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4 Gastroesophageal Refl ux Disease: Preoperative Evaluation
48
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M.E. Allaix et al.
49
P.M. Fisichella et al. (eds.), Surgical Management of Benign Esophageal Disorders,
DOI 10.1007/978-1-4471-5484-6_5, © Springer-Verlag London 2014
Abstract The goal of this chapter is to discuss the preoperative evaluation, anes-
thesia concerns in special situations, and postoperative management of patients pre-
senting for esophageal operations and procedures.
Keywords Cardiac risk and optimization • Obstructive sleep apnea • Intraoperative
monitoring • Fluid management • Pain management
Patients with benign esophageal disorders frequently present with several comorbid
conditions, which should be optimized prior to elective surgeries and procedures.
In this chapter, we discuss the preoperative evaluation, anesthesia concerns in
special situations, and postoperative management of patients presenting for esopha-
geal operations and procedures.
Preoperative Evaluation
The history and physical examination are the most effective screening tools in the
preoperative evaluation and the optimization of patients for anesthesia and surgery.
Patients with esophageal disorders frequently have comorbidities including cardio-
pulmonary diseases and a smoking history.
Chapter 5
Surgery for Esophageal Disorders:
The Anesthesiologist’s View
Barbara G. Jericho
B. G. Jericho , MD
Department of Anesthesiology , The University of Illinois Hospital and Health Sciences System ,
1740 W. Taylor Street, Room 3200 , Chicago , IL 60612 , USA
e-mail: jericho@uic.edu
50
Cardiac Evaluation
Patients with cardiopulmonary diseases are evaluated preoperatively by utilizing the
American College of Cardiology (ACC)/American Heart Association (AHA)
Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac
Surgery (Fig. 5.1 ). To determine which patient needs to be medically optimized
prior to elective noncardiac surgery, one needs to evaluate patient risk factors, surgi-
cal risk factors, and functional capacity [ 1 ].
Patient risk factors include “Active Cardiac Conditions” and “Clinical Risk
Factors.” “Active Cardiac Conditions” include unstable coronary syndromes (recent
myocardial infarction, unstable or severe angina), decompensated heart failure, sig-
nifi cant arrhythmias, and severe valvular disease [ 1 ]. If the patient has “Active
Cardiac Conditions” and is scheduled for elective surgery, the patient should be
evaluated and treated prior to the operation or procedure. “ Clinical Risk Factors ”
include ischemic heart disease, cerebrovascular disease, compensated heart failure,
diabetes mellitus, and renal insuffi ciency [ 1 ].
In addition to patient risk factors, the risk of the surgical procedure is another
component of cardiac risk stratifi cation to consider in the evaluation of patients for
noncardiac surgery. High - risk surgeries (cardiac risk >5 %) include emergency
Need for emergency
noncardiac surgery?
Active cardiac
conditions*
Yes
(Class I, LOE C)
Yes
(Class I, LOE B)
Yes
(Class I, LOE B)
Yes
(Class I, LOE B)
No or unknown
No
No
No
Class I,
LOE B
Class IIa,
LOE B
Low risk surgery
Good functional capacity (MET level
greater than or equal to 4) without
symptoms†
Operating room
Evaluate and treat per
ACC/AHA guidelines
Perioperative surveillance
and postoperative risk
stratification and risk factor
management
Consider
operating room
Proceed with
planned surgery
Proceed with
planned surgery
1 or 2 clinical
risk factors‡
3 or more clinical
risk factors‡
No clinical
risk factors‡
Vascular surgery
Intermediate
risk surgery
Vascular surgery
Intermediate risk
surgery
Proceed with
planned surgery
Proceed with planned surgery with HR control§ (Class Ila, LOE B)
or consider noninvasive testing (Class lI b, LOE B) if it will change management
Step 1
Step 2
Step 3
Step 4
Step 5
Consider testing if it will
change management§
Fig. 5.1 Cardiac evaluation and treatment algorithm for noncardiac surgery based on active clini-
cal conditions, known cardiovascular diseases, or cardiac risk factors for patients > 50 years
(Fleischer et al. [
1 ]. Reprinted with permission)
B.G. Jericho
51
procedures, aortic and other major vascular surgeries, and peripheral vascular sur-
geries [ 1 ]. Intermediate - risk surgeries (cardiac risk 1–5 %) include carotid endarter-
ectomy, head and neck surgery, abdominal and thoracic surgery, orthopedic surgery,
prostate surgery, and endovascular aortic aneurysm repair [ 1 ]. Low - risk surgeries
(cardiac risk <1 %) include endoscopic procedures, cataract surgery, and breast sur-
gery [ 1 ].
Lastly, one needs to determine the patient’s functional capacity . A patient has
good functional capacity when he or she is able to perform a Metabolic Equivalent
Task (MET) of greater than or equal to four without chest pain or shortness of
breath. Activities involving METs of four include climbing stairs or walking at a
brisk pace (4 miles per hour).
Electrocardiogram (ECG)
Per ACC/AHA Guidelines, a preoperative 12-lead ECG is recommended for
patients with at least one clinical risk factor who are undergoing vascular proce-
dures and for patients with known coronary heart disease, peripheral arterial
disease, or cerebrovascular disease who are undergoing intermediate-risk sur-
gery [ 1 ]. If the preoperative ECG is abnormal, the ECG should be compared to a
previous ECG to assess if the change is old or new. In addition, patients with
pacemakers and/or implantable cardioverter-defi brillators should have a preop-
erative ECG.
Hypertension
Hypertension is known to cause end-organ disease including coronary artery dis-
ease, congestive heart failure, renal, and cerebrovascular disease. To address the
association of hypertension and perioperative cardiac risk in the perioperative
period, Howell et al. showed that postponing anesthesia and surgery in patients with
hypertension does not reduce perioperative risk [ 2 ]. Thus, for patients with a sys-
tolic blood pressure ≥180 mmHg and a diastolic blood pressure ≥110 mmHg, the
risks of performing an operation or a procedure must be weighed against the bene-
fi ts of delaying it for a period of time required to medically optimize the patient’s
blood pressure [ 1 ].
Angioplasty
Patients who had balloon angioplasty should have their elective surgery or proce-
dure delayed for at least 2–4 weeks [ 3 ].
5 Surgery for Esophageal Disorders: The Anesthesiologist’s View
52
Coronary Stents
Patients with coronary stents scheduled for esophageal operations or procedures need
to have prior to surgery a note in their medical record from the cardiologist stating
whether the patient has a bare-metal stent or drug-eluting stent, when the coronary
stent was placed, the type of stent, the results of any cardiac testing completed since
the stent was placed, and the cardiologist’s recommendations of when it is safe to
discontinue thienopyridine (Clopidogrel) and aspirin therapy. It is the prescribing phy-
sician’s decision when it is safe to stop thienopyridine and aspirin therapy. The patient
should be asked what symptoms he or she had prior to the stent placement and if those
symptoms have returned since the coronary stent was placed. If the patient’s symp-
toms have returned since the coronary stent was placed, this may be a sign that the
patient is having coronary ischemia. This change in symptoms should be communi-
cated to the cardiologist prior to proceeding with an elective operation or procedure.
Bare-Metal Stents
Patients with bare-metal stents are at increased risk of stent thrombosis in the fi rst
2 weeks, which can result in a myocardial infarction or death [ 1 ]. Four to six weeks
after stent placement, endothelialization of the stent occurs, after which the risk of
thrombosis decreases [ 1 ]. It is thus recommended to delay elective surgery
4–6 weeks after bare-metal stent placement [ 1 ]. Thienopyridine and aspirin are
administered for 4 weeks after bare-metal stent placement to reduce the risk of stent
thrombosis. Aspirin therapy is often continued perioperatively unless the risk of
bleeding outweighs the benefi ts of continued therapy.
Drug-Eluting Stents
For patients with drug-eluting stents, thienopyridine therapy and aspirin are continued
for at least 1 year after stent placement to prevent stent thrombosis that can result in a
myocardial infarction or death [ 1 ]. Elective surgeries or procedures should be delayed
at least 12 months after the initiation of thienopyridine and aspirin therapy [ 1 ].
Cardiac Implantable Electronic Devices (CIED): Pacemakers,
Implantable Cardioverter-Defi brillators (ICD)
During the preoperative evaluation, information from patients with CIEDs needs to
be obtained to avoid untoward events in the perioperative period including abnormal
rhythms, electromagnetic interference, and pulseless-electrical activity. It is
B.G. Jericho
53
essential to inquire about the type of device (pacemaker, ICD), if the patient is CIED
dependent, when the device was last interrogated, when the battery was last changed,
and the functioning of the device. A comprehensive evaluation of the device should
be completed by a cardiologist or a CIED service preoperatively. Stone et al. recom-
mend that in general pacemakers be evaluated within the last 12 months and ICDs
be checked within the last 6 months [ 4 ]. Perioperative recommendations for the
management of the CIED are obtained from the cardiologist or CIED service includ-
ing whether or not reprogramming of the device is required.
Pulmonary Evaluation
Chest X-Ray (CXR)
Patients with esophageal disease may have a smoking history or a history of aspira-
tion. A preoperative CXR may reveal aspiration and pulmonary or cardiac disease.
The clinical indications for a preoperative CXR include cardiac or thoracic surgery,
assessment of a possible mass compressing the trachea, active chest disease, decom-
pensated heart failure, intrathoracic malignancy, radiation to the thoracic region,
and pulmonary or mediastinal masses [ 5 ].
Pulmonary Function Tests (PFTs)
There usually are no routine clinical indications to obtain preoperative PFTs.
However, preoperative PFTs can reveal potential pulmonary function in patients
undergoing surgical resection of the lung [ 5 ]. Baseline PFTs for patients with
severely compromised pulmonary function, such as patients with bronchiolitis
obliterans syndrome related to GERD after lung transplantation surgery scheduled
for laparoscopic antirefl ux surgery, can aid in the assessment of weaning from
mechanical ventilation and extubation [ 6 ].
Smoking
Smokers have an increased risk of postoperative wound infections [ 7 ], pulmonary
complications, anastomotic leaks [ 8 ], a higher rate of intensive care unit admissions
postoperatively [ 9 ], and prolonged mechanical ventilation [ 10 ]. For those patients
offered a program to stop smoking with an assumed 25 % cessation rate, Mills et al.
estimate two million less postoperative complications [
11 ]. Ideally it is recom-
mended to have patients stop smoking at least 8 weeks prior to surgery [ 12 ].
5 Surgery for Esophageal Disorders: The Anesthesiologist’s View
54
Obstructive Sleep Apnea Syndrome (OSAS)
OSAS affects over 20 million Americans [ 13 ]. By the year 2050, it is estimated that
nearly 100 million Americans will have a sleep disorder [ 13 ]. The prevalence of
OSAS is 1–9 % for patients presenting for surgery [ 14 ]. However, approximately
80–90 % of adults with OSAS are undiagnosed [ 15 ]. This means that patients may
present for surgery and anesthesia without a known diagnosis of OSAS. OSAS that
goes undiagnosed is associated with increased perioperative morbidity and mortal-
ity [ 16 , 17 ]. It is therefore important to screen patients at risk for OSAS preopera-
tively. Chung et al. developed and validated a screening tool, “STOP-BANG” [ 18 ,
19 ]. Patients are considered high risk for OSA if they have three or more of the
items shown in Table 5.1 [ 18 , 19 ]. Vasu et al. showed that a high score (3 or greater)
of the STOP-BANG questionnaire revealed an approximate tenfold risk for postop-
erative complications [ 20 ].
Patients with OSAS are at increased risk for airway collapse and thus are more
sensitive to the effects of narcotics, benzodiazepines, and inhaled anesthetics both
intra- and postoperatively. Furthermore, these patients may have a potentially diffi cult
airway, may experience exacerbation of hypoxemia and hypercarbia, cardiac arrhyth-
mias and ischemia, hypertension, and increased postoperative wound infections [ 17 ]
as well as progression to right heart failure from resulting pulmonary hypertension.
Complications and the length of hospital stay can be reduced if patients with OSAS
use their continuous positive airway pressure (CPAP) mask prior to surgery [ 17 ]. In
addition, preoperative polysomnography should be scheduled for those at risk for
OSAS without CPAP therapy and patients with OSAS should be encouraged to bring
their CPAP machine the day of surgery for possible use after extubation.
Pulmonary Aspiration
When patients are unconscious, they lose their normal ability to protect their airway
refl exes and are then at risk for aspiration. Virtually all patients with esophageal
diseases are at increased risk for aspiration during anesthesia and surgery. Patients
with gastroesophageal refl ux disease (GERD), achalasia, large hiatal and parae-
sophageal hernias, gastrointestinal motility disorders, pregnancy, obesity, and
Table 5.1 Screening tool to
identify patients at risk for
obstructive sleep apnea
syndrome (STOP-BANG)
[
18 , 19 ]
S = Snoring
T = Tired during the day
O = Observed apnea
P = High blood pressure
B = Body mass index >35 kg/m
2
A = Age >50 years
N = Neck circumference >40 cm
G = Gender, male
B.G. Jericho
55
patients who have eaten prior to surgery outside of the American Society of
Anesthesiologists (ASA) Guidelines [ 21 ] (Table 5.2 ) are at increased risk for pul-
monary aspiration and its consequences. Aspiration can occur at the induction of
anesthesia, at extubation, or in the postoperative period.
Aspiration has signifi cant physiological consequences. The clinical effects of
aspiration can range from cough and laryngospasm to a chemical pneumonitis and
death. Chronic aspiration can lead to pneumonia, sepsis, hypoxemia, and restrictive
lung disease. Sakai et al. conducted a 4-year retrospective analysis of the incidence
and outcome of perioperative pulmonary complications (PPA) and found that from
99,441 anesthetic procedures, 14 patients had PPA [ 22 ]. Interestingly, 50 % occurred
during gastroesophageal procedures [ 22 ]. Out of the 14 cases, 10 occurred under
general anesthesia and 4 occurred under monitored anesthesia care [ 22 ]. Six patients
with PPA developed pulmonary complications and one of these six patients died
[ 22 ]. The current incidence, morbidity, and mortality of PPA were therefore 1/7,103,
1/16,573, and 1/99,441, respectively [ 22 ].
To reduce the risk of and consequences of aspiration, one should follow these
preoperative strategies:
1 . Initial assessment that includes the identifi cation of risk factors for aspiration.
2 . Minimization of solid food and liquid intake according to the ASA Practice
Guidelines for preoperative fasting that pertain to patients undergoing elective
surgery under general anesthesia, regional anesthesia, or monitored anesthesia
care (MAC) (Table 5.2 ) [ 21 ].
3 . Preoperative Pharmacologic Management . The ASA Committee on Standards
and Practice Parameters states that there is insuffi cient literature to evaluate the
effects of gastrointestinal prokinetics, histamine-2 receptor antagonists, non-
particulate antacids, and proton pump inhibitors on the incidence of pulmonary
aspiration in the perioperative period [ 21 ]. Yet, in clinical practice, these agents
are utilized to reduce gastric volume and gastric pH and increase gastric empty-
ing preoperatively in selected patients at risk for aspiration [ 21 ].
The routine use of these agents is not recommended in patients not apparently
at increased risk for pulmonary aspiration [ 21 ].
4 . Airway Protection. Various techniques, including an awake intubation, are utilized
to secure the airway and reduce the risk of pulmonary aspiration. For example, an
awake fi beroptic intubation may be used in patients who have a diffi cult airway
and are at high risk of pulmonary aspiration. A rapid sequence induction is another
Table 5.2 Fasting
recommendations to reduce
the risk of aspiration [
21 ]
Clear liquids
a
2 h
Breast milk 4 h
Infant formula 6 h
Light meal 6 h
Fried, fatty foods 8 h
a
Clear liquids include fruit juice without pulp, water, coffee or tea
without milk, and carbonated beverages. Clear liquids should not
include alcohol
5 Surgery for Esophageal Disorders: The Anesthesiologist’s View
56
technique utilized to induce general anesthesia in patients at high risk for aspira-
tion despite few objective data supporting the effi cacy of this technique [ 23 ]. A
rapid sequence induction involves preoxygenating the patient, the application of
cricoid pressure (Sellick maneuver), intravenous medications to induce anesthesia,
the administration of a rapid-acting neuromuscular blocking agent, and the imme-
diate intubation of the trachea without mask ventilation. Cricoid pressure is contra-
indicated in patients with tracheal injury, active vomiting, and an unstable cervical
spine injury. Should alternative airway devices be used, a laryngeal mask airway
offers less protection against aspiration than cuffed endotracheal tubes [ 24 ].
Nasogastric Tubes
Suctioning nasogastric tubes preoperatively and prior to extubation are strategies that
minimize the risk of aspiration. These are especially indicated preoperatively in patients
with achalasia with a dilated esophagus fi lled with food contents and in patients with
large hiatal hernias. Moreover, the blind placement of a nasogastric tube is not indi-
cated in patients with epiphrenic diverticula as it may perforate the diverticulum.
Intraoperative Monitoring
The decision of which monitors to utilize for esophageal surgery and procedures is
based on the planned procedure and the extent of the patient’s comorbidities. ASA
standard monitors of noninvasive blood pressure, electrocardiogram, pulse oxime-
ter, and capnography are utilized for endoscopic procedures and minimally invasive
procedures [ 25 ]. Per ASA Guidelines, signifi cant changes in body temperature
should be monitored when these changes are intended, anticipated, or suspected
[ 25 ]. Invasive monitoring (arterial line) to continuously monitor blood pressure is
utilized in transthoracic surgeries, surgeries involving one-lung ventilation, and in
patients with signifi cant cardiac or pulmonary comorbidities. Central venous lines
are placed in those patients with poor peripheral intravenous access, those patients
requiring vasopressors and inotropic support, and septic patients. Bladder catheter-
ization should be considered for those surgeries of long duration, involving signifi -
cant blood loss, and with extensive fl uid shifts.
One-Lung Ventilation (OLV)
OLV facilitates the surgical approach for transthoracic approaches to the esophagus
and for thoracoscopic esophageal surgery. The practitioner must become familiar
with the airway anatomy, be aware if the patient had any prior radiation therapy to
B.G. Jericho