CHAPTER 1

THEORY: ESOPHAGEAL CANCER

1.1 Introduction

The American Cancer Society's estimates for esophageal cancer in the United States for 2013 are

about 17,990 new esophageal cancer cases diagnosed (14,440 in men and 3,550 in women),and

about 15,210 deaths from esophageal cancer (12,220 in men and 2,990 in women).

This disease is 3 to 4 times more common among men than among women. The lifetime risk of

esophageal cancer in the United States is about 1 in 125 in men and about 1 in 435 in women.

Overall, the rates of esophageal cancer in the United States have been fairly stable for many

years. It was once much more common in African Americans than in whites. But it is now about

equally as common, as rates have fallen in African Americans and increased slightly in whites

over the past few decades. Squamous cell carcinoma is the most common type of cancer of the

esophagus among African Americans, while adenocarcinoma is more common in whites. Cancer

of the esophagus is much more common in some other countries. For example, esophageal cancer

rates in Iran, northern China, India, and southern Africa are 10 to 100 times higher than in the

United States. The main type of esophageal cancer in these countries is squamous cell carcinoma.

Although many people with esophageal cancer will go on to die from this disease, treatment has

improved and survival rates are getting better. During the 1960s, fewer than 5% of patients

survived at least 5 years after diagnosis. Now, about 20% of patients survive at least 5 years after

diagnosis. This includes patients with all stages of esophageal cancer at the time of diagnosis.

Survival rates for people with early stage cancer are higher.

1.2 Anatomy of Esophagus

The esophagus is a hollow, muscular tube that connects the throat to the stomach. It lies behind

the trachea (windpipe) and in front of the spine. Food and liquids that are swallowed travel

through the inside of the esophagus (called the lumen) to reach the stomach. In adults, the

esophagus is usually between 10 and 13 inches long and is about ¾ of an inch across at its

smallest point.

1.3 Histology of Esophagus

Mucosa: This is the layer that lines the inside of the esophagus. The mucosa has 3 parts:

• The epithelium forms the innermost lining of the esophagus and is normally made up

of flat, thin cells called squamous cells. This is where most cancers of the esophagus

start.

• The lamina propria is a thin layer of connective tissue right under the epithelium.

• The muscularis mucosa is a very thin layer of muscle under the lamina propria.

Submucosa: This is a layer of connective tissue just below the mucosa that contains blood vessels

and nerves. In some parts of the esophagus, this layer also contains glands that secrete mucus.

Muscularis propria: This is a thick band of muscle under the submucosa. This layer of muscle

contracts in a coordinated, rhythmic way to push food along the esophagus from thethroat to the

stomach.

Adventitia: This is the outermost layer of the esophagus, which is formed by connective tissue.

The upper part of the esophagus has a special area of muscle at its beginning that relaxes to open

the esophagus when it senses food or liquid coming toward it. This muscle is called the upper

esophageal sphincter.

The lower part of the esophagus that connects to the stomach is called the gastroesophageal (GE)

junction. A special area of muscle near the GE junction, called the lower esophageal sphincter,

controls the movement of food from the esophagus into the stomach and it keeps the stomach's

acid and digestive enzymes out of the esophagus.

Reflux and Barrett’s Esophagus

The stomach has strong acid and enzymes that digest food. The epithelium (inner lining) of the

stomach is made of gland cells that release acid, enzymes, and mucus. These cells have special

features that protect them from the stomach's acid and digestive enzymes.

In some people, acid escapes from the stomach back into the esophagus. The medical term for

this is gastroesophageal reflux disease (GERD), or just reflux. In many cases, reflux can cause

symptoms such as heartburn or a burning feeling spreading out from the middle of the chest. But

sometimes, reflux can occur without any symptoms at all.

If reflux of stomach acid into the lower esophagus continues for a long time, it can damage the

lining of the esophagus. This causes the squamous cells that usually line the esophagus to be

replaced with gland cells. These gland cells usually look like the cells that line the stomach and

the small intestine and are more resistant to stomach acid. The presence of gland cells in the

esophagus is known as Barrett's (or Barrett) esophagus. People with Barrett's esophagus are much

more likely to develop cancer of the esophagus. These people require close medical follow-up in

order to find cancer early. Still, although they have a higher risk, most people with Barrett's

esophagus do not go on to develop cancer of the esophagus

1.4 Esophageal Cancer

Cancer of the esophagus (also referred to as esophageal cancer) starts in the inner layer (the

mucosa) and grows outward (through the submucosa and the muscle layer). Since 2 types of cells

can line the esophagus, there are 2 main types of esophageal cancer: squamous cell carcinoma

and adenocarcinoma.

The esophagus is normally lined with squamous cells. The cancer starting in these cells is called

squamous cell carcinoma. This type of cancer can occur anywhere along the esophagus. At one

time, squamous cell carcinoma was by far the more common type of esophageal cancer in the

United States. This has changed over time, and now it makes up less than half of esophageal

cancers in this country.

Cancers that start in gland cells are called adenocarcinomas. This type of cell is not normally part

of the inner lining of the esophagus. Before an adenocarcinoma can develop, gland cells must

replace an area of squamous cells, which is what happens in Barrett's esophagus. This occurs

mainly in the lower esophagus, which is the site of most adenocarcinomas. Cancers that start at

the area where the esophagus joins the stomach (the GE junction), which includes about the first

2 inches of the stomach (called the cardia), tend to behave like esophagus cancers (and are treated

like them, as well), so they are grouped with esophagus cancers

1.4.1 Risk Factor

There are several risks factor such as:

Age: Less than 15% of cases are found in people younger than age 55.

Gender: Compared with women, men have more than a 3-fold higher rate of esophageal cancer.

Gastroesophageal reflux disease

Barrett's esophagus: The risk of cancer is highest if dysplasia is present or if other people in

family also have Barrett’s.

Tobacco and alcohol: The link to squamous cell esophageal cancer is even stronger. Drinking

alcohol also increases the risk of esophageal cancer. The chance of getting esophageal cancer

goes up with higher intake of alcohol.

Obesity: This is in part explained by the fact that people who are obese are more likely to have

esophageal reflux.

Diet: A diet high in fruits and vegetables is linked to a lower risk of esophageal cancer. Drinking

very hot liquids frequently may increase the risk for the squamous cell type of esophageal cancer

due to long-term damage the liquids do to the cells lining the esophagus. Overeating, which leads

to obesity, increases the risk of the adenocarcinoma of the esophagus.

Achalasia: People with achalasia have a risk of esophageal cancer that is many times normal. On

average, the cancers are found about 15-20 years after the achalasia is diagnosed.

Tylosis: This is a rare, inherited disease that causes excess growth of the top layer of skin on the

palms of the hands and soles of the feet. People with tylosis need to be watched closely to try to

find esophageal cancer early. Often this requires regular monitoring with an upper endoscopy

Esophageal webs: A web is a thin membrane extending out from the inner lining of the

esophagus that causes an area of narrowing. Most esophageal webs do not cause any problems,

but larger webs may cause food to get stuck in the esophagus, which can lead to problems

swallowing. When an esophageal web is found along with anemia, tongue irritation (glossitis),

brittle fingernails, and a large spleen it is called Plummer-Vinson syndrome. Another name for

this is Paterson-Kelly syndrome. About 1 in 10 patients with this syndrome eventually develop

squamous cell cancer of the esophagus.

Workplace exposures: Exposure to chemical fumes in certain workplaces may lead to an

increased risk of esophageal cancer. For example, exposure to the solvents used for dry cleaning

may lead to a greater risk of esophageal cancer. Some studies have found that dry cleaning

workers may have a higher rate of esophageal cancer.

Injury to the esophagus: Lye is a chemical found in strong industrial and household cleaners

such as drain cleaners. Lye is a corrosive agent, meaning it can burn and destroy cells. Sometimes

small children mistakenly drink from a lye-based cleaner bottle. The lye causes a severe chemical

burn in the esophagus. As the injury heals, the scar tissue can cause an area of the esophagus to

become very narrow (called a stricture). People with these strictures have an increased rate of the

squamous cell type of esophageal cancer as adults. The cancers occur on average about 40 years

after the lye was swallowed.

History of certain other cancers: People who have had certain other cancers, such as lung

cancer, mouth cancer, and throat cancer have a high risk of getting squamous cell carcinoma of

the esophagus as well. This may be because all of these cancers can be caused by smoking.

Human papilloma virus: Genes from human papilloma virus (HPV) have been found in up to

one-third of esophagus cancer tumors from patients living in Asia and South Africa. Signs of

HPV infection have not been found in esophagus cancers from patients living in the other areas,

including the US. HPV is a group of more than 100 related viruses. They are called papilloma

viruses because some of them cause a type of growth called a papilloma (or wart). Infection with

certain types of HPV is linked to a number of cancers, including throat cancer, anal cancer, and

cervical cancer

1.4.2 Diagnosis of Esophageal Cancer

1.4.2.1 Sign and Symptoms

Dysphagia : The most common symptom of esophageal cancer is a problem swallowing. This is

often mild when it starts, and then gets worse over time as the opening inside the esophagus gets

narrower. Dysphagia is commonly a late symptom caused by a large cancer. When swallowing

becomes difficult, people often change their diet and eating habits without realizing it. They take

smaller bites and chew their food more carefully and slowly. As the cancer grows larger, the

problem gets worse. People then may start eating softer foods that can pass through the

esophagus more easily. They may avoid bread and meat, since these foods typically get stuck.

The swallowing problem may even get bad enough that some people stop eating solid food

completely and switch to a liquid diet. If the cancer keeps growing, at some point even liquids

will not be able to pass. To help pass food through the esophagus, the body makes more saliva.

This causes some people to complain of bringing up lots of thick mucus or saliva.

Chest Pain: Sometimes, people complain of pain or discomfort in the middle part of their chest.

Some people describe a feeling of pressure or burning in the chest. These symptoms are more

often caused by problems other than cancer, such as heartburn, and so they are rarely seen as a

signal that a person may have cancer. Swallowing may become painful when the cancer is large

enough to limit the passage of food through the esophagus. Pain may be felt a few seconds after

swallowing, as food or liquid reaches the tumor and has trouble getting past it.

Weight Loss: About half of patients with esophageal cancer lose weight (without trying to). This

happens because their swallowing problems keep them from eating enough to maintain their

weight. Other factors include a decreased appetite and an increase in metabolism from the cancer.

Other symptoms are: Hoarseness, chronic cough, hiccups, pneumonia, bone pain, and bleeding

into the esophagus.

1.4.2.2 Imaging Tests

Barium Swallow: A barium swallow test can show any irregularities in the normally smooth

surface of the inner lining of the esophagus. Even small, early cancers can often be seen using

this test. Tumors grow out from the lining of the esophagus and stick out into the lumen (the open

area of the tube). They cause the barium to coat that area of the esophagus unevenly. Early

cancers can look like small round bumps or flat, raised areas (called plaques), while advanced

cancers look like large irregular areas and cause a narrowing of the width of the esophagus. This

test can also be used to diagnose one of the more serious complications of esophageal cancer

called a tracheo-esophageal fistula.

Barium swallow demonstrating stricture due to

cancer

Barium swallow demonstrating an endoluminal

mass in the mid esophagus

Computed Tomography (CT) Scan: CT scans are not usually used to make the initial diagnosis

of esophageal cancer, but they can help see how far it has spread. CT scans often can show where

the cancer is in the esophagus. These scans can also show the nearby organs and lymph nodes

(bean-sized collections of immune cells to which cancers often spread first), as well as distant

areas of cancer spread.

Magnetic resonance imaging (MRI) scan: Like CT scans, MRI scans provide detailed images

of soft tissues in the body. But MRI scans use radio waves and strong magnets instead of X-rays.

The energy from the radio waves is absorbed and then released in a pattern formed by the type of

tissue and by certain diseases. A computer translates the pattern of radio waves given off by the

tissues into a very detailed image of parts of the body. A contrast material might be injected into

a vein. MRI scans are very helpful in looking at the brain and spinal cord, but they are not often

needed to assess spread of esophageal cancer.

Positron emission tomography (PET) scan: For a PET scan, a form of radioactive sugar

(known as fluorodeoxyglucose or FDG) is injected into the blood. The amount of radioactivity

used is very low. Cancer cells in the body are growing rapidly, so they absorb large amounts of

the radioactive sugar. The picture is not finely detailed like a CT or MRI scan, but it provides

helpful information about whole body.

Endoscopy

Upper endoscopy: Performing esophagogastroduodenoscopy allows direct visualization and

biopsies of the tumor.

Endoscopy demonstrating intraluminal

esophageal cancer

Chest CT scan showing invasion of the trachea

by esophageal cancer

Endoscopic ultrasound: This is actually a type of imaging test that involves the use of endoscopy.

Ultrasound tests use sound waves to take pictures of parts of the body. They use no radiation and

are very safe. For an endoscopic ultrasound, the probe that gives off the sound waves is at the end

of an endoscope, which is passed down the throat and into the esophagus. This allows the probe

to get very close to the cancer. This is done with local anesthesia and light sedation.

This test is very useful in determining the size of an esophageal cancer and how far it has grown

into nearby tissues. It can also help determine if nearby lymph nodes might be affected by the

cancer. If enlarged lymph nodes are seen on the ultrasound and not beside the tumor, the doctor

may use a thin, hollow needle to get biopsy samples of them. This helps to decide if the tumor

can be surgically removed.

Bronchoscopy: This exam may be done for cancer in the upper part of the esophagus to see if it

has spread to the windpipe (trachea) or the tubes leading from the trachea into the lung (bronchi).

If abnormal areas are seen, small instruments can be passed down the bronchoscope to take

biopsy samples.

Laparoscopy and thoracoscopy have a greater than 92% accuracy in staging regional nodes.

Lab testing of biopsy samples

An area seen on endoscopy or on an imaging test may look like cancer, but the only way to know

for sure is to do a biopsy. This is most often done during an endoscopy exam. A doctor called a

pathologist then looks at the tissue under a microscope to see if any cancer cells are present. If

there is cancer, the pathologist will determine the type (adenocarcinoma or squamous cell) and

the grade of the cancer (how abnormal the patterns of cells look under the microscope).

HER2 testing: If esophageal cancer is found but is too advanced for surgery, samples may be

tested for the HER2 gene or protein. Some people with esophageal cancer have too much of a

protein called HER2 on the surface of their cancer cells, which helps the cells grow. However, a

drug that targets the HER2 protein, known as trastuzumab (Herceptin®), may help treat these

cancers when used along with chemotherapy. Only cancers that have too much of the HER2 gene

or protein are likely to be affected by this drug, which is why doctors may test tumor samples for

it.

Other tests are: blood test, complete blood count (CBC) to look for anemia (which could be

caused by internal bleeding). A stool sample may be checked to see if it contains occult (unseen)

blood. Also check for liver and kidney functions are normal.

1.4.3 Staging

Esophageal cancer staging was changed in the last edition of the Union for International Cancer

Control/American Joint Cancer Committee (UICC/AJCC) manual in 2009. All esophageal

tumors and tumors with epicenters within 5 cm of the esophagogastric junction that also extend

into the esophagus are classified and staged according to the esophageal scheme. All other tumors

with an epicenter in the stomach greater than 5 cm from the esophagogastric junction or those

within 5 cm of the esophagogastric junction without extension into the esophagus are staged

using the gastric carcinoma scheme.

Conventional staging tools such as esophagoscopy or barium esophagogram can demonstrate

only intraluminal disease extent, and CT scan of the chest is relatively insensitive, except for the

presence of extensive local disease. Esophageal ultrasound allows the visualization of both the

esophageal wall and local lymph nodes. As such, it allows a clinical determination of both T and

N stage in most patients.

Survival rates are not readily available for each stage in the AJCC staging system for esophageal

cancer. The survival rates below come from the National Cancer Institute's Surveillance,

Epidemiology, and End Results (SEER) database, and are based on patientswho were diagnosed

with esophageal cancer between 2002 and 2008. The SEER database does not divide survival

rates by AJCC stage. Instead, this database divides cancers into 3 larger, summary stages:

• Localized means that the cancer is only growing in the esophagus. It includes AJCC

stage I and some stage II tumors (such as those that are T1, T2, or T3, N0, M0). Stage

0 cancers are not included in these statistics.

• Regional means that the cancer has spread to nearby lymph nodes or tissues. This

includes T4 tumors and cancers with lymph node spread (N1, N2, or N3).

• Distant means that the cancer has spread to organs or lymph nodes away from the

tumor, and includes all M1 (stage IV) cancers.

Stage 5-Year Relative Survival Rates are: Localized 38%, regional 20% and distant 3%

These survival rates for esophageal cancer do not separate squamous cell carcinomas from

adenocarcinomas, although adenocarcinomas are generally thought to have a slightly better

prognosis (outlook) overall.

1.4.4 Treatment of Esophageal Cancer

General treatment information

The main options for treatment of cancer of the esophagus include:

• Surgery

• Radiation

• Chemotherapy

• Targeted therapy

• Endoscopic treatments

Endoscopic treatments, such as endoscopic mucosal resection, radiofrequency ablation, and

photodynamic therapy, may be used for early cancers and pre-cancers of the esophagus. Some of

these treatments can also be used as palliative treatment when all the cancer cannot be removed.

Palliative treatment is meant to relieve symptoms, such as pain and trouble swallowing, but it is

not expected to cure the cancer.

Esophagectomy: Often a small part of the stomach is removed as well. The upper part of the

esophagus is then connected to the remaining part of the stomach. Part of the stomach is pulled

up into the chest or neck to become the new esophagus. How much of the esophagus is removed

depends upon the stage of the tumor and where it's located. If the cancer is in the lower part of

the esophagus (near the stomach) or at the place where the esophagus and stomach meet (the

gastroesophageal or GE junction), the surgeon will remove part of the stomach, the part of the

esophagus containing the cancer, and about 3 to 4 inches of normal esophagus above this. Then

the stomach is connected to what is left of the esophagus either high in the chest or in the neck.

If the tumor is in the upper or middle part of the esophagus, most of the esophagus will need to be

removed to be sure to get enough tissue above the cancer. The stomach will then be brought up

and connected to the esophagus in the neck. If the stomach cannot be used to replace the

esophagus, the surgeon may use a piece of the intestine instead. When a piece of intestine is used,

it must be moved without damaging its blood vessels. If the vessels are damaged, not enough

blood will get to that piece of intestine, and the tissue will die.

Esophagectomy may be done using either of 2 main types of techniques. The standard, open

technique uses one or more large incisions (cuts) in the neck, chest, or abdomen to perform the

surgery. In minimally invasive surgery, the surgeon operates through several smaller incisions

using special long, thin surgical instruments.

Open esophagectomy: Many different approaches can be used in operating on esophageal cancer.

For a transthoracic esophagectomy, the esophagus is removed with the main incisions in the

abdomen and the chest. If the main incisions are in the abdomen and neck, it is called a

transhiatal esophagectomy. Some approaches use incisions in the neck, chest, and abdomen.

Minimally invasive esophagectomy: For some early (small) cancers, the esophagus can be

removed through several small incisions instead of 1 or 2 large incisions. The surgeon puts a

scope (like a tiny telescope) through one of the incisions to see everything during the operation.

Then the surgical instruments go in through other small incisions. In order to do this type of

procedure well, the surgeon needs to be highly skilled and have a great deal of experience

removing the esophagus this way. Because it uses smaller incisions, minimally invasive

esophagectomy may allow the patient to leave the hospital sooner and recover faster.

Lymph node removal: For either type of esophagectomy, nearby lymph nodes are removed

during the operation as well. These are then checked to see if they contain cancer cells. If the

cancer has spread to lymph nodes, the outlook is not as good, and the doctor may recommend

other treatments (like chemotherapy and/or radiation) after surgery.

Radiation therapy for cancer of the esophagus: Radiation therapy is the use of high-energy

radiation to kill cancer cells. It is often combined with other types of treatment, such as

chemotherapy (chemo) and/or surgery, to treat esophageal cancer. Radiation therapy may be

used:

• As part of the primary (main) treatment of esophageal cancer in some patients,

typically along with chemo. This is often used for people who can't have surgery due

to poor health.

• Before surgery (usually along with chemo), to try to shrink the cancer and make it

easier to remove (called neoadjuvant treatment).

• After surgery (usually along with chemo), to try to kill any areas of cancer cells that

may have been left behind but are too small to see. This is known as adjuvant therapy.

• To ease the symptoms of advanced esophageal cancer such as pain, bleeding, or

trouble swallowing. This is called palliative therapy.

There are 2 main types of radiation therapy:

External-beam radiation therapy: This type of treatment focuses radiation from outside the

body on the cancer. This is the type of radiation therapy most often used when the intent is to try

to cure esophageal cancer.. Radiation therapy is much like getting an x-ray, but the radiation is

stronger. The procedure itself is painless. Each treatment lasts only a few minutes. Most often,

radiation treatments are given 5 days a week for several weeks.

Internal radiation therapy (brachytherapy): For this type of treatment, the doctor places

radioactive material very close to the cancer through an endoscope. The radiation travels only a

short distance, so it reaches the tumor but has little effect on nearby normal tissues. The

radioactive source is then removed a short time later. Brachytherapy can be given 2 ways; for

high-dose rate (HDR) brachytherapy, the doctor leaves the radioactive material near the tumor for

a few minutes at a time, which may require several treatments. In low-dose rate (LDR)

brachytherapy, a lower dose of radiation is put near the tumor for longer periods (1 or 2 days) at a

time. This requires that the patient stay in the hospital during treatment, but it can usually be

completed in only 1 or 2 treatments. Brachytherapy is most often used with more advanced

esophageal cancers to shrink tumors so a patient can swallow more easily. This technique cannot

be used to treat a very large area, so it is better used as a way to relieve symptoms (and not to try

to cure the cancer).

Chemotherapy for cancer of the esophagus: Chemotherapy (chemo) uses drugs that are given

through a vein or by mouth to treat cancer. These drugs enter the bloodstream and reach all areas

of the body, making this treatment useful for cancer that has spread. Depending on the type and

stage of esophageal cancer, chemo may be given:

• As part of the main (primary) treatment, along with radiation therapy.

• Before surgery (usually along with radiation therapy) to try to shrink the cancer and

make it easier to remove. This is called neoadjuvant treatment.

• After the cancer has been removed by surgery (usually along with radiation therapy)

to try to kill any small areas of tumor cells that may have been left behind. This is

known as adjuvant treatment.

• Alone or with radiation to help control symptoms like pain or trouble swallowing

when the cancer can't be cured. This is called palliative treatment.

Chemo by itself rarely cures esophageal cancer. It is often given together with radiation therapy.

This combination (called chemoradiation or chemoradiotherapy) can be useful for large tumors

that couldn't be removed otherwise. It can shrink the tumor enough for surgery to be an option.

Chemoradiation is also often used before surgery for smaller tumors. Using chemoradiation

before surgery can help people live longer than using surgery alone. Chemoradiation is also

sometimes given after surgery, but it isn’t clear that it is as helpful as giving it before surgery.

In some cases, chemoradiation may be used as the only treatment. This may be a good choice for

patients who cannot have surgery because they have other major health problems. This may also

be an option for some patients who could have surgery.

Chemo is given in cycles, with each period of treatment followed by a rest period to allow the

body time to recover. Each chemo cycle typically lasts for a few weeks. Many different chemo

drugs can be used to treat esophageal cancer. Common regimens are:

• Carboplatin and paclitaxel (Taxol®) (which may be combined with radiation)

• Cisplatin and 5-fluorouracil (5-FU) (often combined with radiation)

• ECF: epirubicin (Ellence®), cisplatin, and 5-FU (especially for gastroesophageal

junction tumors)

• DCF: docetaxel (Taxotere®), cisplatin, and 5-FU

• Cisplatin with capecitabine (Xeloda®)

Other chemo drugs that have been used to treat cancer of the esophagus include oxaliplatin,

doxorubicin (Adriamycin®), bleomycin, mitomycin, methotrexate, vinorelbine (Navelbine®),

topotecan, and irinotecan (Camptosar®). For some esophagus cancers, chemo may be used along

with the targeted drug trastuzumab (Herceptin®).

Targeted therapy for cancer of the esophagus: As researchers have learned more about the

changes in cells that cause cancer, they have been able to develop newer drugs that specifically

target these changes. Targeted drugs work differently from standard chemotherapy drugs. They

often have different (and less severe) side effects. A small number of esophagus cancers have too

much of a protein called HER2 on the surface of their cells. This protein may help the cancer

cells to grow. Having too much of this protein is caused by having too many copies of the HER2

gene. A drug that targets the HER2 protein, known as trastuzumab (Herceptin), may help treat

these cancers when used along with chemotherapy. If you have esophageal cancer and cannot

have surgery, your doctor may have your tumor biopsy samples tested for the HER2 protein or

gene. Only cancers that have too much of the HER2 protein or gene are likely to be affected by

this drug.

Trastuzumab is given by injection into a vein (IV) once every 3 weeks along with chemo. The

optimal length of time to give it is not yet known. Most of the side effects of trastuzumab are

relatively mild and may include fever and chills, weakness, nausea, vomiting, cough, diarrhea,

and headache. These occur less often after the first dose. Less often, this drug can cause heart

damage, leading to the heart muscle becoming weak. That is why this drug is not often given with

certain chemo drugs called anthracyclines, such as epirubicin (Ellence) or doxorubicin

(Adriamycin), because it may further increase the risk of heart damage if they are given together.

Endoscopic treatments for cancer of the esophagus: Several types of treatment for esophageal

cancer can be done by passing an endoscope (a long, flexible tube) down the throat and into the

esophagus. Some of these treatments may be used to try to cure very early stage cancers, or even

to prevent them from developing by treating Barrett's esophagus or dysplasia. Other treatments

are used mainly to help relieve symptoms from more advanced esophageal cancers that can't be

removed. Endoscopic mucosal resection

Endoscopic mucosal resection (EMR) is a technique where the inner lining of the esophagus is

removed with instruments attached to the endoscope. EMR can be used for dysplasia (precancer)

and some very early focal (single, small tumors) cancers of the esophagus. After the abnormal

tissue is removed, patients take drugs called proton pump inhibitors to suppress acid production

in the stomach. This can help keep the disease from returning.

Photodynamic therapy: Photodynamic therapy (PDT) is a method that can be used to treat

esophageal pre-cancer (dysplasia) and some early esophageal cancers. These may be found when

Barrett's esophagus is biopsied. PDT can also be used to help with symptoms for some cancers

that are too advanced to be removed. For this technique, a light-activated drug called porfimer

sodium (Photofrin®) is injected into a vein. Over the next couple of days, the drug is more likely

to collect in cancer cells than in normal cells. A special type of laser light is then focused on the

cancer through an endoscope. This light causes changes in the drug that has collected inside the

cancer cells, changing it into a new chemical that can kill cancer cells. The dead cells may then

be removed a few days later during an upper endoscopy. This process can be repeated if needed.

The advantage of PDT is that it can kill cancer cells with very little harm to normal cells. But

because the chemical must be activated by light, it can only kill cancer cells near the inner

surface of the esophagus – those that can be reached by the light. This light cannot reach cancers

that have spread deeper into the esophagus or to other organs.

Radiofrequency ablation (RFA): This procedure can be used to treat dysplasia in areas of

Barrett's esophagus. It may lower the chance of cancer developing in that area. In this procedure,

a balloon containing many small electrodes is passed into an area of Barrett's esophagus through

an endoscope. The balloon is then inflated so that the electrodes are in contact with the inner

lining of the esophagus. Then an electrical current is passed through it, which kills the cells in the

lining by heating them. Over time, normal cells will grow in to replace the Barrett's cells. The

patient needs to stay on drugs to block stomach acid production after the procedure. Endoscopy

(with biopsies) then is done periodically to watch for any further changes in the lining of the

esophagus. RFA rarely causes strictures (narrowing) or bleeding in the esophagus.

Laser ablation: This technique can be used to help open up the esophagus when it is blocked by

an advanced cancer. This can help improve problems swallowing. In this treatment, a laser beam

is aimed at the cancer through the tip of an endoscope. The laser opens up the esophagus by

vaporizing and coagulating cancerous tissue. The laser used is called a neodymium: yttrium-

aluminum-garnet (Nd:YAG) laser. Most patients will benefit from laser endoscopy, but the

cancer often grows back, so the procedure may need to be repeated every month or two.

Argon plasma coagulation: This technique is similar to laser ablation, but it uses argon gas and

a high-voltage spark delivered through the tip of an endoscope. The spark causes the gas to reach

very high temperatures, which can then be aimed at the tumor. This approach is used to help

unblock the esophagus when the patient has trouble swallowing. Electrocoagulation

(electrofulguration).This method involves passing a probe down into the esophagus through an

endoscope and then burning the tumor off with electric current. In some cases, this treatment can

help relieve esophageal blockage.

Esophageal stent: A stent is a device made of mesh material. Most often stents are made out of

metal, but they can also be made out of plastic. Using endoscopy, a stent can be placed into the

esophagus across the length of the tumor. Once in place, it self-expands (opens up) to become a

tube that helps hold the esophagus open. The success of the stent depends on the type of stent that

is used and where it is placed. Stents will relieve trouble swallowing in most patients that are

treated. They are often used after other treatments to help keep the esophagus open.

References:

1. American Cancer Society. Cancer Facts and Figures 2013. Atlanta, Ga: American Cancer

Society; 2013.

2. American Joint Committee on Cancer. AJCC Cancer Staging Manual. 7th ed. New York,

NY: Springer; 2010:103–111

3. National Cancer Institute. Physician Data Query (PDQ). Esophageal Cancer Treatment.

7/13/2012. Accessed at

www.cancer.gov/cancertopics/pdq/treatment/esophageal/HealthProfessional on May 17,

2013.

4. Keith M Baldwin, DO. Esophageal cancer. Attending Surgical Oncologist, Roger

Williams Medical Center, Boston University School of Medicine. Accessed at

http://emedicine.medscape.com/article/277930

CHAPTER 2

THEORY: DOUBLE-LUMEN ENDOTRACHEAL TUBE AND GENERAL

ANESTHESIA

2.1 Double-Lumen Endotracheal Tube

2.1.1 Introduction

Double-lumen endotracheal tube placement is performed to achieve lung separation.

However, thoracic surgeons may require lung separation and one-lung ventilation to perform

certain procedures and provide optimal surgical exposure.

For double-lumen endotracheal tube placement, the anesthesiologist places a tube with

two lumens through which to ventilate the lungs. This double-lumen tube is placed in the trachea,

with one lumen in either the left or right bronchial main stem; the other lumen remains in the

trachea. This allows the clinician to ventilate both lungs or the right/left lung independently. The

operative lung is referred to as the surgical lung or nondependent lung. The image below depicts

a double-lumen endotracheal tube.

Double-lumen endotracheal tube

Of the three methods of lung separation—double-lumen endotracheal tube placement,

bronchial blocker, and single-lumen endobronchial tube placement—double-lumen endotracheal

tube placement is the most common way of separating the two lungs. It is not only quicker than

the other two methods, but it allows for access into an isolated lung, suctioning from the isolated

lung, and application of continuous positive airway pressure if required to improve oxygenation.

Ventilation of either or both lungs can be easily achieved. In addition, even though a fiberoptic

scope is very helpful with double-lumen endotracheal tube placement, it is not absolutely

required, which can also be an advantageous in some situations.

However, double-lumen endotracheal tubes may be challenging to place in patients with

difficult airways. Double-lumen endotracheal tubes are not meant for postoperative ventilation. In

addition, because of their significantly larger size and stiffness, they have a higher propensity for

trauma after insertion, which may result in postoperative hoarseness and/or vocal cord lesions.

2.1.2 Indication

a. Absolute Indications

Separation of the two lungs for any of the absolute indications discussed here should be

considered a lifesaving maneuver because failure to separate the lungs under any of

these conditions could result in a life-threatening complication or situation. Absolute

indications are as follows:

Isolation of each lung to prevent contamination of a healthy lung (eg, infection,

massive hemorrhage)

Control of distribution of ventilation to only one lung (eg,

bronchopleural/bronchopleural cutaneous fistulas, unilateral cyst or bullae, major

bronchial trauma/disruption)

Unilateral lung lavage

Video-assisted thoracoscopic surgery (VATS)

b. Relative Indications

There are a large number of relative indications for separation of the lungs, and they are

all for the purpose of facilitating surgical exposure by collapsing the lung in the

operative hemithorax. Relative indications are as follows:

Thoracic aortic aneurysm

Pneumonectomy

Lung volume reduction

Minimally invasive cardiac surgery

Upper lobectomy

Esophageal procedures

Lobectomy (middle and lower lobes)

Mediastinal mass resection

Thymectomy

Bilateral sympathectomies

2.1.3 Technique

a. Tube Insertion

• Several methods can be used to insert the double-lumen endotracheal tube: under

direct laryngoscopy, via tube exchanger, or over fiberoptic bronchoscope.

• During placement, a curved laryngoscope blade is used to intubate the airway. The

distal, bronchial (blue) tube is held with the tip directed upward. As it passes

through the glottis, the stylet is removed. At this point, the tube is advanced and

rotated 90 degrees (towards the side to be intubated) and advanced until resistance is

felt; this depth is usually between 28-30 cm.

• At this point, the tracheal (white) cuff is inflated, breath sounds are auscultated, and

end-tidal CO2 is noted on the capnogram to tell the clinician that the tube is in the

airway. At this point, correct tube placement is confirmed by direct visualization via

bronchoscopy.

• The flexible, fiberoptic bronchoscope is passed down the tracheal lumen. The

clinician will deflate the tracheal cuff and pull back until the carina is seen. At this

point, tracheal cartilaginous rings are anterior and the tracheal membrane is

posterior. Advance the tube until the bronchial blue tip enters the left main stem.

• At this point, inflate the blue balloon with 1-3 mL of air until the blue cuff is visible

in the left main stem. A portion of the blue cuff should be seen seated in the left

main stem.

• After placement, the patient is positioned laterally on the operating room table.

After positioning, the tube should be checked again to validate that it has not

moved. The tube can either become malpositioned by coming out or advancing to a

deeper level.

• When patient position is changed to lateral, the tube can be displaced, mainly due to

extension of the neck.

• The clinician should check position periodically throughout the surgery.

b. Position Verification

• There are multiple methods available to confirm placement, including radiographic

verification, auscultation, fiberoptic visualization, and various clinical tests such as

selective capnography and use of underwater seal. Auscultation and fiberoptic

examination are used most commonly.

Auscultation

• Auscultation is a widely available first-line test. After placement of the double-

lumen endotracheal tube, the tracheal cuff is inflated and ventilation is attempted.

The patient should have bilateral breath sounds and end-tidal CO2 should be noted

on capnogram. This tells the clinician that the tube is in the airway.

• Next, the tracheal lumen is clamped and opened. The bronchial cuff is inflated with

minimal volume to stop the leak (usually about 2 mL of air). At this point,

confirmation of separation of lungs can be done with air bubble leak test. One-sided

breath sounds should be heard, only over the desired lung field.

• Next, with the bronchial cuff up, the tracheal lumen is unclamped and reconnected,

the bronchial lumen is clamped, and ventilation is attempted through tracheal

lumen. If the tube is positioned correctly, breath sounds should be heard over

contralateral hemithorax. Then the bronchial lumen is unclamped and reconnected

and bilateral breath sounds should be audible again. This concludes auscultation for

correct placement.

Fiberoptic Bronchoscope

• The fiberoptic bronchoscope first is advanced through the tracheal lumen to confirm

that the bronchial tube is placed in the desired bronchus. For the left bronchus, the

cuff should be ideally placed 5 mm below the carina. It is crucial to identify the

right bronchus. The right main bronchus gives off the right upper lobe bronchus,

which is the only one that has 3 orifices in it. Then examination through the

bronchial tube is done to assure tube patency and determine margin of safety.

Therefore, orifices to both upper and lower lobes must be identified. Identification

of those bronchi confirms correct placement of a left-sided tube.

2.2 General Anesthesia

General anesthesia uses intravenous and inhaled agents to allow adequate surgical access

to the operative site. A point worth noting is that general anesthesia may not always be the best

choice; depending on a patient’s clinical presentation, local or regional anesthesia may be more

appropriate.

Anesthesia providers are responsible for assessing all factors that influence a patient's

medical condition and selecting the optimal anesthetic technique accordingly. Attributes of

general anesthesia include the following:

Advantages

• Reduces intraoperative patient awareness and recall

• Allows proper muscle relaxation for prolonged periods of time

• Facilitates complete control of the airway, breathing, and circulation

• Can be used in cases of sensitivity to local anesthetic agent

• Can be administered without moving the patient from the supine position

• Can be adapted easily to procedures of unpredictable duration or extent

• Can be administered rapidly and is reversible

Disadvantages

• Requires increased complexity of care and associated costs

• Requires some degree of preoperative patient preparation

• Can induce physiologic fluctuations that require active intervention

• Associated with less serious complications such as nausea or vomiting, sore throat,

headache, shivering, and delayed return to normal mental functioning

• Associated with malignant hyperthermia, results in acute and potentially lethal

temperature rise, hypercarbia, metabolic acidosis, and hyperkalemia

Nowadays, the risk caused by anesthesia to a patient undergoing routine surgery is very

small. Mortality attributable to general anesthesia is said to occur at rates of less than 1:100,000.

Minor complications occur at predicable rates, even in previously healthy patients.

2.2.1 Preparation for General Anesthesia

Safe and efficient anesthetic practices require certified personnel, appropriate medications

and equipment, and an optimized patient.

Minimum infrastructure requirements for general anesthesia include a well-lit space of

adequate size; a source of pressurized oxygen (most commonly piped in); an effective suction

device; standard ASA (American Society of Anesthesiologists) monitors, including heart rate,

blood pressure, ECG, pulse oximetry, capnography, temperature; and inspired and exhaled

concentrations of oxygen and applicable anesthetic agents.

Beyond this, some equipment is needed to deliver the anesthetic agent. This may be as

simple as needles and syringes, if the drugs are to be administered entirely intravenously. In most

circumstances, this means the availability of a properly serviced and maintained anesthetic gas

delivery machine.

An array of routine and emergency drugs, including Dantrolene sodium (the specific

treatment for malignant hyperthermia), airway management equipment, a cardiac defibrillator,

and a recovery room staffed by properly trained individuals completes the picture.

2.2.2 Preparing the patient

Preoperative evaluation allows for proper laboratory monitoring, attention to any new or

ongoing medical conditions, discussion of any previous personal or familial adverse reactions to

general anesthetics, assessment of functional cardiac and pulmonary states, and development of

an effective and safe anesthetic plan. It also serves to relieve anxiety of the unknown surgical

environment for patients and their families. Overall, this process allows for optimization of the

patient in the perioperative setting.

Physical examination associated with preoperative evaluations allow anesthesia providers

to focus specifically on expected airway conditions, including mouth opening, loose or

problematic dentition, limitations in neck range of motion, neck anatomy, and Mallampati

presentations. By combining all factors, an appropriate plan for intubation can be outlined and

extra steps, if necessary, can be taken to prepare for fiberoptic bronchoscopy, video

laryngoscopy, or various other difficult airway interventions.

Airway management

Presence of obesity, large breasts, short muscular neck, receding jaw, prominent upper incisor

and high arched palate suggest difficult intubation.

Predictive tests

a. Mallampati Classification : indicatiors of difficult intubation

Mallampati classification

b. Cormack and Lehane Grading : used to grade the view at laryngoscopy

c. Thyromental distance : measured form upper edge of thyroid cartilage to the chin with the

head fully extended

d. Cervical spine movement : Assesment of the full range of motion at atlanto-occipital joint

(flexion, extension and rotation)

When suspicion of an adverse event is high but a similar anesthetic technique must be

used again, obtaining records and previous anesthetic records from previous operations or from

other institutions may be necessary.

Other requirements

The need for coming to the operating room with an empty stomach is to reduce the risk of

pulmonary aspiration during general anesthesia when a patient loses his or her ability to

voluntarily protect the airway.

Patients should continue to take regularly scheduled medications up to and including the

morning of surgery. Exceptions may include the following:

Anticoagulants to avoid increased surgical bleeding

Oral hypoglycemics (For example, metformin is an oral hypoglycemic agent that is

associated with the development of metabolic acidosis under general anesthesia.)

Monoamine oxidase inhibitors

Beta blocker therapy (However, beta blocker therapy should be continued perioperatively

for high-risk patients undergoing major noncardiac surgery)

2.2.3 The process of anesthesia

a. Premedication

This is the first stage of a general anesthetic and usually conducted in the surgical

ward or in a preoperative holding area. The goal of premedication is to have the patient arrive

in the operating room in a calm, relaxed frame of mind.

The most commonly used premedication is midazolam, a short-acting benzodiazepine.

In anticipation of surgical pain, nonsteroidal anti-inflammatory drugs or acetaminophen can

be administered preemptively. When a history of gastroesophageal reflux exists, H2 blockers

and antacids may be administered. Drying agents (eg, atropine, scopolamine) are now only

administered routinely in anticipation of a fiberoptic endotracheal intubation.

b. Induction

This is the critical part of the anesthesia process. This stage can be achieved by

intravenous injection of induction agents (drugs that work rapidly, such as propofol), by the

slower inhalation of anesthetic vapors delivered into a face mask, or by a combination of

both.

In addition to the induction drug, most patients receive an injection of an opioid

analgesic, such as fentanyl (a synthetic opioid many times more potent than morphine).

Induction agents and opioids work synergistically to induce anesthesia. In addition,

anticipation of events that are about to occur, such as endotracheal intubation and incision of

the skin, generally raises the blood pressure and heart rate of the patient. Opioid analgesia

helps control this undesirable response.

The next step of the induction process is securing the airway. This may be a simple

matter of manually holding the patient's jaw such that his or her natural breathing is

unimpeded by the tongue, or it may demand the insertion of a prosthetic airway device such

as a laryngeal mask airway or endotracheal tube. The major decision is whether the patient

requires placement of an endotracheal tube. Potential indications for endotracheal intubation

under general anesthesia may include the following:

• Potential for airway contamination (full stomach, gastroesophageal [GE] reflux,

gastrointestinal [GI] or pharyngeal bleeding)

• Surgical need for muscle relaxation

• Predictable difficulty with endotracheal intubation or airway access (eg, lateral or

prone patient position)

• Surgery of the mouth or face

• Prolonged surgical procedure

Not all surgery requires muscle relaxation. If surgery is taking place in the abdomen

or thorax, an intermediate or long-acting muscle relaxant drug is administered in addition to

the induction agent and opioid. This paralyzes muscles indiscriminately, including the

muscles of breathing. Therefore, the patient's lungs must be ventilated under pressure,

necessitating an endotracheal tube.

Persons who, for anatomic reasons, are likely to be difficult to intubate are usually

intubated electively at the beginning of the procedure, using a fiberoptic bronchoscope or

other advanced airway tool.

c. Maintenance phase

At this point, the drugs used to initiate the anesthetic are beginning to wear off, and

the patient must be kept anesthetized with a maintenance agent. Anesthetic gas must be

provided. These may be inhaled as the patient breathes spontaneously or delivered under

pressure by each mechanical breath of a ventilator.

The maintenance phase is usually the most stable part of the anesthesia. As the

procedure progresses, the level of anesthesia is altered to provide the minimum amount of

anesthesia that is necessary to ensure adequate anesthetic depth. Traditionally, this has been a

matter of clinical judgment, but new processed EEG machines give the anesthesia provider a

simplified output in real time, corresponding to anesthetic depth.

If muscle relaxants have not been used, inadequate anesthesia is easy to spot. The

patient moves, coughs, or obstructs his airway if the anesthetic is too light for the stimulus

being given. If muscle relaxants have been used, then clearly the patient is unable to

demonstrate any of these phenomena. In these patients, the anesthesia provider must rely on

careful observation of autonomic phenomena such as hypertension, tachycardia, sweating,

and capillary dilation to decide whether the patient requires a deeper anesthetic. This requires

experience and judgment.

Excessive anesthetic depth, on the other hand, is associated with decreased heart rate

and blood pressure, and, if carried to extremes, can jeopardize perfusion of vital organs or be

fatal. Short of these serious misadventures, excessive depth results in slower awakening and

more adverse effects.

As the surgical procedure draws to a close, the patient's emergence from anesthesia is

planned. Experience and close communication with the surgeon enable the anesthesia

provider to predict the time at which the application of dressings and casts will be complete.

In advance of that time, anesthetic vapors have been decreased or even switched off entirely

to allow time for them to be excreted by the lungs. Excess muscle relaxation is reversed using

specific drugs and an adequate long-acting opioid analgesic to keep the patient comfortable in

the recovery room. If a ventilator has been used, the patient is restored to breathing by

himself, and, as anesthetic drugs dissipate, the patient emerges to consciousness.

Removal of the endotracheal tube or other artificial airway device is only performed

when the patient has regained sufficient control of his or her airway reflexes.

d. Reversal

It is a process of discontinuation of anesthetic agents at the end of surgery to allow

return of consciousness and recovery from muscle paralysis while maintaining analgesia.

Volatile agents are discontinued first and later the nitrous oxide. Patient is given 100%

oxygen. Wait for return of spontaneous breathing; this can be observed on capnography and

can also be felt with reservoir bag if patient is manually ventilated.

Administer reversal agent such as neostigmine (anticholinesterase) or glycopyrrolate

to counteract non-depolarizing muscle relaxant; atropine is usually given to counteract the

parasympathetic effects of anticholinesterase.

Reversal agent is given when there is evidence of spontaneous breathing effort.

Patient’s tidal volume has to be ensured that it is adequate and able to control own airway

before attempting extubation.

2.2.4 Postoperative Care

The anesthesia should conclude with a pain-free awakening and a management plan for

postoperative pain relief. This may be in the form of regional analgesia, oral, transdermal or

parenteral medication. Minor surgical procedures are amenable to oral pain relief medication

such as paracetamol and NSAIDs such as ibuprofen. Moderate levels of pain require the addition

of mild opiates such as tramadol. Major surgical procedures may require a combination of

modalities to confer adequate pain relief.

Parenteral methods include patient-controlled analgesia (PCA) involving a strong opiate

such as morphine, fentanyl or oxycodone. To activate a syringe device, patient will press a button

and receive a preset dose or bolus of the drug (eg: 1mg of morphine). The PCA device then locks

out for a preset period to allow drug to take effect. If the patient becomes too sleepy or sedated,

they make no more morphine requests.

Shivering is a frequent occurs in the post operative period. Apart from causing discomfort

and exacerbating post operative pain, shivering has been shown to increase oxygen consumption,

cathecolamine release, cardiac output, heart rate, blood pressure and intra ocular pressure. There

are number of techniques used to reduce this occurrence, such as increasing the ambient

temperature in theatre, using conventional or forced warm air blankets and using warmed

intravenous fluids.

2.2.5 Common Anesthetic Drugs

The main group of drugs commonly used in general anesthesia are broadly classified into

induction agents, muscle relaxants, analgesics and reversal agents.

Induction agents then are further classified into inhalational and parenteral/

a. Inhalational Anaesthetic Agents

It exists as gaseous form (nitrous oxide) or volatile liquids (isoflurane). Halothane

is a halogenated alkane derivative. Other modern volatile agents are halogenated methyl

ether derivatives (enflurane, isoflurane). Controllability is by pulmonary administration

and is delivered via vaporizers. The commonly used inhalational agents are liquids at

room temperature and therefore they need to be converted to the gaseous state for

administration to patients. Vaporizers is a device for producing a clinically useful and

stable concentration of an anesthetic vapour in a carrier gas ( oxygen and nitrous oxide).

The aim of inhalational anaesthesia is the development of an appropriate tension or partial

pressure of anesthetic agent within the brain.

Gaseous anaesthetic agents

Nitrous oxide

It is stored in steel cylinders as a liquid under pressure in equilibrium with the

gas phase at normal room temperature.

N2O is a colorless gas without appreciable odour or taste and non explosive.

It is a potent analgesic but a weak anaesthetic agents

It cause depress hematopoietic function ( megaloblastic anemia,

thrombocytopenia and leucopenia), thus not advisable for administration of more

than 24 hours.

It is widely used as an adjuvant to lower the MAC of volatile anesthetics. With

inhalation of 70% N2O / 30% O2 MAC value are reduced (~35%- 45%)

Volatile Anesthetic agents

Halothane

Halothane is a haloalkane and has a MAC value of 70%. It can be used for

induction of anesthesia in children. Halothane is a non specific Ca2+ influx inhibitor and it

may cause bradycardia. It increases the automaticity of the heart and when combined with

adrenaline it may cause tachyarrythmias. One of the important side effects is ha;othane

hepatotoxicity. The diagnosis of halothane hepatitis is by exclusion. This may progress

into fulminant hepatic failure with a high mortality. Obese middle aged women having

repeat halothane exposures are at risk. Halothane hepatitis may occur following a single

exposure.

Isoflurane

It causes a dose dependent reduction in blood pressure. The decrease in blood

pressure is due to vasodilatation and decreased total peripheral resistance. The heart rate is

increased via reflex mechanisms but arrhythmias are uncommon. Isoflurane does not

affect ventricular conduction and does not increase the excitability of ventricular

myocardium. Induction of anesthesia is difficult with isoflurane due to its pungent odour

and preanesthetic concentration of isoflurane may cause an airway reflex stimulation, with

increased secretions and/or coughing and laryngospasm.

Sevoflurane

It is a new inhalational agent and more expensive than others. It has pleasant odour

and can be used as induction agents in paediatric and adult patients. It has rapid onset of

induction and recovery of anesthesia because it is less soluble in blood than isoflurane. It

has a mild negative inotropic effect. It also decreases systemic vascular resistance but

does not cause reflex tachycardia. Sevoflurane is less arrythmogenic when compared to

halothane and it is suitable for daycare surgery.

b. Intravenous induction agents

Criteria for ideal intravenous anesthetic agents:

Induction of anesthesia should be rapid, smooth and safe

It should have limited effects on cardiovascular and respiratory systems

It should possess analgesic activity.

Consciousness should return rapidly, smoothly and predictably.

i. Sodium thiopental (Pentothal)

Thiopental is the only intravenous barbiturate being used today and is classified

under an ultra short acting barbiturate. It is prepared as a 2.5% solution, water soluble,

pH of 10.5 and stable for up to 1-2 weeks if refrigerated.

Mechanism of action: Depress the reticular activating system, reflecting the ability

of barbiturates to decrease the rate of dissociation of the inhibitory neurotransmitter

GABA from its receptors

Pharmacokinetics

Short duration of action (5-10 minutes) following IV bolus reflects high lipid

solubility and redistribution from the brain to inactive tissues.

Protein binding parallels lipids solubility, decreased protein binding increases drug

sensitivity.

Fat is the only compartment in which thiopental continues to accumulate 30

minutes after injection

Thiopental is metabolized in the liver slowly. Its hepatic excretion ratio is 0.15

It has an anticonvulsant effect and is a useful drug for cerebral protection in head

injury. It also has an analgesics effect. In the presence of inadequate anaesthesia, airway

manipulation may result in bronchospasm and laryngospasm. Cardiovascular effects of

barbiturate include decrease in blood pressure due to vasodilatation and direct myocardial

depression. There is a compensatory increased in heart rate.

It should be used cautiously in haemodynamically unstable patients and is

contraindicated in hypovolaemia and hypotensive patients. Induction dose is 3-5mg/kg in

a healthy adult.

ii. Propofol

It is 2,6-diisopropyl-phenol, under group of hindered phenol, an alkylphenol

derivative. Formulated in a solution with 10% soy bean oil, hydrophobic nature. It has

rapid onset and short duration of action. Emergence and awakening are prompt and

complete after even prolonged infusions.

Mechanism of action: Propofol increases the inhibitory neurotransmission

mediated by gammaaminobutyric acid.

It has extensive metabolism by hepatic and extrahepatic. It has no cumulative

effects, has antiemetic property and suitable for daycare surgery. It does not has

antianalgesic activity.

Propofol is an ideal drug for total intravenous anesthesia. The target controlled

induction (TCI) and maintenance of anesthesia can be achieved nowadays with propofol

by a special TCI pump. Propofol also can be used to provide sedation in ICU, for minor

procedures or in combination with regional anesthesia.

Effects on organ system

Cardiovascular: decrease in arterial blood pressure secondary to a drop in systemic

vascular resistance, contractility, and preload. Hypotension is more pronounced than with

thiopental. Propofol markedly impairs the normal arterial baroreflex response to

hypotension.

Respiratory: propofol causes profound respiratory depression. Propofol induced

depression of the upper airway reflexes exceeds that of thiopental

Cerebral: decreases cerebral blood flow and intracranial pressure.

Induction dose: 1.5-3 mg/ kg in a healthy adult.

iii. Ketamine

It is a phenicyclidine derivative. It produces dissociative anesthesia resulting in

catatonia, amnesia and analgesia. Patient may appear awake and reactive but does not

response to sensory stimuli

Mechanism of action: It acts on NMDA receptor. It blocks polysynaptic reflexes in

the spinal cord, inhibiting excitatory neurotransmitter effects. It has both anesthetic and

analgesic properties. It causes postoperative psychic phenomena- emergence delirium,

vivid dreams, hallucination. Therefore it is not suitable for adults. These effects can be

minimized by combination with benzodiazepines.

Clinical usage:

Induction of anesthesia in poor risk patients (eg: hypotension or bronchial asthma)

As sole agent in dressing of burns, radiological procedures in children, mass

casualties in the field.

In the management of unresponsive severe bronchospasm

It is contraindicated in raised intracranial pressure, perforating eye surgery,

hypertension, heart failure, recent myocardial infarction, aneurysm and valvular heart

disease.

Dosage:

o IV 1.5-2 mg/kg, onset 30 sec. duration 5-10min.

o IM 10 mg/kg, onset 3-8min, duration 10-20min

Systemic effects:

Increase intracranial and intraocular pressures

Postoperative nausea and vomiting

Increased salivation. An antisialagogue is recommended before used

Preservation of airway reflexes and produces brochodilatation

Increased in cathecolamines secretion

Ketamine has cardiovascular effects: increases heart rate, blood pressure and

pulmonary arterial pressure. It is most likely due to direct stimulation of the sympathetic

nervous system.

c. Neuromuscular blocking agents

Muscle relaxants are generally classified into two groups (depolarizing and non-

depolarizing), depending on their mechanism of action.

Depolarizing muscle relaxants

Used to provide skeletal muscle relaxation to facilitate tracheal intubation and

optimal surgical condition. Ventilation must be provided as the diaphragmatic muscle

would also be paralysed. There is no CNS activity and the problem of awareness begin

with introduction induction of muscle relaxants.

Factors that influence inclusion of muscle relaxants in general anesthesia are types

of surgical procedures (anatomic location and patient position), anesthetic techniques and

patient factors (ASA class, obese, exreme of age).

Succinylcholine

The only depolariser drug that is used clinically. It consists of two molecules of

acetylcholine linked together. It acts on nicotinic receptors at neuromuscular junction

(NMJ) to cause sustained depolarization that prevents propagation of action potential. The

net effect of SCh induced depolarization is uncoordinated skeletal muscle activity that is

seen as fasciculation.

It remains a useful muscle relaxants because of its rapid onset and short duration

of muscular relaxation that cannot be achieved by any other available nondepolarising

muscle relaxants.

A dose of 1-2 mg/kg produces profound muscle relaxation within one minute. Full

recovery is 10-12 minutes. It is used in emergency surgery as rapid sequence induction

technique and in situation of difficult airway management.

Side effects

It may cause cardiac dysarryhmias such as bradycardia especially in children.

Hyperkalemia – at risk patients (burns, extensively trauma, unrecognized muscular

dystrophy and denervation injuries.

Increased intragastric pressure (offset by even greater increase in lower

oesophageal sphincter)

Increased intraocular pressure (due to cycloplegic action of succinylcholine)

Prolonged response in presence of atypical cholinesterase

Increased intracranial pressure

Muscle pain and myoglobinuria

Non depolarizing muscle relaxant

Acts on nicotinic receptors in a competitive fashion to produce neuromuscular

blockade- absence od depolarization. Can be antagonized by anticholinesterase drugs.

They are used to facilitate endotracheal intubation, controlled ventilation and maintenance

of muscle relaxation during surgical procedures.

a. Atracurium

It is an intermediate acting benzyliso-quinolinium type NDMR. The

intubation dose is 0.5-0.6mg/kg. It presents as 10mg/ml solution in 25mg or 50mg

glass ampoules and is stored at 4 °C. Histamine release may occur in susceptible

patients but anaphylactoid reaction is very rare.

b. Vecuronium

It is an aminosteroid group and presents as freezed dried powder and

diluted with sterile water before used. There is no histamine release and devoid of

cardiovascular side effects. It does not antagonize fentanyl induced bradycardia. It

is metabolized by liver and also excreted unchanged in bile. The intubation dose is

0.08-0.1 mg/kg.

c. Rocuronium

It is an aminosteroid group. Its rapid onset of action makes it a potential

replacement for SCh when rapid tracheal intubation is needed. Its duration of

action is similar to vecuronium and has similar pharmacokinetic characteristic. It

has minimal cardiovascular side effects and very low potential for histamine

release. Dosage for endotracheal intubation is 0.6 mg/kg.

d. Pancuronium

It is a long acting NDMR with a steroid structure (Bisaminoquaternary

steroid). It increases heart rate and blood pressure and cardiac output due to

cardiac vagal blockade. Histamine release is very rare and bronchospasm is

extremely uncommon.

Assessment of neuromuscular blockade

1. Clinical assessment

a. Ability to lift up head for 5 second

b. Hand grip for 5 second

c. Ability to produce vital capacity breath > 10 ml/kg

d. Tongue protrusion

2. Responses to electrical stimulation of a peripheral nerve stimulator

Anticholinesterase

Anticholinesterase is used to reverse non depolarizers. It inhibits the action of

acetylcholinesterase and increase the concentration of acetylcholine at the neuromuscular

junction. It also acts at parasympathetic nerve endings. Anticholinesterase increases acetylcholine

at both nicotinic and muscarinic receptors. Muscarinic effects can be blocked by administration

of atropine or glycopyrolate.

d. Opioid analgesics

Few examples of this drugs are morphine, pethidine, fentanyl and nalbuphine.

This drugs act on opioid receptors and classified as full agonist, antagonist, or mixed

agonist-antagonist depending on the actions on the opioid receptors. Three main receptors

are mu, kappa and delta.

Morphine pharmacokinetics:

Elimination halftimes for morphine following bolus administration is about 1.7-4.5

hours.  Following bolus administration onset time is relatively slow (15-30 minutes)

because:

1. morphine exhibits relatively low lipid solubility about 2.5% of fentanyl

(Sublimaze)

2. at physiological pH, morphine, a weak base with the pKa of about 8.0, is

primarily ionized.  The ionized form does not favor passage through the lipid

membrane; accordingly, only about 10%-20% of molecules are un-ionized.

Relatively high plasma clearance (15-40 ml/kg/minute) has implicated extrahepatic

clearance mechanisms, most likely renal.

Fentanyl (Sublimaze) pharmacokinetics:

Fentanyl (Sublimaze) is significantly more lipid-soluble, compared morphine and,

relative to morphine, has a more rapid onset of action (fentanyl (Sublimaze) is also a

weak base and at physiological pH only about 10% of molecules are un-ionized).

Clearance of about 10-20 ml/kg/minute is consistent with a primary hepatic

mechanism.  Fentanyl (Sublimaze)'s short duration of action following bolus

administration is explained by rapid redistribution from brain to other compartments

such as skeletal muscle and fat. If, however, fentanyl (Sublimaze) is administered by

continuous IV infusion or multiple IV dosing, other non-CNS compartments will

saturated and remaining CNS fentanyl will contribute to postoperative ventilatory

depression.

Action of opioid drugs:

A. Central nervous system: Analgesia, sedation, euphoria, nausea, vomiting, miosis,

depression of ventilation, pruritus and skeletal muscle rigidity.

B. Respiratory system: bronchospasm in susceptible patients and depressed cough reflex

C. Cardiovascular system: bradycardia (fentanyl) or tachycardia ( pethidine)

D. Skin: pruritus may be due to histamine release or action on opioid receptor.

E. Gastrointestinal tract: constipation, delays gastric emptying, increased tone of the

common bile duct and sphincter of Oddi.

F. Urinary tract: increased sphincter tone and retention of urine.

Use of opioids in anesthesias

Premedication drugs

Induction of anaesthesia

Blunt haemodynamic reactions to noxious stimulation

Intraoperative analgesia

Postoperative analgesia

Used in ICU as analgesia to facilitate mechanical ventilation

Drug Doses

Morphine 2.5 - 5 mg (IV), 15 - 30 mg (oral)

Pethidine 50 to 100 mg S.C., I.M or in reduced doses I.V.

repeated every 3 to 4 hours

Fentanyl 25 - 50 µg (IV), 150 - 300 µg (oral)

Naloxone

It is an antagonist at all opioid receptors of pure opioid antagonist. It reverse all opioid

actions including analgesia. It has short duration of action ( 1-4 hours) and has limited action

against partial or mixed actions opioids. Abrupt reversal of opioid analgesia can result in

sympathetic stimulation (tachycardia, ventricular irritability, hypertension and pulmonary

oedema).

Dosage :

Bolus:

o Adult: 0.04 mg IV in titrated bolus every 23 minutes until the desired

effects

o Child: 1-4mcg/kg titrated

Continuous infusion: 5mcg/kg/hr IV will prevent respiratory depression without

altering the analgesia produced by neuraxial opioids.

Tramadol

It is an opioid agonist at mu receptor and inhibits noradrenaline reuptake and release of 5-

hydroxytryptamine (monoaminergic pathways). It is given intravenously with the dose of 1-2

mg/kg and also can be given orally (good bioavailability). It produces less respiratory depression

in equivalent dose if compared with morphine.

Non opioids

Use of non steroidal anti-inflammatory drugs as analgesics (eg: Ketorolac, Diclofenac). It

block synthesis of prostaglandins by inhibiting cyclooxygenase enzyme. It reduces pain by

peripheral action and centrally by reducing input of nociceptive information in spinal cord.

Ketorolac and Ketoprufen has opioid sparing effects.

Side effects:

Reduced platelet aggregation may increase bleeding – it is not advisable for neurosurgical

and ophthalmic surgery.

It may cause damage to gastric mucosa causing ulceration and bleeding.

Bronchospasm – patients with asthma have an increased incidence of sensitivity to aspirin

Renal failure- inhibition of renal prostaglandin synthesis may interfere with maintenance

of renal blood flow.

Drug Doses

Voltaren (Diclofenac) 100-200 mg daily

Paracetamol 2 x 500mg 4-6 hourly

Synflex Initially 550 mg then 275 mg

6-8 hrly

CHAPTER 3

CASE: PERIOPERATIVE ASSESSMENT

3.1. Preoperative Assessment

3.1.1. Case History

IDENTIFICATION DATA

Name : Rosli bin Ahmad Tajudin

Sex : Male

Age : 45 years old

Nationality/Tribe : Malaysian/Malay

Religion : Islam

Address : Kangar, Perlis

Marital Status : Married

Occupation : Government Officer

Admission Date :14th May 2013

CHIEF COMPLAINT

This 45-year old malay gentleman presented with a chief complaint of difficulty in

swallowing for the past two months, worsening last week.

HISTORY OF PRESENTING ILLNESS

Patient suddenly developed difficulty in swallowing since two months ago. This is the

first episode. Patient’s condition is progressively worsening. Initially, he was unable to take solid

food but later on, he could not tolerate fluid as well. He vomited out food particles and fluid after

each meal. Patient also had loss of appetite and he lost around five to six kilogram body weight in

two months period.

Gastroscopy (OGDS) and tissue biopsy was done on 8th May 2013 with the impression of

esophageal carcinoma. CT Scan done on 9th May 2013 shows soft tissue mass at the mid

esophagus (2.8 cm length) which is causing stenosis of its lumen. On 13 th May 2013, Barium

Swallow Test was carried out with the impression of persistent narrowing of distal esophagus

with irregular wall outline suggesting esophageal tumour.

Otherwise, he has no regurgitation, no cough, no choking and aspiration, no painful

swallowing, no heartburn, no fever, no alteration of bowel habit, no shortness of breath, no

hoarseness of voice, no abdominal pain, no upper respiratory tract infection and no urinary tract

infection.

PAST MEDICAL HISTORY

He has no known of other medical condition.

PAST SURGICAL HISTORY

Patient had undergone oesophagogastroduodenoscopy (OGDS) on 8th May 2013.

ANAESTHETIC HISTORY

Patient has never gone through any anaesthetic procedures.

DRUG HISTORY

Patient is not on any medication. There’s no history of drug or food allergy. Patient

claimed he is not taking any traditional medication or over the counter drugs.

FAMILY HISTORY

There is no history of malignancy in the family. However, patient’s father has diabetes

mellitus and his mother has hypertension.

SOCIAL HISTORY

Patient is a government officer, married with 4 children. Currently, he lives with his wife

and children. He is able to carry out activity of daily life independently. He is an active smoker

(20 sticks/day) for 20 years. He is non-alcoholic. There is no recent travel. He denied any high-

risk behavior.

3.1.2. Physical Examination

GENERAL EXAMINATION

Patient is alert and conscious, lying comfortably on the bed. He does not look ill, not in

pain, and not in respiratory distress. He has normal body build, and his hydration and nutritional

status is fair. There’s no gross deformity, no involuntary or abnormal movement, and there’s a

branula attached at his left hand.

VITAL SIGNS

Vital signs Value Interpretation

Temperature 37°C Afebrile

Blood pressure 135/80 mmHg Normal

Pulse rate 78 bpm Normal

Respiratory rate 18x/minute Normal

Pain score 0/10 Not in pain

Height 170 cm -

Weight 61 kg -

Body Mass Index 21 kg/m2 Normoweight

HEAD, NECK & EXTREMITIES EXAMINATION

On general examination (extremities), the palm is moist, no pallor, no palmar erythema

and the temperature was normal. There’s no clubbing finger, and no bluish discoloration of the

nail. No leukonychia or koilonychia noted. There’s no fine tremor or flapping tremor. There’s

also no pedal edema at both lower extremities.

Examination of the head did not reveal pallor of the conjunctiva, no jaundice of the sclera,

no exophthalmus, no arcus senilis and no xanthelasma. There’s also no bluish discoloration of the

lips and the tongue. The dental hygiene is good.

For neck examination, on inspection, there’s no redness, no skin changes, no discharge,

no surgical scar and no prominent vein and no increase in jugular venous pressure. On palpation,

there is no increase in temperature and no palpable lymph nodes and no trachea deviation. On

auscultation, there’s no bruit can be heard.

RESPIRATORY SYSTEM EXAMINATION

From airway assessment, patient was classified as Mallampati class I, and the thyromental

distance was 6.5 cm or three fingers wide.

Patient has no history or symptoms of upper respiratory tract infection. On examination;

on inspection, the chest moved symmetrically with respiration, with abdominal-thoraco breathing

pattern. The chest shape was normal and there was no deformity or scar noted on both anterior

and posterior chest wall. There were also no signs of respiratory distress. On palpation, the chest

expansion and tactile vocal fremitus were symmetrical on both anterior and posterior chest. On

percussion, it was a symmetrical resonance sounds. On auscultation, no wheezing or crepitation

heard. Air entry was equal on both sides.

CARDIOVASCULAR SYSTEM EXAMINATION

The peripheral pulses were palpable, equal and regular. There was no surgical scar seen

on the chest. There was neither heave nor thrill can be palpated. Apex beat was palpable at left

midclavicular line between 4th and 5th intercostal space. Normal 1st and 2nd heart sounds were

heard and there were no additional sounds or murmurs heard in the mitral, tricuspid, aortic and

pulmonary area.

ABDOMINAL EXAMINATION

On inspection, the abdomen was not distended, moves with each respiration. The

umbilicus is centrally located. Otherwise, there is no surgical scar, no visible peristalsis or

pulsation, no skin discolouration and no cough impulse.

On palpation, the abdomen is soft and non-tender. No mass can be appreciated and no

hepatomegaly or splenomegaly. The kidney was not ballotable.

The percussion gives tympanic sound, and there’s no shifting dullness. On auscultation,

the bowel sound was present and no renal bruit heard.

CENTRAL NERVOUS SYSTEM EXAMINATION

Patient was alert, and well oriented to person, time and place. Glasgow Coma Scale was

15/15. Facial expression was symmetry. All cranial nerves were intact.

MUSCULOSKELETAL SYSTEM EXAMINATION

Patient has a normal muscle bulk, strength, tone and power for both upper and lower

extremities. The shape of vertebral spine is normal. No deformities noted. Gait was normal.

PHYSICAL STATUS

ASA score is 1. Patient was healthy with no systemic disease, and the surgery was an

elective surgery.

3.1.3. Investigation

• Full blood count:

Components Value Normal Range Interpretation

White blood cell 8.8 (109/L) 4.0 – 11.0 Normal

Red blood cell 4.7 (106/L) 3.8 – 4.8 Normal

Haemoglobin 13.0 (g/dL) 12.0 – 15.0 Normal

Haematocrit 38.8 (%) 36.0 – 46.0 Normal

Mean cell volume 82.0 (fL) 83.0 – 101.0 Normal

MCH 29.4 (pg) 27.0 – 32.0 Normal

MCHC 31.7 (g/dL) 31.5 – 34.5 Normal

Platelet 298 (103/uL) 150 – 450 Normal

Differential:

Neutrophils

Lymphocytes

Monocytes

Eosinophils

Basophils

4.75 (103/uL)

2.90 (103/uL)

0.35 (103/uL)

0.30 (103/uL)

0.05 (103/uL)

2.0 – 7.0

1.0 – 3.0

0.2 – 1.0

0.02 – 0.50

0.02 – 0.10

Normal

Normal

Normal

Normal

Normal

• Renal profile

Components Value Normal Range Interpretation

Sodium 138 (mmol/L) 135 – 145 Normal

Potassium 3.7 (mmol/L) 3.3 – 5.3 Normal

Urea 3.7 (mmol/L) 1.7 – 8.3 Normal

Creatinine 61 (umol/L) <97 Normal

• Coagulation:

Components Value Normal Range Interpretation

Prothrombin time 11.7 (sec) 10.4 – 13.2 Normal

INR 0.99 0.9 – 1.1 Normal

APTT test 28.5 (sec) 20.1 – 34.9 Normal

APTT ratio 1.0

EKG:

• Sinus rhythm

• No ischemic changes

• Interpretation: Normal

Chest X-Ray:

• Lung: Normal

• No cardiomegaly

• Bones: Intact

• Soft tissues: Normal

• Trachea is not deviated

Indirect Laryngoscope:

• Both vocal fold mobile equally

• No anterior compression

• Impression: Normal vocal cord

3.1.4. Summary

A 45 years old malay gentleman, an active smoker, presented with difficulty in

swallowing since the past 2 months, worsening one week before admission to the hospital.

Initially he was unable to tolerate solid food but later on he could not take fluid as well. This is

accompanied by loss of appetite and weight loss. On physical examination, patient is clinically

stable and not dehydrated. Gastroscopy and tissue biopsy, CT scan, Barium Swallow Test results

are suggestive of esophageal carcinoma. Otherwise, there’s no significant finding in any other

system.

3.1.5. Preoperative Diagnosis

• Esophageal Carcinoma

3.1.6. Plan

• Lower Esophagectomy + thoracotomy + pyloroplasty

• To keep nil by mouth by 12 midnight (8 hours prior to surgery)

• To inquire informed consent for the surgery and anaesthetic procedures

• Send blood for blood crossmatch

• To plan for general anaesthesia/intermittent positive pressure volume (double lumen

intubation).

3.2. Intraoperative Assessment

Anaesthesia : Balanced general anaesthesia with intermittent positive pressure ventilation

(double lumen intubation)

Fasting : Patient was kept nil by mouth 8 hours prior to operation.

Premedication : Patient was given tablet midazolam 7.5 mg night before operation and in the

morning prior to operation.

3.2.1. Anaesthesia Procedures :

I. Preoperative assessment was done and consent was taken from the patient.

II. GA machine was checked and anaesthetic drug was prepared before patient was

entered into the operation room.

III. Intravenous assessed was established by inserting IV catheter 18G and patient was

preloaded with normal saline.

IV. Procedures were done in a full aseptic technique, scrubbed, gloved and gowned.

V. Patient was preoxygenated with 100% oxygen for 3 minutes at 8am.

VI. Administration of intravenous Fentanyl 100mcg and intravenous Propofol 100mg.

VII. Loss of consciousness was assessed by loss of eyelash reflex.

VIII. Test ventilate before give muscle relaxant.

IX. Then, IV rocuronium bromide 50mg was given and mask ventilate with oxygen and

volatile gas Sevoflurane 2% for 3minutes.

X. Laryngoscopy and intubation were then performed by using double lumen

endobronchial tube size 39mm, Cormack Lehane I, anchored at 29mm.

XI. Post intubation, both lungs were tested for one sided lung ventilation and tube was

confirmed further by fibreoptic bronchoscopy visualization.

XII. Arterial line was inserted at right radial artery.

XIII. Triple lumen catheter was inserted at right internal jugular vein.

XIV. Other IV access available: right hand 16G branula, left hand 18G branula

XV. The vital sign which are oxygen saturation, brain tissue carbon dioxide, respiratory

rate, blood pressure, heart rate, any blood loss and urine output was monitored during

the operation.

XVI. Estimated blood loss is 500ml. Patient was given 7 pint fluid; 2 pint IV Voluven, 2

pint IV Nacl 0.9%, 3 pint IV Hartman Solution. No blood transfusion was done during

the operation.

XVII. Anaesthesia was maintained with Sevoflurane and morphine 12mg.

XVIII. Intra operatively patient was also given IV Ranitidine 50mg, IV Cefobid 1g, and IV

Flagyl 500mg

XIX. Post operatively, double lumen endobronchial tube was exchanged with portex ETT

size 8.0 mm, anchored at 21 mm.

XX. Patient was sent to intensive care unit (ICU) for weaning, transfer by manual bagging.

3.2.2. Drugs :

3.2.2.1. Intravenous :

a. Fentanyl 100mcg

b. Propofol 140 mg

c. Rocuronium bromide 50g

d. Morphine 12mg

e. Ranitidine 50mg

f. Cefoperazone 1g

g. Metronidazole 500mg

h. Ephedrine 6mg

i. Phenylephrine 100 mcg

3.2.2.2. Gases :

1. Oxygen / air (L/min) 1:2

2. Volatile : Sevoflurane MAC 1.0

3.2.3. Monitoring :

Time 930

am

10.00

am

10.30

am

11.00

am

11.30

am

12.00

pm

12.30

pm

1.00

pm

1.30

pm

2.00

pm

O2 Sat

(%)100 100 99 100 100 100 98 100 100 100

Resp

(x/min)12 12 12 13 15 12 12 12 14 12

CVP

(mmHg)9 6 9 8 8 12 12 9 9 10

Urine

(ml)100 500 500

Temp

(°C)35.6 35.6 35.6 35.1 35.0 34.7 34.7 34.6 35.0 35.1

Blood Pressure and Heart Rate :

Blood pressure was monitored every 5 minutes during the whole operation procedure. The

systole reading range was between 90 – 150 mmHg and diastolic pressure was between

50 – 90mmHg. Heart rate was monitored every 5minutes and noted to be in normal range

which was within 70 – 90 beats per minutes.

3.2.4. Summary:

Patient was hemodynamically stable throughout the operation with 500ml

estimated blood loss but no blood transfusion was needed. There is a tumor at the lower

esophagus noted 1 cm above cardia measuring 3 X 3 cm. Proximal gastrectomy was done.

Due to limited space over superior resectable margin, surgeon proceed with thoracotomy

and single lung ventilation initiated. Lower end esophagectomy was done and proceed with

proximal gastric and lower end esophagus anastomosis. Air leak test done – no leaking.

Vagus nerve is preserved. Chest tube size 32 Fr was inserted. Right chest wall incision

closed layer by layer. Patient was transferred to intensive care unit.

3.3. Post Operative Assessment

After the operation, double lumen endobronchial tube was exchanged with endotracheal

tube size 8 mm anchored at 21 mm.

Patient was sent to the intensive care unit (ICU) for weaning, transferred with manual

bagging.

Non-invasive blood pressure (NIBP) monitor, ECG monitoring, pulse oximeter and DVT

venocuff prophylaxis were set-up.

Patient was keep nil by mouth, put below radiant warmer to prevent hypothermia.

Pain was minimal and there were no complaints of headache, nausea or vomiting.

Otherwise, no other post-operative complications noted.

Vital Signs Reading Interpretation

Blood pressure 111/89 mmHg Normal

Pulse rate 65 x/min Normal

Respiratory rate 20x/ min Normal

Temperature 37°C Afebrile

SpO2 100% Normal

Pain score 2/10 Mild pain

Post-operative anaesthesia recovery score

Parameters Signs Score

Activity Able to lift the head or has a good hand grip

None of the above

1

0

Respiration Able to breathe and cough easily

Dyspnoeic or apnoeic

1

0

Circulation BP within 20% of pre-operative level

BP above or below 20% of pre-operative

1

0

level

Pulse regular rate, within 20% of pre-

operative level

Pulse irregular, above or below 20% of pre-

operative level

1

0

Consciousness Arousable

Not responding

1

0

Colour Pink

Dusky

1

0

Total score 3/6

Note:

Score 5 or more may be coming home with the conditions of operation/ action possible

Score 4 to the treatment room when the breathing value is 1

Score 3 or less to ICU

Operative findings:

Tumor at the lower esophagus noted 1 cm above cardia measuring 3 X 3 cm.

Proximal gastrectomy was done.

Thoracotomy and single lung ventilation initiated due to limited space over superior

resectable margin.

Lower end esophagectomy was done and proceed with proximal gastric and lower end

esophagus anastomosis. Air leak test done – no leaking.

Vagus nerve is preserved.

Noted multiple metastatic lymph nodes involving caeliac lymph nodes and metastatic

nodules over the pancreas. No liver nodules.

Plan:

i. To put patient on CPAP PEEP setting.

ii. To give IV morphine 3 mg/hour

iii. To give IV Dexmedetomidine (Precedex) 0.4 mcg/kg/hour

iv. To give IV pantoprazole 40 mg

v. To give IV Sulfaperazone 2g twice daily

vi. Infuse 2 pints of dextrose 5% and 3 pints normal saline 0.9% in 24 hours

vii. Keep nil by mouth for 6-8 hours