Table Of ContentDK073X_half 4/26/06 3:49 PM Page 1
Gastrointestinal
and Colorectal
Anesthesia
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Gastrointestinal
and Colorectal
Anesthesia
Edited by
Chandra M. Kumar
The James Cook University Hospital
Middlesbrough, U.K.
Mark Bellamy
St. James's University Hospital
Leeds, U.K.
New York London
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Library of Congress Cataloging‑in‑Publication Data
Gastrointestinal and colorectal anesthesia / edited by Chandra Kumar, Mark Bellamy.
p. ; cm.
Includes bibliographical references and index.
ISBN‑13: 978‑0‑8493‑4073‑4 (hardcover : alk. paper)
ISBN‑10: 0‑8493‑4073‑X (hardcover : alk. paper)
1. Anesthesia in gastroenterology. I. Kumar, Chandra M. II. Bellamy, Mark C.
[DNLM: 1. Anesthesia‑‑methods. 2. Digestive System Surgical Procedures. WI 900 G2572 2006]
RD87.3.G37G37 2006
617.9’6743‑‑dc22 2006046569
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Foreword
Medicine in all of its component specialties continues to advance. The continuing
development of new and improved techniques of anesthesia and perioperative care
hastomatchchangesinotherfields.Thepresentimpressiverecordforlowmorbidity,
mortality, and complication rates due to anesthesia can only be achieved byregular
updatesandauthoritativetexts.State-of-the-arttextbooksareonekeyelementinthis
process, and a new book should be viewed with delight; particularly one that is as
scholarlyasthisone.Amajorpartofsurgicalpracticeisencompassedbythesurgical
specialties of gastrointestinal and colorectal practice in its broadest sense.
Of course, all existing general anesthesia texts contain sections concerning
gastrointestinalandcolorectaltopics.Whatwehavelongneeded,though,isanauth-
oritative text devoted to these areas of practice. Now we have it.
The importance of the anesthetist in perioperative care cannot be too greatly
emphasized. Correct patient selection and procedure planning can only be optimized
by a team approach and together with the surgeon; the anesthetist forms the core of
the team. A thorough understanding of the underlying physiologyofthe gastrointes-
tinal tract is important and a logical starting place for this book. Surgical
considerations, outcomes, and morbidity prediction are key and are covered in the
following chapters. I am particularly pleased to see whole chapters devoted to preas-
sessment,preoptimization,andperioperativefluidmanagement—allcrucialareasand
ones that are sadly often inadequately considered.
Much of modern surgical practice is undertaken using cameras, fiber optics,
and display screens. Three-dimensional goggles, head-up displays, and robotics are
justaroundthecorner.Thesevariedendoscopictechniquesarecontinuallywidening
the limits of surgical practice and bringing with them new frontiers for the anesthe-
tist, each with their own individual considerations. Not only that, but the drive for
expanding the ‘‘basket’’ of procedures that can be undertaken on an ambulatory
basis seems almost unstoppable (not that it should be curtailed). Sedation, regional
block, or general anesthesia? These are all covered in this book. With this drive to
everything ambulatory comes the need to push back the boundaries on recovery,
postoperative analgesia, and postoperative nausea and vomiting—all vitally impor-
tant topics given their own space in this book.
Of course, one would expect all of the‘‘usual’’ chaptersto be present,and the
reader will not be disappointed. They are all there—hepatobiliary, pancreatic, gas-
tric, bariatric, intestinal, colorectal, etc. Relevant endocrine conditions are also
included. It is difficult to see what might be missing. I certainly could not find
anything important which had been omitted.
iii
iv Foreword
I can see this book being a valuable addition to the library of any anesthetist
who regularly works with gastrointestinal and colorectal surgeons. Not only that,
but it will also be of value to nonmedical anesthetists, theatre practitioners, nurses,
and even surgeons. I am honored to have been asked to be a (very small) part of it.
Brian J. Pollard
Preface
Anesthetists usually acquire skills of anesthesia for gastrointestinal and colorectal
surgery from their peers during training. The techniques are later modified and
adopted depending on the circumstances and opportunities available. The purpose
of this book is to improve the perioperative management of patients undergoing
gastrointestinalandcolorectalsurgery.Anesthesiaforgastrointestinalandcolorectal
surgery is not comprehensively covered in any textbook: While much topical
material has recently appeared in journals, it has been scattered. In this book, we
have brought this material together in a cohesive and organized fashion.
The material in this book has been collated and written by acknowledged
international experts skilled in specific areas relating to gastrointestinal and colo-
rectal surgery.
Thisbookwillbethemostcomprehensiveandup-to-datecollectionofmaterial
in the field. The multiple authors provide authoritative information on a broad and
comprehensivescalethatisnotpossibleinasinglemedicalinstitution.Eachchapter
aims to provide the scientific and clinical basis for anesthetic practice.
This book will appeal to all practicing anesthetists, as well as to trainees in
anesthesiaandsurgery,clinicalspecialistnurses,andotherhealth-careprofessionals
involved in the care of patients undergoing gastrointestinal and colorectal surgery.
Chandra M. Kumar
Mark Bellamy
v
Contents
Foreword Brian J. Pollard . . . . iii
Preface . . . . v
Contributors . . . . xvii
1. Physiology of the Gastrointestinal Tract Including Splanchnic
Blood Flow and Tonometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Gareth L. Ackland and Monty G. Mythen
Introduction . . . . 1
Hepatosplanchnic Circulation . . . . 1
Gastrointestinal Microvasculature . . . . 3
Neural Control of the Gastrointestinal
Tract . . . . 5
Neurotransmitters . . . . 7
Central Nervous System Control of the
Gastrointestinal System . . . . 8
Neuroimmune Interactions . . . . 9
Metabolic Interactions . . . . 10
Clinical Measurement of Splanchnic
Blood Flow . . . . 10
Clinical Studies . . . . 12
Summary . . . . 12
References . . . . 12
2. Surgical Considerations in Upper Gastrointestinal Surgery . . . . . . . 13
Bussa R. Gopinath, Peter A. Davis, and Chandra M. Kumar
Introduction . . . . 13
Esophagectomy . . . . 13
Surgery for Gastric Neoplasm . . . . 15
Gastroesophageal Reflux Surgery . . . . 17
Laparotomy for Perforated
Peptic Ulcer . . . . 19
Laparotomy for Gastroduodenal
Bleeding . . . . 20
vii
viii Contents
Cholecystectomy . . . . 21
References . . . . 22
3. Surgical Considerations in Lower Gastrointestinal Surgery . . . . . . . 25
Tim Brown and Al Windsor
Introduction . . . . 25
Preoperative Fasting . . . . 25
Laparoscopic Lower Gastrointestinal
Surgery . . . . 26
Bowel Preparation . . . . 29
Conclusion . . . . 30
References . . . . 30
4. Stress Response During Surgery . . . . . . . . . . . . . . . . . . . . . . . . . 33
Grainne Nicholson and George M. Hall
Introduction . . . . 33
Hormonal Aspects of the
Stress Response . . . . 33
Cytokines . . . . 37
Metabolic Consequences . . . . 37
Modifying the Stress Response . . . . 39
References . . . . 41
5. Measurement and Prediction of Surgical Outcomes . . . . . . . . . . . . 45
Graham P. Copeland
Introduction . . . . 45
Techniques for Assessing Outcome . . . . 46
Using Predictive Models of
Surgical Outcome . . . . 51
References . . . . 56
6. Reducing Morbidity After Colorectal Surgery:
Surgical Perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Anil Reddy, Vikram Garoud, and Robert Wilson
Introduction . . . . 59
Preoperative Evaluation . . . . 60
Physiologic Monitoring of
Surgical Patients . . . . 61
Nutritional and Metabolic Support . . . . 61
Thermoregulation . . . . 62
Patient Factors . . . . 63
Deep Vein Thrombosis Prophylaxis . . . . 63
Antibiotic Prophylaxis . . . . 64
Nasogastric Tubes . . . . 64
Mechanical Bowel Preparation . . . . 65
Incisions . . . . 66
Anastomotic Techniques . . . . 67
Contents ix
The Role of Stomas . . . . 68
Drains and Colorectal Surgery . . . . 69
Prevention of Postoperative Ileus . . . . 70
Prevention of Postoperative Adhesions and
Internal Hernia . . . . 70
Prevention of GI Bleeding . . . . 71
Prevention of Postoperative GI Fistulae . . . . 71
Postoperative Care and Early Recognition
of Complications . . . . 72
Specialization in Colorectal Surgery . . . . 72
Blood Transfusion . . . . 73
Conclusion . . . . 73
References . . . . 74
7. Preoperative Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Heinz E. Schulenburg, Stuart D. Murdoch, and Hamish A. McLure
Introduction . . . . 81
Systems Review . . . . 82
Investigations . . . . 87
Specific Medical Conditions . . . . 89
Premedication . . . . 92
Consent . . . . 93
Summary . . . . 94
References . . . . 94
8. Perioperative Fluid Management and Optimization . . . . . . . . . . . . 97
Korat Farooq and R. Jonathan T. Wilson
Introduction . . . . 97
Fluid Compartment Homeostasis . . . . 97
Intravenous Replacement Fluids . . . . 99
Fluid Homeostasis and Major Surgery . . . . 101
Monitoring the Circulation . . . . 104
Optimizing Oxygen Delivery in the
High-Risk Patient . . . . 105
Goal-Directed Therapy in Practice . . . . 107
Conclusion . . . . 108
References . . . . 109
9. Regional Anesthesia in Abdominal Surgery . . . . . . . . . . . . . . . . . 111
Timothy Jackson and Frank Loughnane
Introduction . . . . 111
Central Neuraxial Techniques . . . . 111
Discrete Nerve Blocks . . . . 117
Special Patient Groups . . . . 118
Summary . . . . 119
References . . . . 120
Description:This resource stands as the only authoritative text to specifically focus on developments and best practices in anesthesiology for procedures affecting the gastrointestinal tract and related appendages. This book provides in-depth coverage of topics such as risk assessment, stress response, and scor
