Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint

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.

Comparison of early postoperative pulmonary complications between two-lung ventilation with artificial pneumothorax and one-lung ventilation with bronchial blockade in patients undergoing minimally invasive esophagectomy: a retrospective propensity score-matched cohort study

Background

Two-lung ventilation (TLV) with artificial carbon dioxide (CO2) pneumothorax is used during the thoracoscopic phase of minimally invasive esophagectomy (MIE). However, the impact of TLV with artificial pneumothorax on postoperative pulmonary complications (PPCs) after MIE is unclear. This study aimed to compare the incidence of early PPCs between TLV with CO2 pneumothorax and one-lung ventilation (OLV) with bronchial blockade in patients undergoing MIE.

Methods

Five hundred ninety-three patients with esophageal cancer who underwent elective MIE with two-field lymph node dissection were analyzed. Patients in the TLV group were intubated using a single-lumen endotracheal tube and underwent surgery using TLV with artificial CO2 pneumothorax. Patients in the OLV group underwent surgery using OLV with a bronchial blocker. Patient characteristics and intraoperative and PPC data were collected and analyzed. Propensity score matching (PSM) was performed to reduce confounding bias.

Results

The TLV and OLV group comprised 513 and 80 patients, respectively. PSM matched 197 TLV group and 73 OLV group patients. Incidence of pneumonia within the first 3 days of surgery was higher in the TLV group (11.7% vs. 4.1%) but the difference was not significant (P=0.06). The incidence of infiltrates on chest radiography was 36.0% in the TLV group and 28.8% in the OLV group (P=0.26). Incidence of other major PPCs requiring treatment and major non-pulmonary postoperative complications did not significantly differ between the groups. Length of hospital stay was significantly longer in the TLV group (13.0 vs. 11.0 days; P=0.03).

Conclusions

Compared with OLV with bronchial blockade, TLV with CO2 pneumothorax did not reduce the incidence of early PPCs after MIE.

High flow nasal oxygen vs. conventional oxygen therapy over respiratory oxygenation index after esophagectomy: an observational study

Background

Postoperative pulmonary complications after esophagectomy still represent a matter of concern. High flow nasal cannula (HFNC) early after major abdominal and thoracic surgery has demonstrated some advantages over conventional oxygen therapy. Data about respiratory effect of HFNC after esophagectomy is scarce. The primary aim of this study is to investigate if the early use of HFNC after esophagectomy could enhance patients' postoperative respiratory oxygenation (ROX) index and, ultimately, reduce postoperative pneumonia.

Methods

In this single center retrospective study all patients undergoing to esophagectomy for cancer from May 2020 to November 2022 were evaluated. Historical cohort (HC) received postoperative oxygen supplementation with Venturi mask or nasal goggles, and a cohort was put under HFNC (HFNC cohort). ROX index, blood gas analysis, radiological atelectasis score (RAS), post-operative complications' data and information on hospital stay have been collected and analyzed.

Results

Seventy-one patients were included for the final statistical analysis, 31 in the HFNC and 40 in the HC cohort. Mean age was 64±10 years and body mass index (BMI) was 26 [24-29] kg/m2. ROX index was higher in the HFNC patients than in the HC, 20.8 [16.7-25.9] vs. 14.9 [10.8-18.2] (P<0.0001). In the HFNC cohort patients, pH was higher, 7.42 [7.40-7.44] vs. 7.39 [7.37-7.43] than HC, while PaCO2 was lower in HFNC cohort compared with HC, 39 [36-41] vs. 42 [39-45] mmHg, respectively (P=0.01). RAS was similar between the two cohorts of patients, 1.5±0.98 vs. 1.4±1.04 in the HFNC and the HC cohort, respectively (P=0.611). Lower acute respiratory failure (ARF) rate was recorded among HFNC than HC cohort, 0% vs. 13% respectively, P=0.06. No difference in pneumonia frequency between two cohorts was shown.

Conclusions

HFNC improved the ROX index after esophagectomy through significant respiratory rate reduction. This tool should be considered for early respiratory support after extubation in this category of patients, not only as a rescue therapy for ARF, but also to optimize early postoperative respiratory function. Whether this will improve patients' outcomes requires further large randomized controlled trials.

Perioperative Risk Factors for Postoperative Pulmonary Complications After Minimally Invasive Esophagectomy

Background

Postoperative pulmonary complications (PPCs) are the most prevalent complication after esophagectomy and are associated with a worse prognosis. This study aimed to investigate the perioperative risk factors for PPCs after minimally invasive esophagectomy (MIE).

Methods

Seven hundred and sixty-seven consecutive patients who underwent McKeown MIE via thoracoscopy and laparoscopy were retrospectively studied. Patient characteristics, perioperative data, and postoperative complications were analyzed.

Results

The incidence of PPCs after MIE was 25.2% (193/767). Univariate analysis identified age (odds ratio [OR] 1.022, P = 0.044), male sex (OR 2.955, P < 0.001), pulmonary comorbidities (OR 1.746, P = 0.032), chronic obstructive pulmonary disease (COPD) (OR 2.821, P = 0.003), former smoking status (OR 1.880, P = 0.001), postoperative albumin concentration (OR 0.941, P = 0.007), postoperative creatinine concentration (OR 1.011, P = 0.019), and perioperative transfusion (OR 2.250, P = 0.001) as risk factors for PPCs. In multivariate analysis, the independent risk factors for PPCs were male sex (OR 3.135, P < 0.001), body mass index (BMI) (OR 1.088, P = 0.002), COPD (OR 2.480, P = 0.012), neoadjuvant chemoradiotherapy (OR 2.057, P = 0.035), postoperative albumin concentration (OR 0.929, P = 0.002), and perioperative transfusion (OR 1.939, P = 0.013). The area under the receiver operating characteristic curve for the predictive model generated by multivariate logistic regression analysis was 0.671 (95% confidence interval 0.628-0.713).

Conclusions

Male sex, BMI, COPD, neoadjuvant chemoradiotherapy, postoperative albumin concentration, and perioperative transfusion were independent predictors of PPCs after MIE.

Prognostic analysis and treatment utilization of different treatment strategies in elderly esophageal cancer patients with distant metastases: a SEER database analysis

PURPOSE

The purpose of this study was to explore which therapeutic strategy is more beneficial for elderly esophageal cancer (EC) patients with distant metastasis, the treatment utilization status and the screening of factors related to prognosis, so as to better guide the treatment of these patients.

METHODS

Patients in the Surveillance Epidemiology and End Results (SEER) database were divided into chemoradiotherapy (Group A), chemotherapy (Group B), radiotherapy (Group C), and no treatment (Group D) according to different treatment methods. Propensity score matching (PSM) was performed to adjust for baseline differences between the two groups. Overall survival (OS) and esophageal cancer-specific survival (ECSS) was calculated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

A total of 7027 patients were included in this study, 5739 males (81.7%) and 1288 females (18.3%) with the median age was 70 (60-98). In the original cohort, the number of patients in the four groups was 2260 (Group A), 2087 (Group B), 945 (Group C) and 1735 (Group D), respectively. After PSM, there was no significant difference in mean OS (A vs B, 13.5 months VS 13.4 months, P = 0.511) and mean ECSS (A vs B, 15.6 vs 15.5 months, P = 0.374), while both OS (B vs C, 7 vs 3 months, P < 0.001) and ECSS (B vs C, 8 vs 3 months, P < 0.001) of chemotherapy alone were significantly better than those of radiotherapy alone. Subgroup analysis of patients older than 80 years showed that the median OS (A vs B, 7 vs 6 months) and median ECSS (A vs B, 8 vs 7 months) of Group A were significantly better than those of Group B (P < 0.05). In addition, all patients were randomly divided into a training set and a validation set with a ratio of 7:3. Based on the independent risk factors for OS, a nomogram model was constructed and validated.

CONCLUSION

For elderly EC patients with distant metastasis, aggressive treatment was still necessary after a comprehensive assessment of the patient's physical condition, especially for patients over 80 years old, and chemoradiotherapy maybe still the first choice. In addition, a nomogram model was constructed to intuitively and accurately evaluate the prognosis of this population.

Association of DLT versus SLT with postoperative pneumonia during esophagectomy in China: a retrospective comparison study

BACKGROUND

Double lumen tube (DLT) and single lumen tube (SLT) are two common endotracheal tube (ETT) types in esophageal cancer surgery. Evidence of the relationship between two ETT types and postoperative pneumonia (PP) remains unclear. We aimed to determine the association between two types of ETT (DLT and SLT) and PP and assess the perioperative risk-related parameters that affect PP.

METHODS

This study included 680 patients who underwent esophageal cancer surgery from January 01, 2010 through December 31, 2020. The primary outcome was PP, and the secondary outcome was perioperative risk-related parameters that affect PP. The independent variable was the type of ETT: DLT or SLT. The dependent variable was PP. To determine the relationship between variables and PP, univariate and multivariate analyses were performed. The covariables included baseline demographic characteristics, comorbidity disease, neoadjuvant chemotherapy, tumor location, laboratory parameters, intraoperative related variables.

RESULTS

In all patients, the incidence of postoperative pneumonia in esophagectomy was 32.77% (36.90% in DLT group and 26.38% in SLT group). After adjusting for potential risk factors, we found that using an SLT in esophagectomy was associated with lower risk of postoperative pneumonia compared to using a DLT (Odd ratio = 0.41, 95% confidence interval (CI): 0.22, 0.77, p = 0.0057). Besides DLT, smoking history, combined intravenous and inhalation anesthesia (CIIA) and vasoactive drug use were all significant and independent risk factors for postoperative pneumonia in esophagectomy. These results remained stable and reliable after subgroup analysis.

CONCLUSIONS

During esophagectomy, there is significant association between the type of ETT (DLT or SLT) and PP. Patients who were intubated with a single lumen tube may have a lower rate of postoperative pneumonia than those who were intubated with a double lumen tube. This finding requires verification in follow-up studies.

Advances in targeted therapy and immunotherapy for esophageal cancer

ABSTRACT

Esophageal cancer (EC) is one of the most common aggressive malignant tumors in the digestive system with a severe epidemiological situation and poor prognosis. The early diagnostic rate of EC is low, and most EC patients are diagnosed at an advanced stage. Multiple multimodality treatments have gradually evolved into the main treatment for advanced EC, including surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy. And the emergence of targeted therapy and immunotherapy has greatly improved the survival of EC patients. This review highlights the latest advances in targeted therapy and immunotherapy for EC, discusses the efficacy and safety of relevant drugs, summarizes related important clinical trials, and tries to provide references for therapeutic strategy of EC.

Regional Anesthetic Use in Trans-Hiatal Esophagectomy. Are They Worth Consideration? A Case Series

Background

Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, complications can arise related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominis plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA.

Methods

This is a case series of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block without TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, post-operative hypotension, fluid administration, postoperative pain scores, development of anastomotic leak, and 30-day readmission.

Results

The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. Thirty-four (81%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only seven patients (16.7%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain.

Conclusion

The results of this study demonstrated immediate extubation is possible using TAP blocks while limiting post-operative hypotension and fluid administration. This was shown despite the elevated comorbidity burden of this study's population. Overall, this study supports the use of TAP blocks as a possible alternative for primary analgesia in patients undergoing trans-hiatal esophagectomy.

Trial Registration

This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R.

Outcomes of intravenous and inhalation anesthesia on patients undergoing esophageal cancer surgery: a retrospective observational study

BACKGROUND

Different anesthetics may have opposite effects on the immune system, thus affecting the prognosis of tumor patients. Cell-mediated immunity forms the primary defense against the invasion of tumor cells, so manipulation of the immune system to produce an enhanced anti-tumor response could be utilized as an adjuvant oncological therapy. Sevoflurane has proinflammatory effects, while propofol, has anti-inflammatory and antioxidant effects. Therefore, we compared the overall survival (OS) and disease-free survival (DFS) of patients with esophageal cancer under total intravenous anesthesia and inhalation anesthesia.

METHODS

This study collected the electronic medical records of patients undergoing esophagectomy from January 1, 2014 to December 31, 2016. According to the intraoperative anesthetics, the patients were divided into total intravenous anesthesia (TIVA) group or inhalational anesthesia (INHA) group. Stabilized inverse probability of treatment weighting (SIPTW) was used to minimize differences. Kaplan-Meier survival curve was established to evaluate the correlation between different anesthesia methods in overall survival and disease-free survival of patients undergoing esophageal cancer surgery.

RESULTS

A total of 420 patients with elective esophageal cancer were collected, including 363 patients eligible for study (TIVA, n = 147, INHA, n = 216). After SIPTW there were no significant differences between two groups in overall survival and disease-free survival. However, the adjuvant therapy was statistically significant in improving OS, and the degree of differentiation was correlated with OS and DFS.

CONCLUSIONS

In conclusion, there were no significant difference in overall survival and disease-free survival between total intravenous anesthesia and inhalational anesthesia in patients undergoing esophageal cancer surgery.

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.

Is there a relationship between two different anesthetic methods and postoperative length of stay during radical resection of malignant esophageal tumors in China?: a retrospective cohort study

BACKGROUND

Data providing a relationship between the anesthetic method and postoperative length of stay (PLOS) is limited. We aimed to investigate whether general anesthesia alone or combined with epidural anesthesia might affect perioperative risk factors and PLOS for patients undergoing radical resection of malignant esophageal tumors.

METHODS

The study retrospectively analyzed the clinical data of 680 patients who underwent a radical esophageal malignant tumor resection in a Chinese hospital from January 01, 2010, to December 31, 2020. The primary outcome measure was PLOS, and the secondary outcome was perioperative risk-related parameters that affect PLOS. The independent variable was the type of anesthesia: general anesthesia (GA) or combined epidural-general anesthesia (E-GA). The dependent variable was PLOS. We conducted univariate and multivariate logistic regression and propensity score matching to compare the relationships of GA and E-GA with PLOS and identify the perioperative risk factors for PLOS. In this cohort study, the confounders included sociodemographic data, preoperative chemotherapy, coexisting diseases, laboratory parameters, intraoperative variables, and postoperative complications.

RESULTS

In all patients, the average PLOS was 19.85 ± 12.60 days. There was no significant difference in PLOS between the GA group and the E-GA group either before or after propensity score matching (20.01 days ± 14.90 days vs. 19.79 days ± 11.57 days, P = 0.094, 18.09 ± 9.71 days vs. 19.39 ± 10.75 days, P = 0.145). The significant risk factors for increased PLOS were lung infection (β = 3.35, 95% confidence interval (CI): 1.54-5.52), anastomotic leakage (β = 25.73, 95% CI: 22.11-29.34), and surgical site infection (β = 9.39, 95% CI: 4.10-14.68) by multivariate regression analysis. Subgroup analysis revealed a stronger association between PLOS and vasoactive drug use, blood transfusions, and open esophagectomy. The results remained essentially the same (stable and reliable) after subgroup analysis.

CONCLUSIONS

Although there is no significant association between the type of anesthesia(GA or E-GA) and PLOS for patients undergoing radical esophageal malignant tumor resection, an association between PLOS and lung infection, anastomotic leakage, and surgical site infection was determined by multivariate regression analysis. A larger sample future study design may verify our results.