Gastrectomy

Surgical approach

• Indications: gastric cancer (most common), bleeding/ulcer complications, bariatric (sleeve) differs, this note focuses on oncological partial/total gastrectomy
• Approach: open upper midline laparotomy or laparoscopic/robotic (often converted if difficult)
  • Laparoscopic: pneumoperitoneum + reverse Trendelenburg, longer operating time, less pain, shoulder tip pain possible
  • Open: larger incision, more fluid shifts, higher pain burden
• Subtotal (distal) gastrectomy: resection of distal stomach + lymphadenectomy, reconstruction typically Billroth II or Roux-en-Y gastrojejunostomy
• Total gastrectomy: resection of entire stomach + D1/D2 lymphadenectomy, reconstruction oesophagojejunostomy (Roux-en-Y) ± feeding jejunostomy
  • Anastomosis high in upper abdomen/hiatus region, potential pleural breach, chest drain occasionally
• Key intra-op steps relevant to anaesthesia: retraction of liver, dissection near pancreas/spleen, mobilisation near hiatus, potential major bleeding (left gastric, short gastrics, splenic injury)

Anaesthetic management

• Type of anaesthesia: general anaesthesia with tracheal intubation, consider thoracic epidural or alternative regional techniques for open surgery
  • Regional options: thoracic epidural (T7–T9), or spinal opioid + TAP/rectus sheath blocks, for laparoscopic consider TAP/QL blocks + multimodal analgesia
• Airway: ETT mandatory (aspiration risk, pneumoperitoneum, long duration, need for controlled ventilation). Consider rapid sequence induction if obstruction/delayed gastric emptying/bleeding
• Duration: typically 3–6 hours (laparoscopic often longer early in learning curve, total gastrectomy often longer than subtotal)
• Pain: moderate–severe (open upper abdominal incision), laparoscopic moderate. Aim opioid-sparing with neuraxial/regional + multimodal
• Monitoring: invasive arterial line (major surgery, blood loss, vasoactive support), large-bore IV access, consider CVC if poor access/vasopressors/TPN plans, temperature, urine output, consider cardiac output monitoring in high-risk
• Ventilation: lung-protective (6–8 ml/kg IBW), PEEP, manage pneumoperitoneum effects, consider recruitment manoeuvres, check ETT position after reverse Trendelenburg
• Fluids/haemodynamics: goal-directed therapy, avoid both hypovolaemia (AKI/anastomotic hypoperfusion) and overload (pulmonary complications). Early vasopressor support often preferable to excess crystalloid
• PONV prophylaxis: high risk, use multimodal (dexamethasone + ondansetron ± droperidol), minimise volatile/opioids where possible
• Post-op destination: HDU/ICU for total gastrectomy, open surgery, high-risk patients, major blood loss, significant comorbidity, or epidural requiring close monitoring

Pre-operative assessment and optimisation

• Assess indication and extent: subtotal vs total, open vs laparoscopic, planned feeding jejunostomy, expected blood loss, likelihood of conversion
• Comorbidity and physiology: older patients, malnutrition, frailty, anaemia, cardiorespiratory disease, consider CPET if time and uncertainty about functional capacity
• Aspiration risk: gastric outlet obstruction, bleeding, delayed gastric emptying, opioids, consider NG decompression pre-induction if obstructed (surgeon preference) and RSI
  • If NG present: leave on free drainage/suction before induction, be prepared for large volumes
• Anaemia and transfusion planning: check Hb, iron studies, treat iron deficiency, group and screen/crossmatch (often 2–4 units depending on extent and local practice)
• Nutrition: weight loss, hypoalbuminaemia, consider dietitian input, prehabilitation, carbohydrate loading if appropriate, discuss post-op feeding plan (jejunal feeds/TPN)
• Medication review: anticoagulants/antiplatelets (balance bleeding vs thrombosis), steroids (stress dose if indicated), beta-blockers, ACEi/ARB plan
• Consent discussion (anaesthetic): epidural risks/benefits, arterial line, blood transfusion, ICU, post-op ventilation possibility (rare but consider in high-risk)

Intra-operative conduct (key FRCA points)

• Induction: consider RSI if obstruction/bleeding/high aspiration risk, otherwise modified RSI may be appropriate. Ensure robust IV access before induction if possible
  • Haemodynamic stability: induction can unmask hypovolaemia from poor intake, consider gentle induction and early vasopressor (metaraminol/noradrenaline)
• Analgesia: thoracic epidural (local anaesthetic + opioid) for open surgery reduces opioid requirements and improves respiratory mechanics, ensure haemodynamic plan for sympathectomy
  • Alternatives: TAP/QL blocks, rectus sheath (midline), wound catheters, IV lidocaine infusion (where used), ketamine low-dose, paracetamol, NSAIDs cautiously (bleeding/renal risk, surgeon preference re anastomosis)
• Monitoring: A-line before incision, active warming (forced-air + warmed fluids), urinary catheter, consider serial ABG/lactate if major blood loss or high-risk
• Fluid and blood: balanced crystalloid, consider albumin/blood products if significant loss, use cell salvage if appropriate (often acceptable in cancer surgery with modern leukocyte depletion filters per local policy)
  • Coagulation: consider fibrinogen early in major haemorrhage, use viscoelastic testing if available
• Ventilation and pneumoperitoneum (laparoscopic): increased airway pressures, reduced compliance, manage with PEEP, recruitment, adjust I:E, monitor EtCO2 rise, consider pressure-controlled ventilation
• Positioning: reverse Trendelenburg (laparoscopic) increases V/Q mismatch and hypotension risk, secure patient, protect pressure points, consider DVT prophylaxis (mechanical intra-op)
• Antibiotics: broad-spectrum as per local upper GI protocol, redose if prolonged surgery or major blood loss
• Antiemetics: multimodal, consider TIVA to reduce PONV in high-risk
• Extubation: ensure normothermia, adequate analgesia, acceptable gas exchange, consider ICU ventilation if ongoing bleeding, acidosis, hypothermia, high vasopressor requirement, or severe comorbidity

Post-operative management

• Analgesia: epidural infusion with regular assessment (sensory level, motor block, hypotension), or PCA opioid + regional blocks + paracetamol ± ketamine/lidocaine (local policy)
• Respiratory care: early mobilisation, physiotherapy, incentive spirometry, treat pain to enable deep breathing/cough, consider CPAP in OSA or atelectasis
• Fluids and electrolytes: avoid overload, monitor UO, lactate, creatinine, manage epidural-related hypotension with vasopressors rather than excess fluid where appropriate
• Nutrition: early enteral feeding often via jejunostomy, NG tube may be left for decompression depending on surgeon, coordinate with ERAS
• Glycaemic control: avoid hyperglycaemia (infection risk) and hypoglycaemia (limited oral intake)
• Thromboprophylaxis: mechanical + pharmacological when safe, cancer surgery often requires extended prophylaxis (local policy)
• Complications to anticipate: bleeding, anastomotic leak, pancreatic injury/fistula, ileus, aspiration/pneumonia, AKI, arrhythmias, sepsis

Procedure-specific physiology and complications (useful for viva)

• Anastomotic leak (oesophagojejunostomy/gastrojejunostomy): typically day 3–7, presents with tachycardia, fever, pain, rising inflammatory markers, sepsis, respiratory compromise
  • Anaesthetic implications: high suspicion in unexplained tachycardia, early imaging (CT with contrast), source control, may require return to theatre/ICU
• Bleeding: intra-op from major vessels/spleen, post-op intraluminal or intra-abdominal bleeding
• Respiratory complications: atelectasis, pneumonia (upper abdominal surgery), pleural effusion, higher risk with open surgery, poor analgesia, smoking, COPD
• Metabolic/nutritional sequelae (later): dumping syndrome, B12 deficiency (total gastrectomy), iron deficiency, weight loss, relevant to long-term but may affect pre-op status in revision surgery

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