovascular reflex is attenuated in the elderly. J Physiol. 2004;555(Pt 2):573-583. [Crossref]  [PubMed]  [PMC]
  34. Brunicardi FC, Andersen DK, Billiar TR, et al. Schwartz's Principles of Surgery. 11th ed. McGraw Hill; 2019. [Link]
  35. Talia Z, Mark AP. Immunosuppressive therapies for inflammatory bowel disease. World J Gastroenterol. 2014 28;20(12):3146-3152. [Crossref]  [PubMed]  [PMC]
  36. Gustafsson UO, Scott MJ, Hubner M, J Nygren, N Demartines, N Francis, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS) Society recommendations. World J Surg. 2019;43(3):659-695. [Crossref]  [PubMed]
  37. Mazuski JE, Tessier JM, May AK, Robert G Sawyer , Evan P Nadler, Matthew R Rosengart, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect. 2017;18(1):1-76 [Crossref]  [PubMed]
  38. Y R Huo, A Richards, W Liauw, D L Morris. Hyperthermic intraperitoneal chemotherapy (HIPEC) and cytoreductive surgery (CRS) in ovarian cancer: A systematic review and meta-analysis. Eur J Surg Oncol. 2015;41(12):1578-89. [Crossref]  [PubMed]
  39. Nishkarsh Gupta, Vinod Kumar, Rakesh Garg, Sachidanand Jee Bharti , Seema Mishra , Sushma Bhatnagar ,et al. Anesthetic implications in hyperthermic intraperitoneal chemotherapy. J Anaesthesiol Clin Pharmacol. 2019;35(1):3-11. [Crossref]  [PubMed]  [PMC]
  40. Anjana S Wajekar, Sohan Lal Solanki, Vijaya P Patil. Postoperative complications and critical care management after cytoreduction surgery and hyperthermic intraperitoneal chemotherapy: A systematic review of the literatüre. World J Crit Care Med. 2022;11(6):375-386 [Crossref]  [PubMed]  [PMC]
  41. Michelle LD, Jordan MW, Markus S, Steven CC , John LC, Charles J, et al. Assessment of Complications After Pancreatic Surgery Ann Surg. 2006;244(6):931-939. [Crossref]  [PubMed]  [PMC]
  42. Capasso Mario, Franceschi Marilisa , Isabel Rodriguez-Castro Kryssia, Crafa Pellegrino , Cambiè Ginevra, Miraglia Chiara, et al. Epidemiology and risk factors of pancreatic cancer. Acta Biomed. 2018;89(9):141-146. [Crossref]
  43. Alison PK, Pancreatic cancer epidemiology: understanding the role of lifestyle and inherited risk factors. Nat Rev Gastroenterol Hepatol. PMC: 2022. [Crossref]  [PubMed]  [PMC]
  44. Lesley DP, Roberto M, Bruno B. Anaesthetic perioperative management of patients with pancreatic cancer. World J Gastroenterol. 2014;20(9):2304-2320. [Crossref]  [PubMed]  [PMC]
  45. Yishen M, Xingfei Z, Lihui Z, Bin L, Chen J, Deliang F, et al. Evaluating perioperative glycemic status after different types of pancreatic surgeries via continuous glucose monitoring system: a pilot study. Gland Surg. 2021;10(10):2945-2955. [Crossref]  [PubMed]  [PMC]
  46. Gastrinoma Treatment & Management. Author: Jennifer Lynn Bonheur, MD; Chief Editor: BS Anand, MD. Updated:2021 [Link]
  47. Andrea Carsetti , Eva Vitali , Lucia Pesaresi, Riccardo Antolini , Erika Casarotta, Elisa Damiani, et al. Anesthetic management of patients with sepsis/septic shock. Front Med (Lausanne). 2023;10:1150124. [Crossref]  [PubMed]  [PMC]
  48. Carol Peden , Michael J Scott. Anesthesia for emergency abdominal surgery. Anesthesiol Clin. 2015;33(1):209-21. [Crossref]  [PubMed]