Preoperative assessment and perioperative management in oesophageal and gastric surgery

Introduction

Perioperative management strategies have been shown to be important in postoperative outcome following oesophageal and gastric surgery. The overriding principle of preoperative assessment is to identify comorbidities that may complicate the patient’s operative intervention and perioperative recovery. Identification, recognition, and treatment of these comorbidities allow the patient to be optimised prior to undergoing surgery to reduce the incidence of perioperative mortality and postoperative complications.

Recently, the role of the multidisciplinary team (MDT) and of standardised perioperative/recovery pathways have become increasingly important. In this chapter, we will review principles of preoperative assessment and perioperative management in the context of oesophagogastric surgery and examine recent developments in this field.

Physiological stress during the treatment of oesophagogastric malignancy

The multimodal nature of the treatment of oesophagogastric malignancy imparts significant physiological stress and there are specific comorbidities that can affect a patient’s tolerance to treatment. Clinical outcome following major surgery involves the interplay between patient characteristics (e.g. comorbidities), disease characteristics (e.g. tumour stage, grade, and cell type), choice of treatment modality (e.g. surgery, chemotherapy, radiotherapy, or a combination of several modalities), and postoperative recovery. The results and interpretation of preoperative testing allows a prediction of patient tolerance and enables assignment of a treatment approach tailored to the individual patient.

Diagnosis

The diagnosis of gastro-oesophageal malignancy is based on a good clinical history and examination, with the utilisation of appropriate further investigations.

Clinical assessment undertaken at the primary care consultation must highlight important symptoms, including dysphagia and odynophagia, to trigger further investigation. Studies have shown that an under-appreciation of the importance of dysphagia in younger patients can lead to a delay in presentation and an advanced tumour stage, resulting in a poorer prognosis.

Standard staging investigations for oesophagogastric malignancy ( Box 4.1 ) typically include endoscopy, endoscopic ultrasound (EUS), computed tomography (CT) and positron emission tomography (PET) with or without staging laparoscopy (for oesophagogastric junctional, cardiac, or gastric tumours). Among the currently available staging modalities, EUS is considered the best for T stage and assessment of regional lymph nodes, whereas PET is most accurate for the detection of distant nodal and metastatic spread. EUS has shown poor accuracy in distinguishing early-stage tumours limited to the mucosa (cT1a) from those extending into the submucosa (cT1b). Therefore, endoscopic resection (ER), which is essential for the accurate staging of early-stage cancers, should be performed for early-stage tumours (sT1a and cT1b ≤ 2 cm) as it provides more accurate information on the depth of tumour invasion than EUS. The addition of fine-needle aspiration (FNA) to EUS (EUS-FNA) has shown greater sensitivity and accuracy than either EUS alone or CT scan in the evaluation of cN staging, especially in assessing locoregional and celiac lymph nodes. Apart from being increasingly useful in the initial staging of oesophageal cancer, 2-deoxy-2-[18 F]-fluoro-D-glucose positron emission tomography (FDG-PET) scanning has been identified as a potential tool for assessing the therapeutic response after neoadjuvant therapy and detection of recurrent malignancy. However, FDG-PET is not able to distinguish a good from a complete pathologic response, which would potentially impact future therapeutic decisions.

Box 4.1

Oesophagogastric cancer diagnostic and staging investigations

Endoscopy
Endoscopic ultrasound without fine-needle aspiration
Computed tomography
Positron emission tomography
Staging laparoscopy

Multidisciplinary team evaluation

Patients referred for specialist oesophagogastric treatment are reviewed and discussed by the MDT. This consists of a lead clinician (often a surgeon or a medical specialist in oncology), medical and clinical oncologists, a radiologist (who may have an interest in interventional radiology), a histopathologist, specialist nurses, and MDT coordinators. Other members of the MDT may include gastroenterologists, dieticians, palliative care nurses, intensivists, and anaesthetists. MDT discussion allows presentation of the radiological and histopathological findings in the context of patients’ physical assessment, functional reserve, mental and nutritional status, and social support network.

The MDT has become the cornerstone of cancer treatment in order to provide an unbiased and evidence-based approach to the treatment of malignancy. Presentation to an MDT can produce important changes in management in up to 26% of patients. The role of the cancer specialist nurse is critical in providing a means of communication with the patient and family in order to ascertain their expectations from treatment along with further information regarding social and support networks. In our centre this initial comprehensive interview takes place before travel to the speciality centre and is routinely recognised as valuable in-patient satisfaction surveys. This initial communication includes providing specific information regarding the make-up of the care team, required investigations, and potential treatment options. This also provides a contact person (key worker) within the clinical team for the patient and family.

Centralisation of oesophagogastric cancer treatment has further improved the opportunities for informed multidisciplinary discussion through increasing specialisation and higher volume centres, resulting in improved clinical outcomes. This has in turn led to increased recruitment to clinical trials, a process that has been further facilitated by the presence of clinical oncologists as part of the MDT discussion.

Neoadjuvant therapy

MDT discussion allows for the formulation of a plan based on evidence-based principles including surgery with or without neoadjuvant therapies, given the premorbid status of the patient and characteristics of the tumour. Assessment of physiological issues is important because, although some patients may benefit from multimodality therapy, some will be considered inappropriate on the basis of physiologic health or frailty. Several studies have demonstrated a survival benefit in the use of neoadjuvant chemoradiotherapy prior to esophagectomy for the treatment of oesophageal cancer. Although this combination therapy has been shown to be effective, it may have a significant physiological impact on the patient. Timing of surgery around neoadjuvant chemoradiotherapy is also an important consideration, as in our institution we would recommend surgery 4–6 weeks following the cessation of neoadjuvant chemoradiotherapy; however, surgery within 4–10 weeks is generally considered to be appropriate.

Nutrition

Nutritional assessment and optimisation are a cornerstone of good pre- and perioperative care in cancer surgery and should be a component of the MDT review.

Preoperative malnutrition and associated immunosuppression have been shown to be well correlated with septic complications and mortality following oesophageal cancer surgery. The mechanism of malnutrition is often related to dysphagia, disease cachexia, or neoadjuvant chemotherapy. Criteria for the diagnosis of malnutrition have been updated by the European Society of Clinical Nutrition and Metabolism (ESPEN), focusing on building a global consensus around core diagnostic criteria for malnutrition in adults in clinical settings ( Box 4.2 ). There was strong consensus that the key first step in the evaluation of nutritional status is malnutrition risk screening to identify “at risk” status by the use of a validated screening tool. As such, the Nutrition Risk Screening (NRS) and Subjective Global Assessment (GSA) are frequently used to define patients at risk for malnutrition and their assessment has been implemented in the German Society for Nutritional Medicine guidelines. The second step is the assessment for diagnosis and grading the severity of malnutrition. Preoperative nutrition therapy is proposed for severely malnourished patients defined by weight loss > 10% within 6 months, body mass index (BMI) < 18.5 kg/m ² if < 70 years of age or < 20 kg/m ² if ≥ 70 years of age, Subjective Global Assessment Grade C, serum albumin < 30 g/L (with no evidence of hepatic or renal dysfunction), or NRS > 3. In these severely malnourished patients, surgery should be timed to allow improvement in nutrition status.

Box 4.2

Criteria for the diagnosis of malnutrition according to the ESPEN guidelines.

Fat-free mass can be measured objectively by bioelectrical bioimpedance analyses, dual-energy X-ray absorptiometry, computed tomography, ultrasound, or magnetic resonance imaging.

BMI , Body mass index; FFMI , fat-free mass index.

Definition of malnutrition

Phenotypic criteria
Weight loss (%): > 5% within past 6 months or > 10% beyond 6 months
Low BMI (kg/m ² ): < 20 if < 70 years or < 22 if > 70 years; Asia: < 18.5 if < 70 years or < 20 if > 70 years
Reduced muscle mass: reduced by validated body composition measuring techniques
Etiologic criteria
Reduced food intake or assimilation: ≤ 50% of energy requirements >1 week, or any reduction for > 2 weeks, or any chronic gastrointestinal condition that adversely impacts food assimilation or absorption
Inflammation: Acute disease/injury or chronic disease related

As many patients have to undergo neoadjuvant therapy first, this should be a window of opportunity to improve nutritional status and physical condition. Preoperative nutritional support, either by the enteral or parenteral route, was able to reduce postoperative complications and hospital stay in patients at high risk for malnutrition.

The relative merits of enteral over parenteral methods of feeding in the malnourished patient have been the subject of debate for several years. The proposed benefits of enteral feeding include improved gut oxygenation, colonisation with gut flora serving to reduce septic complications, and a reduced cost compared to parenteral feeding. There are several potential approaches to enteral feeding ( Box 4.3 ).

Box 4.3

Approaches to enteral feeding

Jejunal feeds: nasojejunal tube, surgical or interventional radiologically placed jejunal tubes
Stomach feeds: percutaneous gastrostomy (PEG) – not advisable due to potential compromise of the gastric conduit
Endoscopic removable temporary stents: self-expanding plastic or metal (SEMS) stents

Nasojejunal feeding is often poorly tolerated for long periods by patients, and thus is not routinely used at our institution. Thus, we advocate surgical placement of feeding jejunal tubes either by an open or a laparoscopic approach. We often combine this procedure with other procedures such as subcutaneous port placement or diagnostic laparoscopy.

At the time of surgery, many surgeons would advocate the routine placement of a feeding jejunostomy to ensure nutrition through the perioperative period and allow a more measured approach to reinstating oral nutrition. This can simplify discharge and avoid postoperative problems during the critical healing period, as in our patients jejunal tube feeding is initiated on postoperative day 1. It is important to emphasise that feeding jejunostomies can still be associated with complications in a proportion of cases, which should be discussed with the patient prior to placement. In our own experience, we have found that placing a large 14 Fr feeding tube decreases problems with tube obstructions. In recent years the development of endoscopic stents has served as a well-tolerated treatment modality to bypass obstructing oesophageal lesions and allow oral enteral feeding, either for preoperative optimisation or as a palliative measure. However, despite these benefits, fully covered oesophageal self-expanding metal stents (SEMSs) are associated with an increased risk of migration (6–43.8%) that may significantly impact upon the patient’s nutritional status and surgical resection. In a recent multicentric study, SEMS placement as a bridge to surgery was associated with poor oncologic outcome and decreased 3-year survival when compared with propensity-matched controls. Furthermore, many clinical oncologists are hesitant to use radiotherapy in a patient with an oesophageal metal stent. Thus, the future of stents as a nutritional bridge during neoadjuvant therapy remains inconclusive, with further studies required.

The role of the dietician or nutritionist in optimising perioperative nutrition is important in ensuring that the short- and long-term nutritional requirements of these patients are met. Current practice suggests that most centres employ a dedicated specialised gastrointestinal dietician who will nutritionally assess patients regularly in the postoperative period. Dietician-delivered intensive nutritional support has been shown to reduce severe postoperative complications after esophagectomy.

Preoperative assessment

In general terms, the most familiar and simple classification of preoperative physical status and risk is that of the American Society of Anesthesiologists (ASA) ( Table 4.1 ).The criteria for assigning ASA class include the presence of a systemic disease that affects activity or is a threat to life. The classification system alone does not predict the perioperative risks, but used with other factors (e.g. type of surgery, frailty, level of deconditioning), it can be helpful in predicting perioperative risks. A large-scale study including more than 2 million surgery cases showed that ASA has strong, independent associations with postoperative medical complications and mortality across procedures. Another large-scale systemic review showed that ASA > 2 confers a 4.87-fold increase in postoperative pulmonary complications. Several other clinical risk indices have been developed, including the Eastern Cooperative Oncology Group (ECOG) performance status and the Charlson comorbidity index. ECOG performance status allows assessment of the effect of oesophagogastric cancer on the daily living abilities of the patient. The Charlson comorbidity index predicts the 10-year mortality for a patient who may have a range of comorbid conditions such as heart disease, AIDS, or cancer (22 conditions in total). This index allows quantitative scoring of a patient’s comorbidities and may provide a useful tool in the preoperative assessment. In 2013, the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) implemented a free online surgical risk calculator based on the evaluation of outcome data on 1.4 million patients. The individual surgical risk can be estimated based on the operative procedure and 20 parameters assessing patient characteristics, including certain comorbidities and the ASA score described earlier. The output includes risk estimation in different categories, for example development of pneumonia, cardiac complications, or renal failure. This tool might be useful and handy to assess and discuss procedure risk with the individual patient. Despite the actual clinical value of risk assessment, scoring remains difficult.

Table 4.1

The American Society of Anesthesiologists’ assessment of physical status

Grade	Definition
ASA 1	Normal healthy patient
ASA 2	Patient with mild systemic disease
ASA 3	Patient with a severe systemic disease that limits activity but is not incapacitating
ASA 4	Patient with incapacitating disease that is a constant threat to life
ASA 5	Moribund patient not expected to survive 24 hours with or without surgery
ASA 6	Declared brain-dead patient whose organs are being removed for donor purposes

ASA , American Society of Anesthesiologists.

Cardiac assessment ( Box 4.4 )

As described previously, oesophagectomy or gastrectomy places significant physiological stress upon the cardiovascular system. Up to 10% of patients undergoing oesophagectomy will have a cardiovascular-related complication. Furthermore, with increasing oesophagogastric surgery being undertaken in the elderly population, accurate identification of patients at risk from cardiovascular complications (associated with ischaemia or dysrhythmia) can help guide treatment planning.

Box 4.4

Cardiac preoperative investigations

CPX , Cardiopulmonary exercise testing; ECG , electrocardiogram.

History: including functional capacity
ECG: identifies electric conductional abnormalities
Stress testing: exercise, pharmacological, echocardiography or radioisotope investigation and CPX

History

A thorough history and appropriate clinical examination will help identify major cardiovascular risk factors. Any pertinent findings will help guide further investigations that may be required, including a full cardiology assessment prior to undertaking major surgery.

Functional capacity

Exercise capacity provides a useful measure of functional cardiorespiratory reserve. Poor exercise tolerance correlates with an increased risk of perioperative complications that are independent of age and other patient characteristics. However, the ability to climb a flight of stairs does not preclude a patient from having underlying cardiorespiratory disease, and prior to undertaking surgery the majority of oesophagogastric surgeons and most anaesthetists would advocate the use of further cardiac investigation in all elderly patients or patients with multiple risk factors.

The 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on perioperative cardiovascular evaluation suggest a risk calculator-based assessment of the individual patient. The ACS NSQIP risk calculator described above, the Gupta Perioperative Cardiac Risk calculator, or the Revised Cardiac Risk Index (RCRI) may be used. These risk assessment tools balance patient characteristics, comorbidities, and the surgical procedure to predict the risk of a major adverse cardiac event (MACE). MACEs include postoperative death or myocardial infarction. With the new guidelines, combined assessment of patient characteristics and surgery leads to a procedure being categorised as low risk when the risk for MACE is < 1% and elevated risk when the risk for MACE is ≥ 1%. The ACC/AHA guidelines suggest further cardiac work-up for patients with elevated risk and poor or unknown functional status ( Fig. 4.1 ).

Figure 4.1, Preoperative cardiac assessment for coronary artery disease. MET refers to the activity level of a patient, with 1–3 METs being light activity (TV watching, slow walking) and 4–6 METs being moderate activity (bicycling). ACS , Acute coronary syndrome; CAD , coronary artery disease; MACE , major adverse cardiac event; MET , metabolic equivalent of task; Pt , patient.

Investigations ( Box 4.5 )

Electrocardiogram

Electrocardiogram (ECG) is the most basic objective cardiac assessment, usually as part of any preoperative work-up prior to major surgery. It remains a useful baseline test to identify electric conductional abnormalities within the heart that may indicate further structural abnormalities that warrant further investigations. Patients with no prior history of cardiac disease but with an abnormal ECG represent a group that must undergo a higher level of investigation and are potentially amenable to intervention and risk reduction prior to surgery.

Box 4.5

Preoperative pulmonary risk-reduction strategies

COPD , Chronic obstructive pulmonary disease.

Cessation of cigarette smoking for a minimum of 8 weeks
Aggressively treat airflow obstruction in patients with COPD or asthma
Optimise haemoglobin concentration either with iron supplementation or transfusion if absolutely necessary
Treat any respiratory tract infection with antibiotics, having first cultured the sputum
Begin patient education regarding adequate exercise and lung-expansion techniques with the assistance of a physiotherapist
Encourage the patient to lose weight if obese

Cardiopulmonary exercise testing

The recommendation of the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation endorses cardiopulmonary exercise testing (CPX) for patients undergoing high-risk surgery in whom functional capacity is unknown. A meta-analysis of studies assessing the discriminatory ability of CPX to predict increased morbidity and mortality after surgery suggested an anaerobic threshold of approximately 10 mL O ₂ /kg/min as the optimal discrimination point.

Stress testing

Cardiac stress testing is a well-validated, non-invasive modality that has been shown to accurately predict patients at risk of cardiac complications following noncardiac surgery. Preoperative, non-invasive stress testing has been recommended in the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation for patients with poor or unknown functional status (see Fig. 4.1 ). Exercise-induced hypotension is a sign of possible ventricular impairment secondary to coronary artery disease and warrants further investigation with a coronary angiogram or myocardial perfusion imaging. Cardiac stress echocardiography and radioisotope investigation (to measure cardiac perfusion) are also used to provide a more detailed cardiac assessment. The identification of reduced left ventricular ejection fraction by the latter modalities has been significantly associated with the development of cardiac complications following major surgery.

Optimisation

Preoperative physical cardiopulmonary rehabilitation

Preoperative cardiopulmonary fitness has been shown to be well correlated with postoperative outcome following major surgery. The use of intensive preoperative exercise has been shown to improve cardiopulmonary fitness prior to major surgery. Although intensive preoperative exercise improves cardiopulmonary fitness, this short-term improvement has not been conclusively shown to correlate with postoperative outcome following major surgery and cancer resection.

Beta-blockade

The hypothesis is that adrenergic beta-blockade slows the heart rate and as a result improves ischaemic ventricular dysfunction. Patients on long-term beta-blockade exhibit adrenergic hypersensitivity if the therapy is withdrawn, and therefore beta-blockade should always be continued and the intravenous route should be utilised until oral intake can be resumed in this patient population. A systematic review for the 2014 ACC/AHA guidelines on perioperative cardiovascular evaluation included a meta-analysis on different randomised controlled trials (RCTs) assessing the outcome after preoperative new-onset beta-blocker therapy in patients at risk, where beta-blocker therapy was initiated within 2 days prior to surgery. The main conclusion was that the pooled outcome of these RCTs is conflicting, basically showing that besides a decrease in risk for a myocardial infarction, risk of stroke, death, hypotension, and bradycardia was increased with the treatment. Therefore, no recommendation can be made concerning beta-blocker therapy. Early initiation and titration of beta-blockers prior to surgery might be considered in selected patients; however, no beta-blocker therapy should be initiated on the day of surgery.

The 2014 ACC/AHA focused update on perioperative beta-blockade for non-cardiac surgery states that perioperative beta-blockade started within 1 day or less before non-cardiac surgery prevents nonfatal myocardial infarction but increases the risk of stroke, death, hypotension, and bradycardia. So far, there are insufficient data to recommend beta-blockade started 2 or more days prior to surgery without any reservations.

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