Prevalence and clinical course of postoperative acute lung injury after esophagectomy for esophageal cancer

Management of Major Complications After Esophagectomy

Esophagectomy remains a procedure with one of the highest complication rates. Given the advances in medical and surgical management of patients and increased patient survival, the number of complications reported has increased. There are different grading systems for complications which vary based on severity or organ system, with the Esophageal Complications Consensus Group unifying them. Management involves conservative intervention and dietary modification to endoscopic interventions and surgical reintervention. Treatment is etiology specific but rehabilitation and patient optimization play a significant role in managing these complications by preventing them. Management is a step-up approach depending on the severity of symptoms.

Efficacy of preoperative single-dose dexamethasone in preventing postoperative pulmonary complications following minimally invasive esophagectomy: a retrospective propensity score-matched study

BACKGROUND

The study was performed to investigate the efficacy and safety of preoperative dexamethasone (DXM) in preventing postoperative pulmonary complications (PPCs) after minimally invasive esophagectomy (MIE).

METHODS

Patients who underwent total MIE with two-field lymph node dissection from February 2018 to February 2023 were included in this study. Patients who were given either 5 mg or 10 mg DXM as preoperative prophylactic medication before induction of general anesthesia were assigned to the DXM group, while patients who did not receive DXM were assigned to the control group. Preoperative evaluations, intraoperative data, and occurrence of postoperative complications were analyzed. The primary outcome was the incidence of PPCs occurring by day 7 after surgery.

RESULTS

In total, 659 patients were included in the study; 453 patients received preoperative DXM, while 206 patients did not. Propensity score-matched analysis created a matched cohort of 366 patients, with 183 patients each in the DXM and control groups. A total of 24.6% of patients in the DXM group and 30.6% of patients in the control group had PPCs (P = 0.198). The incidence of respiratory failure was significantly lower in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019). Fewer patients were re-intubated during their hospital stay in the DXM group than in the control group (1.1% vs 5.5%, P = 0.019).

CONCLUSIONS

Preoperative DXM before induction of anesthesia did not reduce overall PPC development after MIE. Nevertheless, the occurrence of early respiratory failure and the incidence of re-intubation during hospitalization were decreased.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (No. ChiCTR2300071674; Date of registration, 22/05/2023).

Dexmedetomidine improved respiratory dynamics and arterial blood gas indices in patients with esophageal cancer after induction of anesthesia

OBJECTIVE

To retrospectively analyze the effects of dexmedetomidine after induction of anesthesia on intraoperative indices in patients with esophageal cancer.

METHODS

The clinical data of 93 patients with esophageal cancer that admitted to our hospital from January 2019 to December 2020 were retrospectively analyzed. The patients were divided into control group (n=31), case group A (n=31, continuous intravenous infusion of 0.3 μg/(kg∙h) dexmedetomidine hydrochloride) and case group B (n=31, continuous intravenous infusion of 0.5 μg/(kg∙h) dexmedetomidine hydrochloride) according to the application condition of dexmedetomidine hydrochloride. Heart rate, blood pressure, arterial blood gas indicators (all measured by blood gas analyzer), respiratory mechanics index (measured by mechanical ventilation), ephedrine and atropine utilization rate of the three groups were compared.

RESULTS

The plateau pressure, peak pressure and airway resistance at the end of one-lung ventilation and at chest closure in case groups A and B were lower than those in the control group, and the pulmonary compliance in case group B was higher than that in the control group (P < 0.05). PaO2, P_(A-a)O2, and RI before the start of OLV, at the end of OLV, and at chest closure in the three groups were significantly increased compared with those before induction of anesthesia (P < 0.05). Compared with the control group, PaO2 significantly increased, while P_(A-a)O2 and RI significantly decreased at the end of OLV and at chest closure in the case group B.

CONCLUSION

Dexmedetomidine can improve respiratory dynamics and arterial blood gas indices after anesthesia induction of esophageal cancer, showing high safety and clinical feasibility.

Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study

OBJECTIVES

Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy.

DESIGN

Retrospective cohort study (level 3 evidence).

SETTING

Tertiary care referral center.

PARTICIPANTS

Patients who underwent esophagectomy from 2007 to 2017.

INTERVENTIONS

The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h).

MEASUREMENTS

Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use.

MAIN RESULTS

A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified.

CONCLUSIONS

Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

Risk factors for and predictive nomogram of postoperative hypoxaemia in elderly patients with femoral neck fractures

Objective

To investigate the related risk factors and predictive nomogram of postoperative hypoxaemia in elderly patients with femoral neck fractures.

Methods

This study included patients aged ≥65 years who underwent surgical treatment of acute femoral neck fractures. Univariate and multivariate logistic analyses were performed to determine the incidence of and risk factors for postoperative hypoxaemia. A predictive nomogram was constructed based on the multivariable model. Using the bootstrap method, discrimination was determined by the C-index and calibration plot.

Results

The logistic regression analysis showed that the anaesthesia type, surgical procedure, American Society of Anesthesiologists (ASA) classification, preoperative hypoxaemia occurrence, and age were independent predictors of development of postoperative hypoxaemia. The predictive formula for hypoxaemia was established as follows: hypoxaemia=−0.8668×spinal anaesthesia (whether)+0.1162×nerve anaesthesia (whether)+1.9555×plate/screw fixation (whether)+1.4950×hip replacement (whether)+0.4883×ASA classification+1.7153×preoperative oxygenation index+0.1608×age. With the bootstrap method, the prediction curve fit well with the ideal curve, suggesting that the prediction curve constructed in this study has good predictive ability.

Conclusions

Anaesthesia type, surgical procedure, ASA classification, preoperative hypoxaemia occurrence, and age were risk factors for postoperative hypoxaemia in elderly patients with femoral neck fractures. The predictive nomogram was designed for preoperative assessment of the risk of postoperative hypoxaemia by calculating the risk score.