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Anesthetic Management for Thoracoscopic Oesophagectomy

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					Anesthetic Management for Thoracoscopic Oesophagectomy
Dr. M. KRISHNAN,
Senior Consultant & HOD Dept Of Anaesthesia And Pain Clinic Meenakshi Mission Hospital & Research Centre, Madurai.

Meenakshi Mission Hospital & Research Centre, Madurai, India.

Aim:
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Conventional transhiatal oesophageal mobilization leads to more post operative lung complications and resulting in more mortality. So this study carried out to assess whether the Thoracoscopic approach could reduce the post operative pulmonary complications. And will increase safety margin of anesthesia and shorten the period hospital stay.

Materials: Methods:
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Materials 9 patient given anesthesia for

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Oesoophagectomy through right thoracoscopic approach
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in one year. Six males and 3 females, between 28 to 65 years weighing between 33 to 58 kg.

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Methods: All had thoroughly evaluated pre operatively with special reference to their nutritional fluid and electrolyte status and cardio respiratory status. - Optimized to maximum satisfaction - Assessed as II- III ASAand informed consent obtained.

Anaesthetic management:
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Premedicated with midazolam + atropine. T8-T9 epidural space was identified, cannula was inserted and 5ml of 2% xylocaine with adrenaline and 4mg morphine given. After Confirmation epidural effect, GA started with induction dose of propofol 1.5mg/kg and muscle relaxant Vecuronium .1mg kg, intubated with DLT (left) position confirmed, safely secured and patient in prone position again position of DLT checked and anaesthesia maintained with N20+ O2 + propofol 100ug/kg/min + Fentanyl 1ug/kg, Vecuronium, OLV started just before the start of endoscopic mobilization.

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Vital parameters vigilantly monitored by ECG, IABP, NIBP, SPO2, EtCO2, CVP, ABG, urinary output. For the Laparoscopic dissection of stomach patient turned back to supine position and anaesthesia maintained after replacing single lumen tube. At end all patient except two reversed and in kept in HDU, ET-tube extubated next day, except two case who were on EPV.

Results:
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Average duration of OLV -90 min 2 had perioperative hypoxia – rectified in time 2 needed Blood transfusion 2 needed PEV-one weaned – one detoriated All others had smooth post operative recovery and discharged with in 10 days.

Discussion:
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Expected complication due to prone position, was safely managed with proper supporting chest and pelvis ensuring free movement of abdomen and safe securing of air way. Expected complications due to OLV. Hypoxia/ Hypoxemia well managed by :carefully checking the position of DLT Prevention of obligatory right to left transpulmonary shunt. maintaining normal FRC maintaining un inhibited HPV

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By: Optimal IPPv-giving importance to FIO2 RR ( Pao2 40mg hg), I:E, Tidal volume (8 -10ml kg), airway resistance Maintaining OLV till the last moment of starting procedure Periodical suction of ventilated lung Ensuring full expansion of lung at the end of the procedure Maintaining normal Co ICD Hypoxia in one case could not improved due to tracheal tear. All except one recovered satisfactorily and had smooth post operative period and discharged with in 10 days

Conclusion:
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Thoracoscopic oesophagectomy relatively safe and Beneficial to the patients with reduced post operative pulmonary complication due to Minimal skin incision Minimal depth of incision and tissue injury less blood loss Little disturbance to normal mechanism of respiration. Less Pain that too relieved by good pain management Patient able to cough out and bring all secretion-do spirometry Faster recovery and shorter the hospital stay. Reducing mortality and morbidity

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Ref.: weylie –Page No 1148 thoracic anaesthesia 6th Edition. Millar – Page No 1847 thoracic anaesthesia 6TH Edition. Conference proceeding 47th anaes conf. ISA endoscopic procedures Page No 342-349. 2000 – NAJ of Anaesthesia –ONL Oxford textbook of surgery year 1994-2000 Page No 897-1291 Transmittal oesophagectomy -nonrandomized have failed to demonstrate less morbidity/mortality or hospital stay.


				
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