[Perioperative management of transthoracic oesophagectomies : Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery]

[Video-assisted Double-lumen Tubes in Robot-assisted Oesophageal Surgery]

Robot-assisted esophagectomies are still considered high-risk procedures requiring complex surgical and anesthesiological planning and coordination. The operative space during the thoracic operative part is created by one-lung ventilation. Due to special patient positioning and intraoperative repositioning maneuvers, however, access to patient airway or double-lumen tube manipulation, if necessary, is only possible to a certain extent. In this work, we present our experiences establishing a video-guided double-lumen tube for esophageal surgery. From our point of view, the use of video-guided double-lumen tubes is very suitable increasing patient safety and coordination in the operational team during esophagectomy.

[Fast-track Rehabilitation after Oesophagectomy]

The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.

[Perioperative enhanced recovery after surgery program for Ivor Lewis esophagectomy : First experiences of a high-volume center]

BACKGROUND AND OBJECTIVE

Transthoracic esophagectomy is generally accepted as the standard of surgical care for patients with esophageal cancer. Despite improvements in the perioperative management this surgical procedure is associated with a clinically relevant morbidity. Fast-track protocols (synonym: enhanced recovery after surgery, ERAS) are conceived to perioperatively maintain the physiological homoeostasis and thereby to accelerate postoperative rehabilitation and reduce morbidity. In this prospective observational study the initial experiences of a high-volume center with the implementation of an ERAS protocol after transthoracic esophagectomy were analyzed.

MATERIAL AND METHODS

A total of 26 patients with esophageal cancer and a low index of comorbidities prior to hybrid Ivor Lewis esophagectomy were included in this study. According to an ERAS protocol all patients underwent a standardized perioperative treatment pathway aiming to discharge the patients from the inpatient treatment on postoperative day 10. The primary outcome parameter was the rate of major complications (Clavien-Dindo IIIb/IV), which was compared to a cohort of 52 non-ERAS patients.

RESULTS AND CONCLUSION

The ERAS programs with the various core elements can be implemented in patients scheduled for transthoracic esophagectomy, although the organizational and personnel expenditure of this fast-track protocol is high. The length of hospital stay appears to be reduced without compromising patient safety. The limiting variable of the ERAS protocol remains the early and adequate enteral feeding load of the gastric conduit before discharge on postoperative day 10.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

Acupuncture reduces the time from extubation to 'ready for discharge' from the post anaesthesia care unit: results from the randomised controlled AcuARP trial

Acupuncture may improve peri-operative care as it reduces post-operative symptoms, such as pain, nausea and vomiting, or sedation. This patient-assessor blinded, randomised trial in 75 women undergoing gynaecologic laparoscopy evaluated the effects of acupuncture combined with a standardised anaesthetic regimen (ACU) on post-anaesthetic recovery, when compared to acupressure (APU) or standard anaesthesia alone (CON). Main outcome measure was the time from extubation to ‘ready for discharge’ from recovery as assessed by validated questionnaires. The main outcome differed significantly between groups (p = 0.013). Median time to ready for discharge in the ACU group (30 (IQR: 24–41) min) was 16 minutes (35%) shorter than in the CON group (46 (36–64) min; p = 0.015) and tended to be shorter than in the APU group (43 (31–58) min; p = 0.08). Compared to CON (p = 0.029), median time to extubation was approximately 7 minutes shorter in both, the ACU and the APU group. No acupuncture or acupressure-related side-effects could be observed. A difference in time to recovery of 16 minutes compared to standard alone can be considered clinically relevant. Thus, results of this study encourage the application of acupuncture in gynaecological laparoscopy as it improves post-anaesthetic recovery.

Recent advancements in esophageal cancer treatment in Japan

The 11th edition of the Japanese Classification of Esophageal Cancer (EC) was published in 2017. Some correction was made in the depth of tumor invasion to be consistent with the TNM classification by the Union for International Cancer Control (UICC). With regard to surgery, short-term safety and long-term effectiveness under thoracotomy/video-assisted thoracoscopic surgery are expected to be proven by the Japan Clinical Oncology Group (JCOG)1409 study. Results of nutritional management and countermeasures for adverse events not only during the perioperative period but also during EC chemotherapy were reported. From now on, the pursuit of low invasiveness and radicality is desired. Esophageal surgery is also expected to be safe at all institutions. To determine the optimal modality of preoperative treatment and a novel chemo(radio)therapy regimen for patients with distant metastasis, the results of the ongoing JCOG1109 and 0807 studies are being released. The effect of the addition of molecular targeted drugs on chemotherapy and concurrent chemoradiation has not yet improved overall survival. Immune checkpoint inhibitor drugs could offer a potential new treatment approach for patients with treatment-refractory advanced squamous cell carcinoma (SCC). The Cancer Genome Atlas Research Network reported the results of a comprehensive genome analysis and molecular analysis of SCC and adenocarcinoma of the esophagus. Further differentiation of SCC and adenocarcinoma by molecular characterization analysis may be useful for the development of clinical trials and targeted drug therapies as precision medicine. The era of ultimate minimally invasive surgery and personalized treatment has begun. Large, prospective studies will be required to confirm the value of these advancements.

[Cancer patients in operative intensive care medicine]

Die Prävalenz onkologischer Erkrankungen ist in den vergangenen Jahrzehnten stetig angestiegen. Durch neue Therapieoptionen können immer mehr Patienten mit einem kurativen Therapieansatz behandelt werden. Diese individualisierten und teilweise sehr aggressiven Therapien können jedoch auch zu schweren Nebenwirkungen führen. Diese sollten als wichtige Differenzialdiagnosen zu anderen vitalbedrohlichen Krankheitsbildern auch dem im OP und als Intensivmediziner tätigen Anästhesisten bekannt sein. Krebspatienten werden häufig auf operativen Intensivstationen aufgenommen, um Komplikationen der malignen Grunderkrankung oder auch Nebenwirkungen einer operativen oder konservativen Therapie zu behandeln. Aktuelle Untersuchungen zeigen, dass die maligne Grunderkrankung entgegen bisheriger Annahme keinen wesentlichen Einfluss auf das Intensivüberleben hat. Bei der Aufnahme eines onkologischen Patienten sollte daher die akut vorliegende Organdysfunktion zunächst im Vordergrund stehen. Bei der Therapiezielplanung gilt es, nicht zu übersehen, wann ein kuratives in ein palliatives Konzept übergehen muss. Hierfür müssen neue Aufnahmestrategien und -kriterien entwickelt und evaluiert werden. In diesem Übersichtsartikel werden Diagnosen und Therapien häufiger intensivmedizinischer Krankheitsbilder von onkologischen Patienten sowie Nebenwirkungen moderner onkologischer Therapien dargelegt und Aufnahmestrategien für Patienten mit malignen Erkrankungen vorgestellt.

[Perioperative management of transthoracic oesophagectomies : Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery]

Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. This thoraco-abdominal operation is associated with significant postoperative morbidity, not least because of a vast array of pre-existing illnesses in the surgical patient. For an optimal outcome, the careful interdisciplinary selection of patients, preoperative risk evaluation and conditioning are essential. The caseload of the centres correlates inversely with the complication rate. The leading surgical complication is anastomotic leakage, which is diagnosed endoscopically and usually treated with the aid of endoscopic procedures. Pulmonary infections are the most frequent non-surgical complication. Thoracic epidural anaesthesia and perfusion-orientated fluid management can reduce the rate of pulmonary complications. Patients are ventilated protecting the lungs and are extubated as early as possible. Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient's quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.