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Sims CR, Abou Chaar MK, Kerfeld MH, Cassivi SD, Hofer RE, Nichols FC, Reisenauer J, Saddoughi SS, Shen KR, Stewart TM, Tapias LF, Wigle DA, Blackmon SH. Esophagectomy Enhanced Recovery After Surgery Initiative Results in Improved Outcomes. Ann Thorac Surg 2024; 117:847-857. [PMID: 38043851 DOI: 10.1016/j.athoracsur.2023.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 09/19/2023] [Accepted: 10/09/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND Esophagectomy for esophageal cancer is a procedure with high morbidity and mortality. This study developed a Multidisciplinary Esophagectomy Enhanced Recovery Initiative (MERIT) pathway and analyzed implementation outcomes in a single institution. METHODS The MERIT pathway was developed as a practice optimization and quality improvement initiative. Patients were studied from November 1, 2021 to June 20, 2022 and were compared with historical control subjects. The Wilcoxon rank sum test and the Fisher exact test were used for statistical analysis. RESULTS The study compared 238 historical patients (January 17, 2017 to December 30, 2020) with 58 consecutive MERIT patients. There were no significant differences between patient characteristics in the 2 groups. In the MERIT group, 49 (85%) of the patients were male, and their mean age was 65 years (range, 59-71 years). Most cases were performed for esophageal cancer after neoadjuvant therapy. Length of stay improved by 27% from 11 to 8 days (P = .27). There was a 12% (P = .05) atrial arrhythmia rate reduction, as well as a 9% (P = .01) decrease in postoperative ileus. Overall complications were reduced from 54% to 35% (-19%; P = .01). CONCLUSIONS This study successfully developed and implemented an enhanced recovery after surgery pathway for esophagectomy. In the first year, study investigators were able to reduce overall complications, specifically atrial arrhythmias, and postoperative ileus.
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Affiliation(s)
- Charles R Sims
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad K Abou Chaar
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mitchell H Kerfeld
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Stephen D Cassivi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Ryan E Hofer
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Francis C Nichols
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Janani Reisenauer
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Sahar S Saddoughi
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - K Robert Shen
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Thomas M Stewart
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Luis F Tapias
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Dennis A Wigle
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Division of Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Takahashi M, Toyama H, Takahashi K, Kaiho Y, Ejima Y, Yamauchi M. Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study. BMC Anesthesiol 2024; 24:29. [PMID: 38238681 PMCID: PMC10795296 DOI: 10.1186/s12871-024-02410-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/10/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear. METHODS After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications. RESULTS Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels. CONCLUSIONS Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.
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Affiliation(s)
- Misaki Takahashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hiroaki Toyama
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Takahashi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yu Kaiho
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Yutaka Ejima
- Department of Surgical Center and Supply, Sterilization, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Masanori Yamauchi
- Department of Anesthesiology and Perioperative Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Kim HJ, Choi YS, Park BJ, Shin HJ, Jeon SY, Kim DJ, Kim SY. Immediate Postoperative High Syndecan-1 is Associated with Short-Term Morbidity and Mortality After Robot-Assisted Esophagectomy: A Prospective Observational Study. Ann Surg Oncol 2023; 30:5870-5880. [PMID: 37261564 DOI: 10.1245/s10434-023-13678-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 05/10/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Disruption of the endothelial glycocalyx (EG) is associated with a poor prognosis in various clinical settings. This study aimed to determine the association between immediate postoperative serum syndecan-1 levels, a representative marker for EG degradation, and major postoperative morbidity and mortality in patients undergoing robot-assisted esophagectomy. METHODS Patients who underwent robot-assisted esophagectomy between 2018 and 2022 were prospectively enrolled. The primary outcome was the association between immediate postoperative syndecan-1 levels and the occurrence of major postoperative morbidity and mortality within 30 days of surgery. Patients were classified into low and high syndecan-1 groups based on the optimal cut-off value of syndecan-1 for predicting major morbidity and mortality. A multivariable logistic regression analysis was performed to investigate the risk factors for major morbidity and mortality. RESULTS A total of 207 patients were analyzed. Patients with high syndecan-1 levels (≥48 ng/mL) showed a significantly greater incidence of unexpected returns to the operating room and anastomotic leaks and longer durations of hospital and intensive care unit stays than patients with low syndecan-1 levels (<48 ng/mL). Immediate postoperative syndecan-1 levels ≥48 ng/mL (odds ratio [OR] 2.32, 95% confidence interval [CI] 1.23-4.76), American Society of Anesthesiologists physical status ≥III (OR 3.36, 95% CI 1.56-7.22), and current smoker (OR 4.02, 95% CI 1.52-10.61) were independently associated with major morbidity and mortality within 30 days of esophagectomy. CONCLUSIONS Immediate postoperative syndecan-1 levels ≥48 ng/mL could be used for the early detection of patients at high risk of complications after robot-assisted esophagectomy.
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Affiliation(s)
- Hye Jin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Jo Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Jung Shin
- Biostatistics Collaboration Unit, Department of Biomedical Systems Informatics, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soo Yeon Jeon
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea.
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea.
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Deana C, Vetrugno L, Bignami E, Bassi F. Peri-operative approach to esophagectomy: a narrative review from the anesthesiological standpoint. J Thorac Dis 2021; 13:6037-6051. [PMID: 34795950 PMCID: PMC8575828 DOI: 10.21037/jtd-21-940] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 08/19/2021] [Indexed: 12/16/2022]
Abstract
Objective This review summarizes the peri-operative anesthesiological approaches to esophagectomy considering the best up-to-date, evidence-based medicine, discussed from the anesthesiologist’s standpoint. Background Esophagectomy is the only curative therapy for esophageal cancer. Despite the many advancements made in the surgical treatment of this tumour, esophagectomy still carries a morbidity rate reaching 60%. Patients undergoing esophagectomy should be referred to high volume centres where they can receive a multidisciplinary approach to treatment, associated with better outcomes. The anesthesiologist is the key figure who should guide the peri-operative phase, from diagnosis through to post-surgery rehabilitation. We performed an updated narrative review devoted to the study of anesthesia management for esophagectomy in cancer patients. Methods We searched MEDLINE, Scopus and Google Scholar databases from inception to May 2021. We used the following terms: “esophagectomy”, “esophagectomy AND pre-operative evaluation”, “esophagectomy AND protective lung ventilation”, “esophagectomy AND hemodynamic monitoring” and “esophagectomy AND analgesia”. We considered only articles with abstract written in English and available to the reader. We excluded single case-reports. Conclusions Pre-operative anesthesiological evaluation is mandatory in order to stratify and optimize any medical condition. During surgery, protective ventilation and judicious fluid management are the cornerstones of intraoperative “protective anesthesia”. Post-operative care should be provided by an intensive care unit or high-dependency unit depending on the patient’s condition, the type of surgery endured and the availability of local resources. The provision of adequate post-operative analgesia favours early mobilization and rapid recovery. Anesthesiologist has an important role during the peri-operative care for esophagectomy. However, there are still some topics that need to be further studied to improve the outcome of these patients.
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy.,Department of Medical Area, University of Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, ASUFC-Academic Hospital of Udine, Udine, Italy
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Reda S, Ahl R, Szabo E, Stenberg E, Forssten MP, Sjolin G, Cao Y, Mohseni S. Pre-operative beta-blocker therapy does not affect short-term mortality after esophageal resection for cancer. BMC Surg 2020; 20:333. [PMID: 33353542 PMCID: PMC7754575 DOI: 10.1186/s12893-020-01017-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND It has been postulated that the hyperadrenergic state caused by surgical trauma is associated with worse outcomes and that β-blockade may improve overall outcome by downregulation of adrenergic activity. Esophageal resection is a surgical procedure with substantial risk for postoperative mortality. There is insufficient data to extrapolate the existing association between preoperative β-blockade and postoperative mortality to esophageal cancer surgery. This study assessed whether preoperative β-blocker therapy affects short-term postoperative mortality for patients undergoing esophageal cancer surgery. METHODS All patients with an esophageal cancer diagnosis that underwent surgical resection with curative intent from 2007 to 2017 were retrospectively identified from the Swedish National Register for Esophagus and Gastric Cancers (NREV). Patients were subdivided into β-blocker exposed and unexposed groups. Propensity score matching was carried out in a 1:1 ratio. The outcome of interest was 90-day postoperative mortality. RESULTS A total of 1466 patients met inclusion criteria, of whom 35% (n = 513) were on regular preoperative β-blocker therapy. Patients on β-blockers were significantly older, more comorbid and less fit for surgery based on their ASA score. After propensity score matching, 513 matched pairs were available for analysis. No difference in 90-day mortality was detected between β-blocker exposed and unexposed patients (6.0% vs. 6.6%, p = 0.798). CONCLUSION Preoperative β-blocker therapy is not associated with better short-term survival in patients subjected to curative esophageal tumor resection.
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Affiliation(s)
- Souheil Reda
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Rebecka Ahl
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Eva Szabo
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Erik Stenberg
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Maximilian Peter Forssten
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Gabriel Sjolin
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital, Orebro, Sweden
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Impact of pretreatment asymptomatic renal dysfunction on clinical course after esophagectomy. Surg Today 2020; 51:165-171. [PMID: 32862341 DOI: 10.1007/s00595-020-02118-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 06/28/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Recent large-scale clinical studies have shown that preoperative renal insufficiency is associated with an increased risk of postoperative complications after esophagectomy; however, it remains unclear whether asymptomatic renal dysfunction affects the postoperative course after esophagectomy. METHODS The subjects of this retrospective study were 177 patients who underwent esophagectomy between May, 2009 and December, 2018. Renal function was evaluated based on the pretreatment estimated glomerular filtration rate (eGFR). Patients were divided into two groups according to the eGFR cut-off value of 55 ml/min per 1.73 m2. RESULTS There were 17 patients in the low eGFR group and 160 patients in the normal group eGFR group. The rate of severe complications was significantly higher in the low eGFR than in the normal eGFR group. A low eGFR was the only significant complication risk factor identified; however, there were no marked differences in mortality or survival between the low and normal eGFR groups. CONCLUSION Our findings demonstrate that pretreatment asymptomatic renal dysfunction may be a significant risk factor for severe morbidity after esophagectomy.
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