Current trends in anesthesia for esophagectomy

Effect of Volatile Anesthesia Versus Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Minimally Invasive Esophagectomy: A Randomized Clinical Trial

BACKGROUND

The effect of intraoperative anesthetic regimen on pulmonary outcome after minimally invasive esophagectomy for esophageal cancer is yet undetermined. The aim of this study was to determine the effect of volatile anesthesia (sevoflurane or desflurane) compared with propofol-based intravenous anesthesia on pulmonary complications after minimally invasive esophagectomy.

METHODS

Patients scheduled for minimally invasive esophagectomy were randomly assigned to 1 of 3 general anesthetic regimens (sevoflurane, desflurane, or propofol). The primary outcome was the incidence of pulmonary complications within the 7 days postoperatively, which was a collapsed composite end point, including respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm, pulmonary embolism, and aspiration pneumonitis. The severity of pulmonary complications, surgery-related complications, and other secondary outcomes were also assessed.

RESULTS

Of 647 patients assessed for eligibility, 558 were randomized, and 553 were analyzed. A total of 185 patients were assigned to the sevoflurane group, 185 in the desflurane, and 183 in the propofol group. Patients receiving a volatile anesthetic (sevoflurane or desflurane) had a significantly lower incidence (36.5% vs 47.5%; odds ratio, 0.63; 95% confidence interval, 0.44-0.91; P = .013) and lower severity grade of pulmonary complications ( P = .035) compared to the patients receiving propofol. There were no statistically significant differences in other secondary outcomes between the 2 groups.

CONCLUSIONS

In patients undergoing minimally invasive esophagectomy, the use of volatile anesthesia (sevoflurane or desflurane) resulted in the reduced risk and severity of pulmonary complications within the first 7 postoperative days as compared to propofol-based intravenous anesthesia.

Impact of fluid balance and opioid-sparing anesthesia within enchanced recovery pathway on postoperative morbidity after transthoracic esophagectomy for cancer

Background

Enhanced Recovery After Surgery (ERAS) protocol for esophagectomy may reduce the high incidence of postoperative morbidity and mortality. The aim of this study was to assess the impact of properly conducted ERAS protocol with specific emphasis on fluid balance and opioid-sparing anesthesia (OSA) on postoperative major morbidity and mortality after esophagectomy.

Methods

Patients undergoing elective esophagectomy for esophageal cancer at the Hospital for Digestive Surgery, University Clinical Center of Serbia, from December 2017 to March 2021, were included in this retrospective observational study. Patients were divided into two groups: the ERAS group (OSA, intraoperative goal-directed therapy, and postoperative “near-zero” fluid balance) and the control group (opioid-based anesthesia, maintenance mean blood pressure ≥ 65 mmHg, and liberal postoperative fluid management). The primary outcome was major morbidity within 30 days from surgery and 30-day and 90-day mortality. Multivariable analysis was used to examine the effect of the ERAS protocol.

Results

A total of 121 patients were divided into the ERAS group (69 patients) and the control group (52 patients). Patients in the ERAS group was received less fentanyl, median 300 (interquartile range (IQR), 200–1,550) mcg than in control group, median 1,100 (IQR, 650–1750) mcg, p < 0.001. Median intraoperative total infusion was lower in the ERAS group, 2000 (IQR, 1000–3,750) mL compared to control group, 3,500 (IQR, 2000–5,500) mL, p < 0.001. However, intraoperative norepinephrine infusion was more administered in the ERAS group (52.2% vs. 7.7%, p < 0.001). On postoperative day 1, median cumulative fluid balance was 2,215 (IQR, −150-5880) mL in the ERAS group vs. 4692.5 (IQR, 1770–10,060) mL in the control group, p = 0.002. After the implementation of the ERAS protocol, major morbidity was less frequent in the ERAS group than in the control group (18.8% vs. 75%, p < 0.001). There was no statistical significant difference in 30-day and 90-day mortality (p = 0.07 and p = 0.119, respectively). The probability of postoperative major morbidity and interstitial pulmonary edema were higher in control group (OR 5.637; CI95%:1.178–10.98; p = 0.030 and OR 5.955; CI95% 1.702–9.084; p < 0.001, respectively).

Conclusion

A major morbidity and interstitial pulmonary edema after esophagectomy were decreased after the implementation of the ERAS protocol, without impact on overall mortality.

Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials

Optimal pain control following esophagectomy remains a topic of contention. The aim was to perform a systematic review and network meta-analysis (NMA) of randomized clinical trials (RCTs) evaluating the analgesia strategies post-esophagectomy. A NMA was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-NMA guidelines. Statistical analysis was performed using Shiny and R. Fourteen RCTs which included 565 patients and assessed nine analgesia techniques were included. Relative to systemic opioids, thoracic epidural analgesia (TEA) significantly reduced static pain scores at 24 hours post-operatively (mean difference (MD): -13.73, 95% Confidence Interval (CI): -27.01-0.45) (n = 424, 12 RCTs). Intrapleural analgesia (IPA) demonstrated the best efficacy for static (MD: -36.2, 95% CI: -61.44-10.96) (n = 569, 15 RCTs) and dynamic (MD: -42.90, 95% CI: -68.42-17.38) (n = 444, 11 RCTs) pain scores at 48 hours. TEA also significantly reduced static (MD: -13.05, 95% CI: -22.74-3.36) and dynamic (MD: -18.08, 95% CI: -31.70-4.40) pain scores at 48 hours post-operatively, as well as reducing opioid consumption at 24 hours (MD: -33.20, 95% CI: -60.57-5.83) and 48 hours (MD: -42.66, 95% CI: -59.45-25.88). Moreover, TEA significantly shortened intensive care unit (ICU) stays (MD: -5.00, 95% CI: -6.82-3.18) and time to extubation (MD: -4.40, 95% CI: -5.91-2.89) while increased post-operative forced vital capacity (MD: 9.89, 95% CI: 0.91-18.87) and forced expiratory volume (MD: 13.87, 95% CI: 0.87-26.87). TEA provides optimal pain control and improved post-operative respiratory function in patients post-esophagectomy, reducing ICU stays, one of the benchmarks of improved post-operative recovery. IPA demonstrates promising results for potential implementation in the future following esophagectomy.

National clinical and financial outcomes associated with acute kidney injury following esophagectomy for cancer

BACKGROUND

Esophagectomy is a complex oncologic operation associated with high rates of postoperative complications. While respiratory and septic complications have been well-defined, the implications of acute kidney injury (AKI) remain unclear. Using a nationally representative database, we aimed to characterize the association of AKI with mortality, resource use, and 30-day readmission.

METHODS

All adults undergoing elective esophagectomy with a diagnosis of esophageal or gastric cancer were identified in the 2010-2019 Nationwide Readmissions Database. Study cohorts were stratified based on presence of AKI. Multivariable regressions and Royston-Parmar survival analysis were used to evaluate the independent association between AKI and outcomes of interest.

RESULTS

Of an estimated 40,438 patients, 3,210 (7.9%) developed AKI. Over the 10-year study period, the incidence of AKI increased from 6.4% to 9.7%. Prior radiation/chemotherapy and minimally invasive operations were associated with reduced odds of AKI, whereas public insurance coverage and concurrent infectious and respiratory complications had greater risk of AKI. After risk adjustment, AKI remained independently associated with greater odds of in-hospital mortality (AOR: 4.59, 95% CI: 3.62-5.83) and had significantly increased attributable costs ($112,000 vs $54,000) and length of stay (25.7 vs 13.3 days) compared to patients without AKI. Furthermore, AKI demonstrated significantly increased hazard of 30-day readmission (hazard ratio: 1.16, 95% CI: 1.01-1.32).

CONCLUSIONS

AKI after esophagectomy is associated with greater risk of mortality, hospitalization costs, and 30-day readmission. Given the significant adverse consequences of AKI, careful perioperative management to mitigate this complication may improve quality of esophageal surgical care at the national level.

Variation in Anesthesiology Provider-Volume for Complex Gastrointestinal Cancer Surgery: A Population-Based Study

OBJECTIVE

Examine between-hospital and between-anesthesiologist variation in anesthesiology provider-volume (PV) and delivery of high-volume anesthesiology care.

BACKGROUND

Better outcomes for anesthesiologists with higher PV of complex gastrointestinal cancer surgery have been reported. The factors linking anesthesiology practice and organization to volume are unknown.

METHODS

We identified patients undergoing elective esophagectomy, hepatectomy, and pancreatectomy using linked administrative health data sets (2007-2018). Anesthesiology PV was the annual number of procedures done by the primary anesthesiologist in the 2 years before the index surgery. High-volume anesthesiology was PV>6 procedures/year. Funnel plots to described variation in anesthesiology PV and delivery of high-volume care. Hierarchical regression models examined between-anesthesiologist and between-hospital variation in delivery of high-volume care use with variance partition coefficients (VPCs) and median odds ratios (MORs).

RESULTS

Among 7893 patients cared for at 17 hospitals, funnel plots showed variation in anesthesiology PV (median ranging from 1.5, interquartile range: 1-2 to 11.5, interquartile range: 8-16) and delivery of HV care (ranging from 0% to 87%) across hospitals. After adjustment, 32% (VPC 0.32) and 16% (VPC: 0.16) of the variation were attributable to between-anesthesiologist and between-hospital differences, respectively. This translated to an anesthesiologist MOR of 4.81 (95% CI, 3.27-10.3) and hospital MOR of 3.04 (95% CI, 2.14-7.77).

CONCLUSIONS

Substantial variation in anesthesiology PV and delivery of high-volume anesthesiology care existed across hospitals. The anesthesiologist and the hospital were key determinants of the variation in high-volume anesthesiology care delivery. This suggests that targeting anesthesiology structures of care could reduce variation and improve delivery of high-volume anesthesiology care.

The Association Between Hospital High-volume Anesthesiology Care and Patient Outcomes for Complex Gastrointestinal Cancer Surgery: A Population-based Study

OBJECTIVE

To examine the association of between hospital rates of high-volume anesthesiology care and of postoperative major morbidity.

BACKGROUND

Individual anesthesiology volume has been associated with individual patient outcomes for complex gastrointestinal cancer surgery. However, whether hospital-level anesthesiology care, where changes can be made, influences the outcomes of patients cared at this hospital is unknown.

METHODS

We conducted a population-based retrospective cohort study of adults undergoing esophagectomy, pancreatectomy, or hepatectomy for cancer from 2007 to 2018. The exposure was hospital-level adjusted rate of high-volume anesthesiology care. The outcome was hospital-level adjusted rate of 90-day major morbidity (Clavien-Dindo grade 3-5). Scatterplots visualized the relationship between each hospital's adjusted rates of high-volume anesthesiology and major morbidity. Analyses at the hospital-year level examined the association with multivariable Poisson regression.

RESULTS

For 7893 patients at 17 hospitals, the rates of high-volume anesthesiology varied from 0% to 87.6%, and of major morbidity from 38.2% to 45.4%. The scatter plot revealed a weak inverse relationship between hospital rates of high-volume anesthesiology and of major morbidity (Pearson: -0.23). The adjusted hospital rate of high-volume anesthesiology was independently associated with the adjusted hospital rate of major morbidity (rate ratio: 0.96; 95% CI, 0.95-0.98; P <0.001 for each 10% increase in the high-volume rate).

CONCLUSIONS

Hospitals that provided high-volume anesthesiology care to a higher proportion of patients were associated with lower rates of 90-day major morbidity. For each additional 10% patients receiving care by a high-volume anesthesiologist at a given hospital, there was an associated reduction of 4% in that hospital's rate of major morbidity.

Role of intraoperative processes of care during major upper gastrointestinal oncological resection in postoperative outcomes: a scoping review protocol

INTRODUCTION

Optimal delivery and organisation of care is critical for surgical outcomes and healthcare systems efficiency. Anaesthesia volumes have been recently associated with improved postoperative recovery outcomes; however, the mechanism is unclear. Understanding the individual processes of care (interventions received by the patient) is important to design effective systems that leverage the volume-outcome association to improve patient care. The primary objective of this scoping review is to systematically map the evidence regarding intraoperative processes of care for upper gastrointestinal cancer surgery. We aim to synthesise the quantity, type, and scope of studies on intraoperative processes of care in adults who undergo major upper gastrointestinal cancer surgeries (oesophagectomy, hepatectomy, pancreaticoduodenectomy, and gastrectomy) to better understand the volume-outcome relationship for anaesthesiology care.

METHODS AND ANALYSIS

This scoping review will follow the Arksey and O'Malley framework and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension framework for scoping reviews. We will systematically search MEDLINE, Embase and Cochrane databases for original research articles published after 2010 examining postoperative outcomes in adult patients undergoing either: oesophagectomy, hepatectomy, pancreaticoduodenectomy, or gastrectomy, which report at least one intraoperative processes of care (intervention or framework) applied by anaesthesia or surgery. The data from included studies will be extracted, charted, and summarised both quantitatively and qualitatively through descriptive statistics and narrative synthesis.

ETHICS AND DISSEMINATION

No ethics approval is required for this scoping review. Results will be disseminated through publication targeted at relevant stakeholders in anaesthesiology and cancer surgery.

TRIAL REGISTRATION NUMBER

10.17605/OSF.IO/392UG; https://archive.org/details/osf-registrations-392ug-v1.

Association Between Familiarity of the Surgeon-Anesthesiologist Dyad and Postoperative Patient Outcomes for Complex Gastrointestinal Cancer Surgery

Importance

The surgeon-anesthesiologist teamwork and relationship is crucial to good patient outcomes. Familiarity among work team members is associated with enhanced success in multiple fields but rarely studied in the operating room.

Objective

To examine the association between surgeon-anesthesiologist dyad familiarity-as the number of times working together-with short-term postoperative outcomes for complex gastrointestinal cancer surgery.

Design, Setting, and Participants

This population-based retrospective cohort study based in Ontario, Canada, included adults undergoing esophagectomy, pancreatectomy, and hepatectomy for cancer from 2007 through 2018. The data were analyzed January 1, 2007, through December 21, 2018.

Exposures

Dyad familiarity captured as the annual volume of procedures of interest done by the surgeon-anesthesiologist dyad in the 4 years before the index surgery.

Main Outcomes and Measures

Ninety-day major morbidity (any Clavien-Dindo grade 3 to 5). The association between exposure and outcome was examined using multivariable logistic regression.

Results

Seven thousand eight hundred ninety-three patients with a median age of 65 years (66.3% men) were included. They were cared for by 737 anesthesiologists and 163 surgeons who were also included. The median surgeon-anesthesiologist dyad volume was 1 (range, 0-12.2) procedures per year. Ninety-day major morbidity occurred in 43.0% of patients. There was a linear association between dyad volume and 90-day major morbidity. After adjustment, the annual dyad volume was independently associated with lower odds of 90-day major morbidity, with an odds ratio of 0.95 (95% CI, 0.92-0.98; P = .01) for each incremental procedure per year, per dyad. The results did not change when examining 30-day major morbidity.

Conclusions and Relevance

Among adults undergoing complex gastrointestinal cancer surgery, increasing familiarity of the surgeon-anesthesiologist dyad was associated with improved short-term patient outcomes. For each additional time that a unique surgeon-anesthesiologist dyad worked together, the odds of 90-day major morbidity decreased by 5%. These findings support organizing perioperative care to increase the familiarity of surgeon-anesthesiologist dyads.

[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.

Pain management after robot-assisted minimally invasive esophagectomy

Background

Adequate pain control after open esophagectomy is associated with reduced complications, earlier recovery and higher patient satisfaction. While further developing surgical procedures like robot-assisted minimally invasive esophagectomy (RAMIE) it is relevant to adapt postoperative pain management. The primary question of this observational survey was whether one of the two standard treatments, thoracic epidural analgesia (TEA) or intravenous patient-controlled analgesia (PCA), is superior for pain control after RAMIE as the optimal pain management for these patients still remains unclear. Use of additional analgesics, changes in forced expiratory volume in 1 s (FEV1), postoperative complications and duration of intensive care and hospital stay were also analyzed.

Methods

This prospective observational pilot study analyzed 50 patients undergoing RAMIE (postoperative PCA with piritramide or TEA using bupivacaine; each n = 25). Patient reported pain using the numeric rating scale score and differences in FEV1 using a micro spirometer were measured at postoperative day 1, 3 and 7. Additional data of secondary endpoints were collected from patient charts.

Results

Key demographics, comorbidity, clinical and operative variables were equivalently distributed. Patients receiving TEA had lower pain scores and a longer-lasting pain relief. Moreover, TEA was an independent predictive variable for reduced length of hospital stay (HR -3.560 (95% CI: -6.838 to -0.282), p = 0.034).

Conclusions

Although RAMIE leads to reduced surgical trauma, a less invasive pain therapy with PCA appears to be inferior compared to TEA in case of sufficient postoperative analgesia and length of hospital stay. According to the results of this observational pilot study analgesia with TEA provided better and longer-lasting pain relief compared to PCA. Further randomized controlled trials should be conducted to evaluate the optimal postoperative analgesic treatment for RAMIE.

Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage

Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.

Two-lung ventilation in video-assisted thoracoscopic esophagectomy in prone position: A systematic review

Esophageal cancer surgery is still carrying a high risk of morbidity and mortality. That is why some anesthesia strategies have tried to reduce those postoperative complications. In this systematic review performed in accordance with the PRISMA-S guidelines (PROSPERO (ID: CRD42022310385)), we aimed to investigate the safety and advantages of two-lung ventilation (TLV) over one-lung ventilation (OLV) in minimally invasive esophagectomy (MIE) in the prone position. Seven trials, with a total number of 1710 patients (765 patients with TLV versus 945 patients with OLV) were included. Postoperative mortality and morbidity rates were similar between TLV and OLV when realised for esophagectomy. Interestingly, we observed no difference in changes in intraoperative respiratory parameters, operative duration, thoraco-conversion rate, number of harvested lymph nodes, postoperative heart rate and respiratory rate between TLV and OLV. TLV brings better results in terms of intraoperative oxygen arterial pressure (PaO₂) during the thoracic time, postoperative oxygenation, PaO2 on inspired fraction of oxygen (FiO₂) ratio, duration of thoracic surgery, preoperative time, blood loss, temperature on postoperative day-1, and C-reactive protein dosage. Our study highlighted the safety of TLV for MIE in prone position when compared to OLV. Interestingly, we found better intra and postoperative ventilation parameters. The choice of ventilation modality did not influence clinical outcome after surgery and the quality of oncological resection. Large randomised controlled trials are needed to confirm these results.

Should fluid management in thoracic surgery be goal directed?

PURPOSE OF REVIEW

To find a reliable answer to the question in the title: Should fluid management in thoracic surgery be goal directed?

RECENT FINDINGS

'Moderate' fluid regimen is the current recommendation of fluid management in thoracic anesthesia, however, especially in more risky patients; 'Goal-Directed Therapy' (GDT) can be a more reliable approach than just 'moderate'. There are numerous studies examining its effects in general anesthesia; albeit mostly retrospective and very heterogenic. There are few studies of GDT in thoracic anesthesia with similar drawbacks.

SUMMARY

Although the evidence level is low, GDT is generally associated with fewer postoperative complications. It can be helpful in decision-making for volume-optimization, timing of fluid administration, and indication of vasoactive agents.

Impact of anesthetics on oncogenic signaling network: a review on propofol and isoflurane

Propofol as an intravenous anesthetic and isoflurane as an inhalational/volatile anesthetic continue to be an important part of surgical anesthetic interventions worldwide. The impact of these anesthetics on tumor progression, immune modulation, and survival rates of cancer patients has been widely investigated. Although most of the preclinical studies have provided a beneficial effect of propofol over isoflurane or other volatile anesthetics, several investigations have shown contradictory results, which warrant more preclinical and clinical studies. Propofol mostly exhibits antitumor properties, whereas isoflurane being a cost-effective anesthetic is frequently used. However, isoflurane has been also reported with protumorigenic activity. This review provides an overall perspective on the network of signaling pathways that may modulate several steps of tumor progression from inflammation, immunomodulation, epithelial-mesenchymal transition (EMT) to invasion, metastasis, angiogenesis, and cancer stemness and extracellular vesicles along with chemotherapeutic applications and clinical status of these anesthetics. A clear understanding of the mechanistic viewpoints of these anesthetics may pave the way for more prospective clinical trials with the ultimate goal of obtaining a safe and optimal anesthetic intervention that would prevent cancer recurrence and may influence better postoperative survival.

Association Between Anesthesiologist Volume and Short-term Outcomes in Complex Gastrointestinal Cancer Surgery

Importance

Intraoperative anesthesiology care is crucial to high-quality surgical care. The clinical expertise and experience of anesthesiologists may decrease the risk of adverse outcomes.

Objective

To examine the association between anesthesiologist volume and short-term postoperative outcomes for complex gastrointestinal (GI) cancer surgery.

Design, Setting, and Participants

This population-based cohort study used administrative health care data sets from various data sources in Ontario, Canada. Adult patients who underwent esophagectomy, pancreatectomy, or hepatectomy for GI cancer from January 1, 2007, to December 31, 2018, were eligible. Patients with an invalid identification number, a duplicate surgery record, and missing primary anesthesiologist information were excluded.

Exposures

Primary anesthesiologist volume was defined as the annual number of procedures of interest (esophagectomy, pancreatectomy, and hepatectomy) supported by that anesthesiologist in the 2 years before the index surgery. Volume was dichotomized into low-volume and high-volume categories, with 75th percentile or 6 or more procedures per year selected as the cutoff point.

Main Outcome and Measures

The primary outcome was a composite of 90-day major morbidity (with a Clavien-Dindo classification grade 3-5) and readmission. Secondary outcomes were individual components of the primary outcome. The association between exposure and outcomes was examined using multivariable logistic regression models, accounting for potential confounders.

Results

Of the 8096 patients included, 5369 were men (66.3%) and the median (interquartile range [IQR]) age was 65 (57-72) years. Operations were supported by 842 anesthesiologists and performed by 186 surgeons, and the median (IQR) anesthesiologist volume was 3 (1.5-6) procedures per year. A total of 2166 patients (26.7%) received care from high-volume anesthesiologists. Primary outcome occurred in 36.3% of patients in the high-volume group and 45.7% of patients in the low-volume group. After adjustment, care by high-volume anesthesiologists was independently associated with lower odds of the primary outcome (adjusted odds ratio [aOR], 0.85; 95% CI, 0.76-0.94), major morbidity (aOR, 0.83; 95% CI, 0.75-0.91), unplanned intensive care unit admission (aOR, 0.84; 95% CI, 0.76-0.94), but not readmission (aOR, 0.87; 95% CI, 0.73-1.05) or mortality (aOR, 1.05; 95% CI, 0.84-1.31). E-values analysis indicated that an unmeasured variable would unlikely substantively change the observed risk estimates.

Conclusions and Relevance

This study found that, among adults who underwent complex gastrointestinal cancer surgery, those who received care from high-volume anesthesiologists had a lower risk of adverse postoperative outcomes compared with those who received care from low-volume anesthesiologists. These findings support organizing perioperative care to increase anesthesiologist volume to optimize patient outcomes.

Effects of therapy modifications during the last decade on the outcome of patients undergoing esophagectomy for esophageal cancer

BACKGROUND

During the last decade, numerous therapeutic regimes were assessed to improve the outcome of patients with esophageal carcinoma. We analyzed the impact of therapy alterations, including the establishment of a standardized clinical pathway and the introduction of an interdisciplinary tumor conference on the outcome of patients undergoing esophagectomy because of esophageal cancer.

METHODS

Three hundred one patients were included (204 adenocarcinoma and 97 squamous cell carcinoma) who underwent an esophagectomy between 2006 and 2015. Patients were divided into 3 groups: interval A (2006-2008), interval B (2009-2011) and interval C (2012-2015) and evaluated separately focusing on therapy management and patients' outcome.

RESULTS

Over the time periods, the incidence of tumor entity of adenocarcinoma increased from 61% to 76.2% (P=0.059). Patients with an initial tumor stage uT1 increased significantly from 4% to 15.9% over the intervals (P=0.002), while positive nodal involvement remained comparable (P=0.237). Patients in the later interval suffered from greater physical impairments preoperatively, represented by a significantly increased American Society Anesthesiologists (ASA) score (P=0.023) and a reduced Karnofsky Index (P<0.001). The tumor conference was accompanied by an increasing implementation of neoadjuvant therapy (27.1% vs. 42.2%, P=0.097). After establishing the clinical pathway 30-day mortality decreased (P=0.67). Grad III anastomotic leakage decreased significantly from 6.5% to 2% (P=0.01). However, gastrointestinal (P=0.007), pulmonary complications (P<0.001) including pneumonia (P<0.001) increased. Over the past ten years both overall survival and relapse-free survival prolonged (P=0.056 and P=0.063, respectively).

CONCLUSIONS

Patients' collective suffering from esophageal cancer has changed over the last decade. Continuous further developments of the therapy regimes are needed to meet the requirements of reducing perioperative mortality and extending survival time.

[Surgical treatment of esophageal cancer-Indicators for quality in diagnostics and treatment]

BACKGROUND

Within the framework of the quality initiative of the German Society for General and Visceral Surgery (DGAV) a review article was compiled based on a systematic literature search. Recommendations for the current diagnostics and treatment of esophageal cancer were also elaborated.

METHODS

The systematic literature search was carried out in March 2019 according to the PRISMA criteria using the MEDLINE databank. The recommendations were formulated based on a consensus in the DGAV.

RESULTS AND CONCLUSION

Operations below the currently valid minimum quantity threshold should no longer be carried out. There are many indications that the minimum quantity in Germany should be raised to ≥20 resections/year/hospital in order to comprehensively improve the quality. Prehabilitation programs with endurance, strength and intensive breathing training as well as nutritional therapy improve patient outcome. The current treatment of esophageal cancer is stage-dependent and incorporates endoscopic resection of (sub)mucosal low-risk tumors (T1m1-3 or T1sm1 low risk), primary esophagectomy of submucosal high-risk tumors (T1a), submucosal cancer (T1sm2-3) and T2N0 tumors, multimodal treatment with neoadjuvant chemoradiotherapy or perioperative chemotherapy and operations for advanced stages. Esophagectomy is nowadays carried out in one stage as a so-called hybrid procedure (laparoscopy and muscle-preserving thoracotomy) or as a total minimally invasive operation (laparoscopy and thoracoscopy).

Minimizing postoperative pulmonary complications in thoracic surgery patients

PURPOSE OF REVIEW

Quantification and optimization of perioperative risk factors focusing on anesthesia-related strategies to reduce postoperative pulmonary complications (PPCs) after lung and esophageal surgery.

RECENT FINDINGS

There is an increasing amount of multimorbid patients undergoing thoracic surgery due to the demographic development and medical progress in perioperative medicine. Nevertheless, the rate of PPCs after thoracic surgery is still up to 30-50% with a significant influence on patients' outcome. PPCs are ranked first among the leading causes of early mortality after thoracic surgery. Although patients' risk factors are usually barely modifiable, current research focuses on procedural risk factors. From the surgical position, the minimal-invasive approach using video-assisted thoracoscopy and laparoscopy leads to a decreased rate of PPCs. The anesthesiological strategy to reduce the incidence of PPCs after thoracic surgery includes neuroaxial anesthesia, lung-protective ventilation, and goal-directed hemodynamic therapy.

SUMMARY

The main anesthesiological strategies to reduce PPCs after thoracic surgery include the use of epidural anesthesia, lung-protective ventilation: PEEP (positive end-expiratory pressure) of 5-8 mbar, tidal volume of 5 ml/kg BW (body weight) and goal-directed hemodynamics: CI (cardiac index) ≥ 2.5 l/min per m2, MAD (Mean arterial pressure) ≥ 70 mmHg, SVV (stroke volume variation) < 10% with a total amount of perioperative crystalloid fluids ≤ 6 ml/kg BW (body weight) per hour.

Feasibility and effectiveness of multi-injection thoracic paravertebral block via the intrathoracic approach for analgesia after thoracoscopic-laparoscopic esophagectomy

BACKGROUND

We observed the feasibility and effectiveness of multi-injection thoracic paravertebral block (TPB) via the intrathoracic approach under thoracoscopic direct vision for analgesia after thoracoscopic-laparoscopic esophagectomy (TLE).

METHODS

Sixty patients undergoing TLE were randomly divided into a control group and an observation group. All patients underwent TPB via the intrathoracic approach at the three levels of T2, 5, and 8 with a scalp needle before closing the chest. The patients in the observation group received 10 ml 0.375% ropivacaine at each level, and the patients in the control group received 10 ml of 0.9% saline at each level. A patient-controlled intravenous analgesic (PCIA) pump with sufentanil was attached to all patients after surgery. The sufentanil consumption, number of PCIA presses and use of rescue analgesia in the first 24 h after surgery were recorded. The visual analogue scale (VAS) scores (rest and coughing) were recorded at 2 h, 6 h, 12 h, 24 h, and 48 h after surgery. The duration of postoperative hospital stay, active cough rate, first ambulation, and the incidence of adverse reactions after surgery was recorded.

RESULTS

The sufentanil consumption in the observation group was significantly lower than that in the control group (34.7 ± 1.9 µg vs. 52.1 ± 2.1 µg; P < 0.001). The VAS score at each postoperative time point, number of PCIA presses, use of rescue analgesia, and the incidence of adverse reactions in the observation group were significantly lower than those in the control group. The postoperative active cough rate of patients in the observation group was significantly higher than those in the control group, and the times of the first ambulation after surgery and postoperative hospital stay in the observation group were significantly shorter than those in the control group (all P < 0.05).

CONCLUSIONS

Multi-injection TPB via the intrathoracic approach under thoracoscopic direct vision is easy to perform and can effectively alleviate postoperative pain after TLE with fewer adverse reactions and contributing to improved postoperative recovery.

Postoperative complications after minimally invasive esophagectomy in the prone position: any anesthesia-related factor?

OBJECTIVE

To evaluate the incidence of postoperative complications arising within 30 days of minimally invasive esophagectomy in the prone position with total lung ventilation and their relationship with 30-day and 1-year mortality. Secondary outcomes included possible anesthesia-related factors linked to the development of complications.

METHODS

The study is a retrospective single-center observational study at the Anesthesia and Surgical Department of a tertiary care center in the northeast of Italy. Patients underwent cancer resection through esophagectomy in the prone position without one-lung ventilation.

RESULTS

We included 110 patients from January 2010 to December 2017. A total of 54% of patients developed postoperative complications that increased mortality risk at 1 year of follow-up. Complications postponed first oral intake and delayed patient discharge to home. Positive intraoperative fluid balance was related to increased mortality and the risk to develop postoperative complications. C-reactive protein at third postoperative day may help detect complication onset.

CONCLUSIONS

Complication onset has a great impact on mortality after esophagectomy. Some anesthesia-related factors, mainly fluid balance, may be associated with postoperative mortality and morbidity. These factors should be carefully taken into account to obtain better outcomes after esophagectomy in the prone position without one-lung ventilation.

Use and Outcomes of Epidural Analgesia in Upper Gastrointestinal Tract Cancer Resections

BACKGROUND

Epidural analgesia (EA) is an appealing adjunct for esophageal and gastric cancer patients. It remains unclear whether EA usage affects postoperative outcomes. There are no national data on the trends of EA utilization for these procedures. This study aims to use the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) to study the utilization and outcomes of EA in open upper GI tract cancer resections.

MATERIALS AND METHODS

A retrospective review of NSQIP was performed for patients undergoing open elective esophagectomies and gastrectomies for nonmetastatic cancer between 2014 and 2017. An Armitage trend test was performed. The population was propensity matched and assessed.

RESULTS

There were 4802 esophagectomies performed. Twenty-nine percent of patients received EA. Of 2599 gastrectomies, 18% of patients received EA. The recent trends of EA use for esophagectomies (EA range [26.9%, 30.3%] P = 0.6535) and gastrectomies (EA [16.9%, 18.4%], P = 0.7797) remain stable. Propensity matching was performed, and the groups with and without EA were compared. For esophagectomies, EA was associated with blood transfusions (EA 14% versus No EA 10.8%, P = 0.0156). For gastrectomies, EA was associated with longer length of stay (LOS) (EA median [IQR] 8 [7,11] versus No EA 7 [6,11], P = 0.0002).

CONCLUSIONS

Despite the current opioid epidemic, the recent trends of EA for esophageal and gastric cancer patients remain stable. EA was associated with blood transfusions for esophagectomies and with a longer LOS for gastrectomies. Therefore, EA should be carefully considered, and its analgesic efficacy in this population should be investigated closely in future studies.

Strategies to prevent anastomotic leakage after esophagectomy and gastric conduit reconstruction

Background

Surgery remains the cornerstone of esophageal cancer treatment but is burdened with high procedure-related morbidity. Anastomotic leakage as the most important surgical complication after esophagectomy is a key indicator for quality in surgical outcome research.

Purpose

The aim of this narrative review is to assess and summarize the current knowledge on prevention of anastomotic leakage after esophagectomy and to provide orientation for the reader in this challenging field of surgery.

Conclusions

There are various strategies to reduce postoperative morbidity and to prevent anastomotic leakage after esophagectomy, including adequate patient selection and preparation, and many technical-surgical and anesthesiological details. The scientific evidence regarding those strategies is highly heterogeneous, ranging from expert’s recommendations to randomized controlled trials. This review is intended to serve as an empirical guideline to improve the clinical management of patients undergoing esophagectomy with a special focus on anastomotic leakage prevention.

Efficacy and Safety of Continuous Paravertebral Block after Minimally Invasive Radical Esophagectomy for Esophageal Cancer

Objective

To compare the effects of continuous paravertebral block analgesia and patient-controlled intravenous analgesia after minimally invasive radical esophagectomy for esophageal cancer and their effects on postoperative recovery.

Methods

A retrospective analysis was performed among 233 patients who underwent minimally invasive esophageal cancer radical operation and met the requirements, including 87 patients (group C) who were successfully placed with a continuous paravertebral block device under direct vision and 146 patients (group P) who used a patient-controlled intravenous analgesia device. Visual analogue pain score (VAS) at rest and in motion for 1, 3, 6, 12, 24, 36, and 48 hours after awakening, incidence of adverse reactions of the two analgesic methods, occurrence of pulmonary complications after operation, use of emergency analgesics, and hospital stay after operation was recorded.

Results

The VAS scores of group C in resting and active state at 1, 3, 6, 12, 24, 36, and 48 hours after operation were significantly lower than those of group P (P < 0.001). The incidence of adverse reactions, pulmonary complications, and the use of emergency analgesics in group C were lower than those in group P (P < 0.05). The hospitalization time of group C was significantly shortened, and the satisfaction degree of group C was significantly higher than that of group P (P < 0.05).

Conclusion

Paravertebral block is safe and effective for patients undergoing minimally invasive radical esophagectomy. The incidence of adverse reactions and complications is lower, and the satisfaction of postoperative analgesia is higher, which is beneficial to the rapid recovery of patients after operation.

The impact of epidural catheter insertion level on pain control after esophagectomy for esophageal cancer

BACKGROUND

Although the effectiveness of epidural anesthesia on pain control after esophagectomy has been reported, the appropriate insertion level of the epidural catheter remains unclear for adequate postoperative pain control. We investigated the relationship between the epidural catheter insertion level and postoperative pain control after esophagectomy for esophageal cancer.

METHODS

We analyzed retrospectively 63 patients who underwent McKeown esophagectomy for esophageal cancer between October 2014 and November 2018. The epidural catheter was inserted at the T4-T10 level before general anesthesia induction, and epidural anesthesia was started during the operation. In the analysis, the epidural catheter insertion level was divided into three groups (over T6/T7, T7/T8, and under T8/T9) and determined. Postoperative pain was evaluated a numeric rating scale (NRS) for at least 7 postoperative days, and the first NRS after extubation was used to evaluate the impact of the epidural catheter insertion level on pain control.

RESULTS

Ten patients (15.9%) failed pain control. The χ² test and a forward stepwise logistic regression analysis revealed that only the epidural catheter insertion level affected pain control (P < 0.05). The T7/T8 insertion level significantly decreased postoperative pain after esophagectomy. In the subgroup analysis, epidural catheter insertion under T8/T9 significantly increased postoperative pain after esophagectomy when thoracoscopy/laparoscopy was assisted. No significant differences were observed in the incidence of postoperative complications among the epidural catheter insertion levels.

CONCLUSIONS

The T7/T8 epidural catheter insertion level contributed to postoperative pain relief and could lead to enhanced recovery after esophagectomy for esophageal cancer.

Efficacy of artificial pneumothorax under two-lung ventilation in video-assisted thoracoscopic surgery for esophageal cancer

BACKGROUND

One-lung ventilation (OLV) is the standard and widely applied ventilation approach used in video-assisted thoracoscopic surgery for esophageal cancer (VATS-e). To address the disadvantages of OLV with respect to difficulties in intubation and induction, as well as the risk of respiratory complications, two-lung ventilation (TLV) with artificial pneumothorax has been introduced for use in VATS-e. However, no studies have yet compared TLV and OLV with postoperative infection and inflammation in the prone position over time postoperatively. Here, we investigated the efficacy of TLV in patients undergoing VATS-e in the prone position.

METHODS

Between April 2010 and December 2016, 119 patients underwent VATS-e under OLV or TLV with carbon dioxide insufflation. Clinical characteristics, surgical outcomes, and postoperative outcomes, including oxygenation and systemic inflammatory responses, were compared between patients who underwent OLV and those who underwent TLV.

RESULTS

Clinical characteristics other than pT stage were comparable between groups. The TLV group had shorter thoracic operation time than the OLV group. No patients underwent conversion to open thoracotomy. The PaO₂/FiO₂ ratios of the TLV group on postoperative day (POD) 5 and on POD7 were significantly higher than those of the OLV group. C-reactive protein levels on POD7 were lower in the TLV group than in the OLV group. There were no significant differences with respect to postoperative complications between the OLV and TLV groups. In the TLV group, the white blood cell count on POD7 was significantly lower than that in the OLV group; body temperature showed a similar trend immediately after surgery and on POD1.

CONCLUSIONS

In this study, we demonstrated that, compared with OLV, TLV in the prone position provides better oxygenation and reduced inflammation in the postoperative course. Accordingly, TLV might be more useful than OLV for ventilation during esophageal cancer surgery.

Anesthesia and Enhanced Recovery After Head and Neck Surgery

Enhanced recovery protocols have been developed from gastrointestinal, colorectal, and thoracic surgery populations. The basic tenets of head and neck enhanced recovery are: a multidisciplinary team working around the patient, preoperative carbohydrate loading, multimodal analgesia, early mobilization and oral feeding, and frequent reassessment and auditing of protocols to improve patient outcomes. The implementation of enhanced recovery protocols across surgical populations appear to decrease length of stay, reduce cost, and improve patient satisfaction without sacrificing patient quality of care or changing readmission rates. This article examines evidence-based enhanced recovery interventions and tailors them to a major head and neck surgery population.

Delayed recovery following thoracic surgery: persistent issues and potential interventions

PURPOSE OF REVIEW

Lung and esophageal surgery remain a curative option for resectable cancers. However, despite advances in surgical and anesthesia practices, the inclusion of patients with comorbidities that would have previously not been offered curative resection presents additional concerns and challenges.

RECENT FINDINGS

Perioperative complication rates remain high and prolonged and/or painful recovery are common. Further, many patients face a permanent decline in their functional status, which negatively affects their quality of life. Examination of the variables associated with high complications following thoracic surgery reveals patient, physician, and institutional factors in the forefront. Anesthesiologist training, Enhanced Recovery After Surgery protocols, and preparations to minimize "failure to rescue" when a complication does arise are key strategies to address adverse outcomes.

SUMMARY

Delayed and complicated recovery after thoracic noncardiac surgery persist in current practice. This review analyzes the diverse factors that can impact complications and quality of life after lung surgery and the interventions that can help decrease length of stay and improve return to baseline conditions.

Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy

Esophagectomy for cancer is associated with high risk for postoperative morbidity. The most serious regularly encountered complication is anastomotic leak and the most feared individual complication is conduit necrosis. Both of these complications affect the length of stay, mortality, quality of life, and survival for patients undergoing esophageal resection. The maintenance of conduit viability is of primary importance in the perioperative care of patients following esophageal resection. It has been shown that restrictive fluid management may be associated with improved postoperative outcomes in abdominal and other types of surgery, but many factors can affect the incidence of anastomotic leak and the viability of the gastric conduit. We have performed a comprehensive review with the aim to give an overview of the available evidence for the use of standardized hemodynamic protocols (SHPs) for esophagectomy and review the hemodynamic protocol, which has been applied within a standardized clinical pathway (SCP) at the Department of Thoracic surgery at the Virginia Mason Medical Center between 2004-2018 where the anastomotic leak rate over the period has been 5.2% and the incidence of conduit necrosis requiring surgical management is zero. The literature review demonstrates that there are few high quality studies that provide scientific evidence for the use of a SHP. The evidence indicates that the use of goal-directed hemodynamic monitoring might be associated with a reduced risk for postoperative complications, shortened length of stay, and decreased need for intensive care unit stay. We propose that the routine application of a SHP can provide a uniform infrastructure to optimize conduit perfusion and decrease the incidence of anastomotic leak.

Is two lung ventilation with artificial pneumothorax a better choice than one lung ventilation in minimally invasive esophagectomy?

Two lung ventilation (TLV) with artificial pneumothorax has been introduced into MIE for several years. A few researches have reported its clinical application, and proved its safety and feasibility. However, it is still controversial whether TLV with artificial pneumothorax is a better choice than one lung ventilation (OLV). Obviously, single lumen endotracheal tube is easy for intubation and intraoperative maintenance. Potential problems during intervention include hemodynamic changes, oxygenation, and air embolism. In this paper, present literature is reviewed about two and one lung ventilation in thoracoscopy, looking for clear conclusions for future application.

Effect of restrictive fluid therapy with hydroxyethyl starch during esophagectomy on postoperative outcomes: a retrospective cohort study

BACKGROUND

To improve prognosis after esophageal surgery, intraoperative fluid optimization is important. Herein, we hypothesized that hydroxyethyl starch administration during esophagectomy reduce the total amount of fluid infused and it could have a positive effect on postoperative complication occurrence and mortality.

METHODS

All consecutive adult patients who underwent elective esophageal surgery for cancer were studied. The primary outcome was the development of composite complications including death, cardio-cerebrovascular complications, respiratory complications, renal complications, gastrointestinal complications, sepsis, empyema or abscess, and multi-organ failure. The relationship between perioperative variables and composite complication was evaluated using multivariable logistic regression.

RESULTS

Of 892 patients analyzed, composite complications developed in 271 (30.4%). The higher hydroxyethyl starch ratio in total fluid had a negative relationship with the total fluid infusion amount (r = - 0.256, P <  0.001). In multivariable analysis, intraoperatively administered total fluid per weight per hour (odds ratio, 1.248; 95% CI, 1.153-1.351; P <  0.001) and HES-to-crystalloid ratio (odds ratio, 2.125; 95% CI, 1.521-2.969; P <  0.001) were associated with increased risks of postoperative composite outcomes.

CONCLUSIONS

Although hydroxyethyl starch administration reduces the total fluid infusion amount during esophageal surgery for cancer, intravenous hydroxyethyl starch infusion is associated with an increasing risk of postoperative composite complications.

Postoperative analgesia after combined thoracoscopic-laparoscopic esophagectomy: a randomized comparison of continuous infusion and intermittent bolus thoracic epidural regimens

Purpose

Judicious postoperative pain management after thoracoscopic–laparoscopic esophagectomy (TLE) facilitates enhanced rehabilitation. Thoracic epidural analgesia (TEA) offers many benefits in esophagectomy, while several complications are associated with the delivery mode by continuous epidural infusion. This study compared the efficiency and safety of intermittent epidural bolus to continuous epidural infusion for pain management after TLE.

Patients and methods

Sixty patients, aged 18–80 years, with American Society of Anesthesiologists classes I–III and scheduled for TLE with combined general anesthesia and TEA were randomly allocated to two groups. Patients received either a continuous epidural infusion with 0.3% ropivacaine and 1.5 µg/mL fentanyl at 6 mL/h plus a patient-controlled bolus of 3 mL (continuous group) or an intermittent bolus of 6 mL of the same solution on demand with lockout time of 30 minutes (intermittent group). If the patient complained of pain and the visual analog scale score was >4, an intravenous injection of tramadol or dezocine was administered as rescue treatment. The primary outcome variable was the consumption of epidural opioids and local anesthetics for TEA.

Results

TEA for pain management following TLE by intermittent epidural bolus was associated with significantly lower consumption of fentanyl and ropivacaine and lower incidences of breakthrough pain and hypotension than continuous epidural infusion. No significant differences were observed between the two groups in terms of pain score at rest or while coughing, patient satisfaction, or incidence of postoperative complications.

Conclusion

Compared with continuous epidural infusion, TEA by on-demand intermittent bolus greatly reduced the consumption of local anesthetics and opioids with comparable pain relief and little impairment in hemodynamics when used for pain management after TLE.

Reduction of oxidative stress a key for enhanced postoperative recovery with fewer complications in esophageal surgery patients: Randomized control trial to investigate therapeutic impact of anesthesia management and usefulness of simple blood test for prediction of high-risk patients

BACKGROUND

Oxidative stress may be an integral determinant of surgical stress severity. We examined whether the preoperative level of derivatives of reactive oxygen metabolites (d-ROMs), an oxidative stress biomarker based on total hydroperoxides in circulating blood, is predictive of increased risk of delayed recovery and complications after surgery, as well as the effects of anesthesia management on postoperative recovery in light of oxidative stress.

METHODS

Patients (American Society of Anesthesiologists physical status I-II) scheduled for a radical esophagectomy (n = 186) were randomly selected to receive inhalational sevoflurane (n = 94) or intravenous propofol (n = 92) anesthesia. Preoperative blood d-ROMs level, as well as pre-and postoperative plasma ferric-reducing ability, were analyzed to assess oxidative stress, with white blood cell (WBC) count, C-reactive protein (CRP) level, incidence of severe postoperative complications, and postoperative recovery process within 30 days after surgery also examined in a double-blind fashion.

RESULTS

Postoperative normalization of WBC and CRP was extended in patients with elevated preoperative d-ROMs [WBC versus d-ROMs: correlation coefficient (r) = 0.58 P < .001; CRP versus d-ROMs: r = 0.46 P < .001]. Receiver operating characteristics analysis of d-ROMs in relation to incidence of severe postoperative complications revealed an optimum d-ROMs threshold value of 410 UCarr and that patients with ≥410 UCarr had a greater risk of complications as compared to those with lower values (odds ratio = 4.7). Plasma ferric-reducing ability was decreased by 61 ± 185 mmol·l (P < .001) after surgery, demonstrating development of surgery-related oxidative stress, the magnitude of which was positively correlated with preoperative d-ROMs level (r = 0.16, P = .043). A comparison of the 2 anesthesia management protocols showed that patients who received propofol, an antioxidant anesthetic, had no postoperative decrease in ferric-reducing ability, lower incidence of severe postoperative complications (7 of 92 versus 18 of 94, P = .030, odds ratio = 0.35), and faster uneventful recovery time (WBC normalization days 7.1 ± 5.2 versus 13.6 ± 10.2, P < .001) as compared to those who received sevoflurane.

CONCLUSIONS

Elevated preoperative blood d-ROMs predicts greater intraoperative oxidative stress and increased postoperative complications with prolonged recovery, thus is useful for identifying high-risk patients for delayed and complicated surgical recovery. Reduction of oxidative stress is vital for enhanced recovery, with control by antioxidants such as propofol a possible solution.

Postoperative complications and survival after surgical resection of esophageal squamous cell carcinoma

Background

Resection of esophageal squamous cell carcinoma (SCC) is associated with a frequent occurrence of postoperative complications. Previously, the impact of complications on long-term survival has been explored primarily in mixed squamous cell and adenocarcinoma (AC) populations with conflicting results. In the present study, the influence of postoperative complications on survival following open esophageal resection was investigated exclusively in a western population with SCC.

Methods

In a retrospective observational study, all patients undergoing open surgical resection for esophageal SCC at our centre between February 2010 and December 2015 were consecutively included. Pre- and perioperative clinical information, mortality and complications were registered.

Results

In the study cohort, 133 patients were enrolled. Eighty-nine patients (67%) experienced one or more postoperative complications. The estimated 5-year survival on the entire population was 57%. Patients without complications had a long-term survival of 52%, whereas in patients with one or more complications survival was reduced to 30% (log rank P=0.039). Cox regression analysis revealed that postoperative complications were associated with an increased mortality risk with an adjusted hazard ratio (HR) of 2.02 (95% CI: 1.1-3.7, P=0.025), specifically sepsis/septic shock and anastomotic leakage significantly reduced long-term survival.

Conclusions

We found an improved 5-year survival in patients undergoing surgical resection for SCC compared to previous studies with mixed populations, despite a more frequent occurrence of complications. The presence of postoperative complications significantly reduced the long-term survival with 42%.

A comparison between two lung ventilation with CO2 artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy

Background

To investigate the feasibility and safety of two lung ventilation with artificial pneumothorax in minimally invasive esophagectomy (MIE) through a comparison with conventional one lung ventilation.

Methods

Eleven hundred and sixty-six patients with esophageal cancer, who underwent McKeown MIE in our center from February 2006 to December 2016, were studied retrospectively. Seven hundred and five patients who underwent one lung ventilation with double lumen endotracheal tube (DLET) were assigned to DLET group. Other 461 patients who underwent two lung ventilation with single lumen endotracheal tube (SLET) were assigned to SLET group. Clinical characteristics, surgical variables and complications were compared between two groups.

Results

There were comparable patient characteristics in two groups. Surgical variables and complications were discussed between two groups. SLET group seemed to have shorter operative time, shorter postoperative hospital stay, and more harvested recurrent laryngeal nerve (RLN) lymph nodes than DLET group, which might be attributed to experienced surgeons. However, there were no significant differences of complications between two groups. Intraoperative clinical parameters were further studied. Before intubation and artificial pneumothorax, there were no significant differences between two groups, except diastolic blood pressure (DBP). With the application of artificial pneumothorax, patients in SLET group have obviously higher PO₂, PCO₂, and PetCO₂ value, and slightly lower pH value and blood pressure during thoracic phase. After the thoracic phase, the changes induced by artificial pneumothorax in SLET group were gradually reversed and clinical parameters gradually return to normal level.

Conclusions

Two lung ventilation with artificial pneumothorax is a safe and feasible choice during MIE.