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Djukanovic M, Skrobic O, Stojakov D, Knezevic NN, Milicic B, Sabljak P, Simic A, Milenkovic M, Sreckovic S, Markovic D, Palibrk I. Impact of fluid balance and opioid-sparing anesthesia within enchanced recovery pathway on postoperative morbidity after transthoracic esophagectomy for cancer. Front Med (Lausanne) 2024; 11:1366438. [PMID: 38770049 PMCID: PMC11102964 DOI: 10.3389/fmed.2024.1366438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/15/2024] [Indexed: 05/22/2024] Open
Abstract
BackgroundEnhanced 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.MethodsPatients 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.ResultsA 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).ConclusionA major morbidity and interstitial pulmonary edema after esophagectomy were decreased after the implementation of the ERAS protocol, without impact on overall mortality.
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Affiliation(s)
- Marija Djukanovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anaesthesiology and Intensive Care, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ognjan Skrobic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Esophagogastric Surgery, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Stojakov
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Surgery Clinic, Clinical Centre “Dr. Dragisa Misovic – Dedinje”, Belgrade, Serbia
| | - Nebojsa Nick Knezevic
- Department of Anaesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, United States
- Department of Anaesthesiology, College of Medicine, University of Illinois, Chicago, IL, United States
- Department of Surgery, College of Medicine, University of Illinois, Chicago, IL, United States
| | - Biljana Milicic
- Department of Medical Statistics and Informatics, School of Dental Medicine, University of Belgrade, Belgrade, Serbia
| | - Predrag Sabljak
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Esophagogastric Surgery, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Aleksandar Simic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Esophagogastric Surgery, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Marija Milenkovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anaesthesiology, Emergency Center, University Clinical Center of Serbia, Belgrade, Serbia
| | - Svetlana Sreckovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anesthesiology, Clinic for Orthopedics Surgery and Traumatology, University Clinical Center of Serbia, Belgrade, Serbia
| | - Dejan Markovic
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Cardiac Anesthesiology, Hospital of Cardiovascular Surgery, University Clinical Center of Serbia, Belgrade, Serbia
| | - Ivan Palibrk
- School of Medicine, University of Belgrade, Belgrade, Serbia
- Department of Anaesthesiology and Intensive Care, Hospital for Digestive Surgery, University Clinical Center of Serbia, Belgrade, Serbia
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Ramjit S, Davey MG, Loo C, Moran B, Ryan EJ, Arumugasamy M, Robb WB, Donlon NE. Evaluating analgesia strategies in patients who have undergone oesophagectomy-a systematic review and network meta-analysis of randomised clinical trials. Dis Esophagus 2024; 37:doad074. [PMID: 38221857 DOI: 10.1093/dote/doad074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 11/20/2023] [Accepted: 12/08/2023] [Indexed: 01/16/2024]
Abstract
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.
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Affiliation(s)
- Sinead Ramjit
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
| | - Matthew G Davey
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Caitlyn Loo
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Brendan Moran
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Eanna J Ryan
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - William B Robb
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Noel E Donlon
- Department of Surgery, Trinity College Dublin, Dublin, Ireland
- Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland
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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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Serafim MCA, Orlandini MF, Datrino LN, Tavares G, Tristão LS, dos Santos CL, Pinheiro Filho JEL, Bernardo WM, Tustumi F. Is early extubation after esophagectomy safe? A systematic review and meta‐analysis. J Surg Oncol 2022; 126:68-75. [DOI: 10.1002/jso.26821] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/07/2022] [Indexed: 01/27/2023]
Affiliation(s)
| | | | | | - Guilherme Tavares
- Department of Evidence‐Based Medicine Centro Universitário Lusíada Santos Brazil
| | | | | | | | - Wanderley Marques Bernardo
- Department of Evidence‐Based Medicine Centro Universitário Lusíada Santos Brazil
- Department of Evidence‐Based Medicine Universidade de São Paulo São Paulo Brazil
| | - Francisco Tustumi
- Department of Evidence‐Based Medicine Centro Universitário Lusíada Santos Brazil
- Department of Evidence‐Based Medicine Universidade de São Paulo São Paulo Brazil
- Department of Surgery Hospital Israelita Albert Einstein São Paulo Brazil
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Ashok A, Niyogi D, Ranganathan P, Tandon S, Bhaskar M, Karimundackal G, Jiwnani S, Shetmahajan M, Pramesh CS. The enhanced recovery after surgery (ERAS) protocol to promote recovery following esophageal cancer resection. Surg Today 2020; 50:323-334. [PMID: 32048046 PMCID: PMC7098920 DOI: 10.1007/s00595-020-01956-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/29/2019] [Indexed: 02/07/2023]
Abstract
Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity and
mortality. The enhanced recovery after surgery (ERAS) protocol which aims to improve perioperative care, minimize complications, and accelerate recovery is showing promise for achieving better perioperative outcomes. ERAS is a multimodal approach that has been reported to shorten the length of hospital stay, reduce surgical stress response, decrease morbidity, and expedite recovery. While ERAS components straddle preoperative, intraoperative, and postoperative periods, they need to be seen in continuum and not as isolated elements. In this review, we elaborate on the components of an ERAS protocol after esophagectomy including preoperative nutrition, prehabilitation, counselling, smoking and alcohol cessation, cardiopulmonary evaluation, surgical technique, anaesthetic management, intra- and postoperative fluid management and pain relief, mobilization and physiotherapy, enteral and oral feeding, removal of drains, and several other components. We also share our own institutional protocol for ERAS following esophageal resections.
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Affiliation(s)
- Apurva Ashok
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Devayani Niyogi
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Priya Ranganathan
- Division of Thoracic Surgery, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Sandeep Tandon
- Division of Thoracic Surgery, Department of Pulmonary Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - Maheema Bhaskar
- Division of Thoracic Surgery, Department of Pulmonary Medicine, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - George Karimundackal
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Sabita Jiwnani
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India
| | - Madhavi Shetmahajan
- Division of Thoracic Surgery, Department of Anesthesiology, Critical Care and Pain, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | - C S Pramesh
- Division of Thoracic Surgery, Department of Surgical Oncology, Tata Memorial Centre, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, 400012, India.
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6
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Buise MP. Proper volume management during anesthesia for esophageal resection. J Thorac Dis 2019; 11:S702-S706. [PMID: 31080647 PMCID: PMC6503285 DOI: 10.21037/jtd.2019.01.33] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 01/09/2019] [Indexed: 12/12/2022]
Abstract
Esophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. Proper fluid management is essential to reduce postoperative pulmonary complications. Restrictive management is advocated in ERAS based protocols and recent guidelines for esophagectomy, however Goal Directed treatment may be useful. Perioperative fluid management must always be seen in light of a multi modal approach and must be balanced at the needs of the patient and the surgical approach chosen.
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Affiliation(s)
- Marc P Buise
- Department of Anesthesia and Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
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7
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Li Y, Dong H, Tan S, Qian Y, Jin W. Effects of thoracic epidural anesthesia/analgesia on the stress response, pain relief, hospital stay, and treatment costs of patients with esophageal carcinoma undergoing thoracic surgery: A single-center, randomized controlled trial. Medicine (Baltimore) 2019; 98:e14362. [PMID: 30762735 PMCID: PMC6408022 DOI: 10.1097/md.0000000000014362] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Appropriate postoperative pain management can improve outcomes in patients with esophageal cancer (EC). OBJECTIVE To compare different combinations of anesthesia and analgesia techniques in patients with EC undergoing open thoracotomy. METHODS This randomized, controlled, open-label trial enrolled 100 patients with EC (aged 40-65 years; American Society of Anesthesiologists [ASA] grade I/II) receiving elective surgery at Jiangsu Province Hospital (China) between July 2016 and December 2017. Patients were randomized to 4 groups (n = 25 per group): total intravenous general anesthesia plus patient-controlled intravenous analgesia (TIVA/PCIA); TIVA plus patient-controlled epidural analgesia (TIVA/PCEA); thoracic epidural anesthesia with intravenous general anesthesia plus PCIA (TEA-IVA/PCIA); and TEA-IVA/PCEA (TEA-IVA plus PCEA). Primary outcomes were plasma cortisol level (measured at baseline, 2 h after skin incision, surgery completion, and 24 and 48 h post-surgery) and pain (assessed at 24, 48, and 72 hours post-surgery using a visual analog scale). Secondary outcomes included time to first flatus, hospital stay and treatment costs. Postoperative adverse events (AEs) were analyzed. RESULTS Baseline and operative characteristics were similar between the 4 groups. Plasma cortisol level increased (P <.05 vs baseline) earlier in the TIVA groups (2 h after skin incision) than in the TEA-IVA groups (24 h after surgery). At 48 hours after surgery, plasma cortisol had returned to baseline levels in the PCEA groups but not in the PCIA groups. VAS pain scores at rest and during coughing were lower in the PCEA groups than in the PCIA groups (P <.05). Compared with the PCIA groups, the PCEA groups had shorter time to first flatus and shorter hospital stay, while use of TEA-IVA lowered the costs of intraoperative anesthesia (P <.05). However, the PCEA groups had a higher incidence of nausea, vomiting, and pruritus. CONCLUSION Thoracic epidural anesthesia/analgesia can reduce the stress response, improve postoperative recovery and reduce hospital stay and costs for patients with EC.
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The original Ivor Lewis two stage esophagectomy revisited in the era of minimally invasive surgery. Am J Surg 2018; 217:454-457. [PMID: 30545686 DOI: 10.1016/j.amjsurg.2018.11.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Esophagectomy has high cardiac and pulmonary complication rates that can reach 43% and 58% respectively. The original Ivor Lewis esophagectomy was a two-stage procedure. We revisited this procedure using a hybrid minimally-invasive approach. METHODS Thirty-five consecutive patients with esophageal cancer were operated on over an eight-year period. The first stage used laparoscopic mobilization of the stomach, while the second stage used open thoracotomy. Six patients were aborted due to unresectable disease. RESULTS Twenty-nine patients were studied. The mean operative times for stage-one and stage-two were 108 ± 18 and 226 ± 63 min respectively. All patients were extubated in the operating room. One (3.4%) patients had cardiac complication and one (3.4%) patient had pulmonary complication. CONCLUSION Metachronous hybrid two-stage esophagectomy was associated with a low rate of cardio-pulmonary complications. It may be considered as an alternative to the one-stage esophagectomy, especially in low-volume centers, to decrease these high-risk cardio-pulmonary complications.
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Low DE, Allum W, De Manzoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh CS, Scott M, Mark Smithers B, Addor V, Ljungqvist O. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society Recommendations. World J Surg 2018; 43:299-330. [DOI: 10.1007/s00268-018-4786-4] [Citation(s) in RCA: 239] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Phillips S, Dedic-Hagan J, Baxter DF, Van der Wall H, Falk GL. A Novel Technique of Paravertebral Thoracic and Preperitoneal Analgesia Enhances Early Recovery After Oesophagectomy. World J Surg 2018; 42:1787-1791. [PMID: 29164294 DOI: 10.1007/s00268-017-4369-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Excellent analgesia following oesophagectomy facilitates patient comfort, early extubation, physiotherapy and mobilisation, reduces post-operative complications and should enhance recovery. Thoracic epidural analgesia (TEA), the gold standard analgesic regimen for this procedure, is often associated with systemic hypotension treated with inotropes or fluid. This may compromise enhanced recovery and be complicated by anastomotic ischaemia or tissue oedema. METHODS We report a novel analgesic regimen to reduce post-operative inotrope usage. Infusion of ropivicaine via bilateral preperitoneal and right paravertebral catheters was used. Patient-controlled epidural pethidine provided rescue analgesia (WC) (n = 21). A retrospective audit of inotrope requirement, mean pain scores, episodes of respiratory depression and excessive sedation, need for reintubation, reoperation in the first 5 post-operative days, time to mobilisation, time in intensive care, time in hospital and 30-day mortality were measured. These results were compared with those of an earlier patient group who received a thoracic epidural infusion of low-dose local anaesthetic and fentanyl (TEA) (n = 21). RESULTS Inotrope use was reduced by 29% in the WC group (p = 0.03) and the mean intensive care stay reduced by 2.4 days (p = 0.03), as was reintubation rate (p = 0.01) and early mobilisation (p = 0.03). The pain score was comparable in both groups, and there was no difference in the other outcomes examined. CONCLUSION The data demonstrated that it was possible to provide excellent post-oesophagectomy analgesia equivalent to thoracic epidural infusions of local anaesthetic with reduction in inotrope requirements, intensive care stay, more rapid mobilisation, facilitating enhanced recovery.
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Affiliation(s)
- Stephanie Phillips
- Sydney Adventist Hospital, Wahroonga, Sydney, Australia.,University of Sydney, Sydney, Australia
| | | | | | | | - G L Falk
- University of Sydney, Sydney, Australia. .,Macquarie University, Sydney, Australia. .,, Suite 29, 12 Tryon Road, Lindfield, NSW, 2070, Australia.
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11
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Imai T, Abe T, Uemura N, Yoshida K, Shimizu Y. Immediate extubation after esophagectomy with three-field lymphadenectomy enables early ambulation in patients with thoracic esophageal cancer. Esophagus 2018; 15:165-172. [PMID: 29951981 DOI: 10.1007/s10388-018-0608-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 03/06/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND We retrospectively compared the effects of immediate extubation (IE) in the operating room with those of overnight mechanical ventilation (MV) after radical transthoracic esophagectomy with 3-field lymphadenectomy in patients with thoracic esophageal cancer. METHODS A total of 96 patients were evaluated. 48 patients were extubated in the operating room after surgery (IE group). The other 48 patients were extubated on the following morning (MV group). The propensity score-matching method was used to assemble a well-balanced cohort. Clinical and postoperative outcomes were investigated in each group. We also compared postoperative laboratory parameters between groups. RESULTS The rate of ambulation on postoperative day (POD) 1 was significantly higher in the IE group compared with that in the MV group (50 vs 19%, respectively, p = 0.003). Moreover, the rate of catecholamine use in the ICU was significantly lower in the IE group compared with that in the MV group (15 vs 65%, respectively, p < 0.001). With regard to postoperative respiratory management, there were no significant differences between groups. The length of ICU stay after esophagectomy was significantly shorter in the IE group compared with that in the MV group (p = 0.01), whereas the length of postoperative hospital stay was similar between groups (p = 0.265). There were also no significant differences in the incidence of postoperative complications. CONCLUSIONS IE in the operating room is not only safe and feasible, even after transthoracic esophagectomy with radical 3-field lymphadenectomy, but also contributes to decrease in catecholamine use, to increase in ambulation on POD 1 and to shorten the ICU stay.
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Affiliation(s)
- Takeharu Imai
- The Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
- The Department of Surgical Oncology, Gifu University, Graduate School of Medicine, Gifu, 501-1194, Japan
| | - Tetsuya Abe
- The Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan.
| | - Norihisa Uemura
- The Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
| | - Kazuhiro Yoshida
- The Department of Surgical Oncology, Gifu University, Graduate School of Medicine, Gifu, 501-1194, Japan
| | - Yasuhiro Shimizu
- The Department of Gastroenterological Surgery, Aichi Cancer Center Hospital, 1-1 Kanokoden, Chikusa-ku, Nagoya, Aichi, 464-8681, Japan
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Feltracco P, Bortolato A, Barbieri S, Michieletto E, Serra E, Ruol A, Merigliano S, Ori C. Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review. Dis Esophagus 2018; 31:4683666. [PMID: 29211841 DOI: 10.1093/dote/dox135] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 10/26/2017] [Indexed: 12/11/2022]
Abstract
Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.
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Affiliation(s)
- P Feltracco
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - A Bortolato
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - S Barbieri
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - E Michieletto
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - E Serra
- Departments of Medicine, UO Anesthesia and Intensive Care
| | - A Ruol
- Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Clinica Chirurgica, University of Padova, Padova, Italy
| | - S Merigliano
- Surgical, Oncological and Gastroenterological Sciences, School of Medicine, Clinica Chirurgica, University of Padova, Padova, Italy
| | - C Ori
- Departments of Medicine, UO Anesthesia and Intensive Care
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13
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Liu YW, Yan FW, Tsai DL, Li HP, Lee YL, Chiang HH, Hsu HT, Chuang HY, Chou SH. Expedite recovery from esophagectomy and reconstruction for esophageal squamous cell carcinoma after perioperative management protocol reinvention. J Thorac Dis 2017; 9:2029-2037. [PMID: 28840003 DOI: 10.21037/jtd.2017.06.13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Surgery for esophageal cancer is invasive and challenging, and always to be followed with arduous post-operative care and recovery. This study, maybe one of the first in Asian populations, is to determine whether a reinvented protocol for perioperative management for esophageal cancer surgery which is being implemented in our department, will lead to a faster convalescence and also significantly decrease financial burdens garnered by patients during hospitalization. METHODS Operated on by the same surgeon and team in the same hospital, consecutive patients who had received esophagectomy and reconstruction for esophageal squamous cell carcinoma were retrospectively reviewed. On the basis of two different treatment periods, patients were divided into two groups: A and B. Group A was patients who had received the new reinvented protocol between 2012 and 2016, while group B patients were those having received the previous protocol between 2008 and 2011. Their demographics, post-operative outcome, and hospital charges were collected and compared. RESULTS There were 64 patients in group A, and 69 in group B. Ventilator days (P<0.001), ICU stay (P<0.001), and post-operative stay (P<0.001) were significantly shorter in group A patients. Complication rates were similar between the two groups. No hospital mortality was noted in either group. Hospital charges in group A were found to be perceptively lower, although not statistically significant (P value =0.078). CONCLUSIONS The current protocol of perioperative care effectively ameliorated convalescence after esophagectomy and reconstruction for esophageal squamous cell carcinoma without increasing complication rate or mortality. It is also potentially more practical in future health care policies during this era of financial shortage.
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Affiliation(s)
- Yu-Wei Liu
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Fan-Wei Yan
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Dong-Lin Tsai
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsien-Pin Li
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Lung Lee
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Hsing Chiang
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hung-Te Hsu
- Department of Anesthesia, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung, Taiwan
| | - Hung-Yi Chuang
- Department of Environmental and Occupational Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shah-Hwa Chou
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
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14
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Recent improvements in the management of esophageal anastomotic leak after surgery for cancer. Eur J Surg Oncol 2016; 43:258-269. [PMID: 27396305 DOI: 10.1016/j.ejso.2016.06.394] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/05/2016] [Accepted: 06/18/2016] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.
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Xing X, Gao Y, Wang H, Qu S, Huang C, Zhang H, Wang H, Sun K. Correlation of fluid balance and postoperative pulmonary complications in patients after esophagectomy for cancer. J Thorac Dis 2015; 7:1986-93. [PMID: 26716037 DOI: 10.3978/j.issn.2072-1439.2015.11.24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND To investigate the association between fluid balance and postoperative pulmonary complications in patients after esophagectomy for cancer in a high volume cancer center. METHODS Data of patients who admitted to intensive care unit (ICU) after esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC) between September 2008 and October 2010 were retrospectively collected and reviewed. RESULTS There were 85 males and 15 females. Among them, 39 patients developed postoperative pulmonary complications and hospital death was observed in 3 patients (3.0%). Univariable analysis showed that patients who developed postoperative pulmonary complications had more cumulative fluid balance in day 1 to 2 (2,669±1,315 vs. 3,815±1,353 mL, P<0.001; and 4,307±1,627 vs. 5,397±2,040 mL, P=0.014, respectively) compared with patients who did not have postoperative pulmonary complications. Multivariable regression analysis demonstrated that only more cumulative fluid balance in day 1 (P=0.008; OR =1.001; 95% CI, 1.000-1.002) was independent risk factor for postoperative pulmonary complications. CONCLUSIONS Positive fluid balance in postoperative day 1 is predictive of pulmonary complications in patients after esophagectomy for cancer.
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Affiliation(s)
- Xuezhong Xing
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Yong Gao
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Haijun Wang
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Shining Qu
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Chulin Huang
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hao Zhang
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Hao Wang
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Kelin Sun
- Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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Khasanov AF, Sigal EI, Trifonov VR, Khasanova NA, Baisheva NA, Shaĭmuratov IM, Gubaĭdullin SR, Sigal AM. [The program of accelerated rehabilitation after esophagoplasty (fast track surgery) in esophageal cancer surgery]. Khirurgiia (Mosk) 2015:37-43. [PMID: 26031818 DOI: 10.17116/hirurgia2015237-43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Esophagectomy with simultaneous plasty in patient with esophageal cancer is still associated with a high incidence of postoperative complications and long-stay patient in the clinic. The purpose of our report is to inform the use of the program of accelerated rehabilitation after esophagectomy in a prospective study of 13 patients during the period from 2010 to 2011 year and the role of the anesthesiologist in its implementation. Methods aimed at the preoperative examination, minimally invasive surgery, thoracic epidural anesthesia/analgesia with local anesthetics as a component of anesthesia and postoperative analgesia, early extubation and mobilization of the patient with the implementation of breathing exercises, early enteral feeding, and the planned short postoperative stay in resuscitation and hospital were used. Postoperative complications were observed in 3 (23/1%) patients: one patient (7/7%) had right-side pneumonia, two patients (15/4%) had right-side pneumothorax requiring emergency re drainage. The average intensive care stay was 2 (1-4) days, postoperative hospital stay--9 (7-12) days. Further monitoring of the patients did not show any long-term complications. The results confirm that it is possible to optimize the healing perioperative process in patients after esophagectomy with simultaneous plasty by using of accelerated rehabilitation program without the risk of increasing the frequency of postoperative complications. it will provide the reduction of length of hospital stay. In view of multifaceted and controversial issue the following researches in this direction are necessary.
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Affiliation(s)
- A F Khasanov
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - E I Sigal
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - V R Trifonov
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - N A Khasanova
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - N A Baisheva
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - I M Shaĭmuratov
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - Sh R Gubaĭdullin
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
| | - A M Sigal
- Respublikanskiĭ klinicheskiĭ onkologicheskiĭ dispanser Minzdrava RT, Privolzhskiĭ filial RONTs im. N.N. Blokhina RAMN, Kazan', Rossiia
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17
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Shewale JB, Correa AM, Baker CM, Villafane-Ferriol N, Hofstetter WL, Jordan VS, Kehlet H, Lewis KM, Mehran RJ, Summers BL, Schaub D, Wilks SA, Swisher SG. Impact of a Fast-track Esophagectomy Protocol on Esophageal Cancer Patient Outcomes and Hospital Charges. Ann Surg 2015; 261:1114-23. [PMID: 25243545 PMCID: PMC4838458 DOI: 10.1097/sla.0000000000000971] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the effects of a fast-track esophagectomy protocol (FTEP) on esophageal cancer patients' safety, length of hospital stay (LOS), and hospital charges. BACKGROUND FTEP involved transferring patients to the telemetry unit instead of the surgical intensive care unit (SICU) after esophagectomy. METHODS We retrospectively reviewed 708 consecutive patients who underwent esophagectomy for primary esophageal cancer during the 4 years before (group A; 322 patients) or 4 years after (group B; 386 patients) the institution of an FTEP. Postoperative morbidity and mortality, LOS, and hospital charges were reviewed. RESULTS Compared with group A, group B had significantly shorter median LOS (12 days vs 8 days; P < 0.001); lower mean numbers of SICU days (4.5 days vs 1.2 days; P < 0.001) and telemetry days (12.7 days vs 9.7 days; P < 0.001); and lower rates of atrial arrhythmia (27% vs 19%; P = 0.013) and pulmonary complications (27% vs 20%; P = 0.016). Multivariable analysis revealed FTEP to be associated with shorter LOS (P < 0.001) even after adjustment for predictors like tumor histology and location. FTEP was also associated with a lower rate of pulmonary complications (odds ratio = 0.655; 95% confidence interval = 0.456, 0.942; P = 0.022). In addition, the median hospital charges associated with primary admission and readmission within 90 days for group B ($65,649) were lower than that for group A ($79,117; P < 0.001). CONCLUSIONS These findings suggest that an FTEP reduces patients' LOS, perioperative morbidity, and hospital charges.
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Affiliation(s)
- Jitesh B. Shewale
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Arlene M. Correa
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Carla M. Baker
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Wayne L. Hofstetter
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Victoria S. Jordan
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Katie M. Lewis
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Reza J. Mehran
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Barbara L. Summers
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Diane Schaub
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sonia A. Wilks
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephen G. Swisher
- Department of Thoracic and Cardiovascular Surgery, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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18
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Talsma AK, Damhuis RAM, Steyerberg EW, Rosman C, van Lanschot JJB, Wijnhoven BPL. Determinants of improved survival after oesophagectomy for cancer. Br J Surg 2015; 102:668-75. [DOI: 10.1002/bjs.9792] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Revised: 11/25/2014] [Accepted: 01/27/2015] [Indexed: 11/11/2022]
Abstract
Abstract
Background
Survival after oesophagectomy for cancer seems to be improving. This study aimed to identify the most important contributors to this change.
Methods
Patients who underwent oesophagectomy from 1999 to 2010 were extracted from the Netherlands Cancer Registry. Four time periods were compared: 1999–2001 (period 1), 2002–2004 (period 2), 2005–2007 (period 3) and 2008–2010 (period 4). Hospital type, tumour location, tumour type, tumour differentiation, neoadjuvant therapy, operation type, (y)pT category, involvement of surgical resection margins, number of removed lymph nodes and number of involved lymph nodes were investigated in relation to trends in survival using multivariable analysis.
Results
A total of 4382 patients were identified. Two-year overall survival rates improved from 49·3 per cent in period 1 to 58·4, 56·2 and 61·0 per cent in periods 2, 3 and 4 respectively (P < 0·001). Multivariable survival analysis revealed that the improvement in survival between periods 3 and 4 was related to the introduction of neoadjuvant therapy. The improvement in survival between periods 1 and 2 could not be explained completely by the factors studied. The number of examined lymph nodes increased, especially between periods 2 and 3, but this increase was not associated with the improvement in survival.
Conclusion
The observed increase in long-term survival after surgery for oesophageal cancer between 1999 and 2010 in the Netherlands is difficult to explain fully, although the recent increase seems to be partly attributable to the introduction of neoadjuvant therapy.
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Affiliation(s)
- A K Talsma
- Departments of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - R A M Damhuis
- Department of Registry and Research, Comprehensive Cancer Centre the Netherlands, Utrecht, The Netherlands
| | - E W Steyerberg
- Departments of Public Health, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - C Rosman
- Department of Surgery, Canisius Hospital, Nijmegen, The Netherlands
| | - J J B van Lanschot
- Departments of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - B P L Wijnhoven
- Departments of Surgery, Erasmus MC – University Medical Centre Rotterdam, Rotterdam, The Netherlands
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19
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Fast-track Ivor Lewis esophageal resection. Eur Surg 2015. [DOI: 10.1007/s10353-015-0304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Esper SA, Bottiger BA, Ginsberg B, Del Rio JM, Glower DD, Gaca JG, Stafford-Smith M, Neuburger PJ, Chaney MA. CASE 8--2015. Paravertebral Catheter-Based Strategy for Primary Analgesia After Minimally Invasive Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1071-80. [PMID: 26070694 DOI: 10.1053/j.jvca.2015.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian Ginsberg
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - J Mauricio Del Rio
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Donald D Glower
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | - Peter J Neuburger
- Department of Anesthesiology, New York University Medical Center, New York, NY
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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21
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Zurbuchen U, Schwenk W, Junghans T, Modersohn D, Haase O. Vagus-preserving technique during minimally invasive esophagectomy: the effects on cardiac parameters in a swine model. Surgery 2014; 156:46-56. [PMID: 24929758 DOI: 10.1016/j.surg.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 04/14/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Cardiac complications are an important cause of morbidity and mortality observed after esophageal resections. We examined whether an high intrathoracic vagotomy during abdominothoracic esophagectomy would have an effect on intraoperative and early postoperative cardiac function in the setting of a minimally invasive resection. Two hypotheses were generated for this study: (1) Vagotomy would cause cardiac changes, and (2) vagus-preserving esophagectomy would prevent cardiac problems during resection and in the early postoperative phase. METHODS AND RESULTS Thirty male pigs were operated on while cardiac parameters (heart rate [HR], cardiac index [CI], preload recruitable stroke work [PRSW], contractility speed [dp/dtmax], relaxation speed [dp/dtmin], and relaxation time [tau]) were monitored using a conductance catheter and the thermodilution method. Animals were randomized into 4 groups (each n = 7): (1) control, thoracoscopy only, (2) thoracoscopy with vagotomy, (3) esophageal resection with vagotomy, and (4) esophageal resection with vagus nerve preservation. To evaluate the first hypothesis, we compared groups 1 and 2; to evaluate the second hypothesis, we compared groups 3 and 4. HR, CI, PRSW, dp/dtmax, and tau were different in the 2 groups without resection (area under the curve; each P < .05). Vagotomy with esophagectomy resulted in nonsignificant differences between groups 3 and 4. The requirement for metoprolol administration to avoid severe tachycardia was greater in the groups that underwent vagotomy (P < .05; Fisher's exact test). CONCLUSION An high intrathoracic vagotomy results in loss of vagal tone and a greater rate of tachycardia during thoracoscopy and esophagectomy. There were no differences, however, in cardiac dynamics between the esophagectomy groups. Thus, vagal injury is not the sole reason for cardiac dysfunction after esophagectomy.
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Affiliation(s)
- Urte Zurbuchen
- Department of General, Visceral and Vascular Surgery, Medical Faculty of the Humboldt University, Charité - Campus Benjamin Franklin, Berlin, Germany.
| | - Wolfgang Schwenk
- Department of General and Visceral Surgery, Asklepios Klinik Altona, Hamburg, Germany
| | - Tido Junghans
- Department of General, Visceral, Thoracic and Vascular Surgery, Klinikum Bremerhaven, Bremerhaven, Germany
| | - Diethelm Modersohn
- Department of General, Visceral, Thoracic, and Vascular Surgery, Medical Faculty of the Humboldt University, Charité - Campus Mitte, Berlin, Germany
| | - Oliver Haase
- Department of General, Visceral, Thoracic, and Vascular Surgery, Medical Faculty of the Humboldt University, Charité - Campus Mitte, Berlin, Germany
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22
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Coisel Y, Jourdan A, Conseil M, Pouzeratte Y, Verzilli D, Jung B, Chanques G, Jaber S. [Esophageal cancer surgery: evolution of pain management, hemodynamics and ventilation practices during 16 years]. ACTA ACUST UNITED AC 2014; 33:16-20. [PMID: 24439493 DOI: 10.1016/j.annfar.2013.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Accepted: 12/05/2013] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To describe the evolution of perioperative anesthesia practices in for esophageal cancer surgery. PATIENTS AND METHODS We conducted an observational retrospective study in a single center evaluating main perioperative practices during 16 years (1994-2009). Statistical analysis was done on 4 chronologic quartiles of same sample size. RESULTS Two hundred and seven consecutive patients were included during the 4 periods 1994-1997 (n=52), 1997-1999 (n=52), 1999-2003 (n=52) and 2004-2009 (n=51). The main significant evolutions between the first and the fourth period were observed: (i) in ventilation: lower tidal volume (9.6[8.6-10.6] vs 7.6[7.0-8.3] mL/kg of ideal body weight (IBW), p<0.01), increased use of Positive End Expiratory Pressure (0 vs 83%, p<0.001) and increased use of post-operative non-invasive ventilation (0 vs 51%, p<0.001); (ii) in hemodynamic management: lower fluid replacement (20.6 [16.0-24.6] vs 12.6 [9.7-16.2] mL/h/kg of IBW, p<0.001); (iii) in analgesia: increased use of epidural thoracic anesthesia (31 vs 57%, p<0.001). Peroperative bleeding, type of fluid replacement, length of mechanical ventilation, length of stay in intensive care unit, ventilatory free days and mortality at day 28 didn't change. CONCLUSIONS During these previous years, anesthesia practices in ventilation, hemodynamics and analgesia for esophageal cancer surgery have changed.
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Affiliation(s)
- Y Coisel
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Inserm U1046, université Montpellier 1, Montpellier, France
| | - A Jourdan
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - M Conseil
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - Y Pouzeratte
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - D Verzilli
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
| | - B Jung
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Inserm U1046, université Montpellier 1, Montpellier, France
| | - G Chanques
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Inserm U1046, université Montpellier 1, Montpellier, France
| | - S Jaber
- Département d'anesthésie-réanimation St-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Inserm U1046, université Montpellier 1, Montpellier, France.
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Hajiesmaeili MR, Motavaf M, Safari S. Regional analgesia in intensive care unit. Anesth Pain Med 2013; 3:263-5. [PMID: 24282780 PMCID: PMC3833044 DOI: 10.5812/aapm.10587] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 06/17/2013] [Accepted: 06/27/2013] [Indexed: 11/16/2022] Open
Affiliation(s)
- Mohammad Reza Hajiesmaeili
- Department of Anesthesiology and Critical Care Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
- Pain Research Center, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd, Iran
| | | | - Saeid Safari
- Department of Anesthesiology and Critical Care Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
- Corresponding author: Saeid Safari, Department of Anesthesiology and Critical Care Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran. Tel: +98-9392117300, Fax: +98-2166509059, E-mail:
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Preston SR, Markar SR, Baker CR, Soon Y, Singh S, Low DE. Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Br J Surg 2012; 100:105-12. [DOI: 10.1002/bjs.8974] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2012] [Indexed: 01/27/2023]
Abstract
Abstract
Background
Defined clinical pathways can contribute to improved outcomes in patients undergoing oesophageal cancer surgery. A standardized oesophagectomy clinical pathway (SOCP) established at the Virginia Mason Medical Center (VMMC) in Seattle, Washington, USA was introduced into the Royal Surrey County Hospital (RSCH), Guildford, UK in 2011. The aim of this study was to see whether transfer and implementation of an oesophagectomy care pathway could change postoperative outcomes significantly.
Methods
Three consecutively accrued study groups were examined at the RSCH: patients operated on immediately before the introduction of the SOCP (group 1), patients operated on after the introduction of the SOCP but not included in the pathway (group 2), and patients managed according to the SOCP (group 3). Outcomes were compared with those of patients who had surgery at the VMMC between 2009 and 2011 using the SOCP (group 4).
Results
There were 12 patients in each of the first three groups and 74 in group 4. All groups were similar with respect to body mass index, medical co-morbidities and clinical stage. The median age of patients in group 3 was significantly lower than that in group 1, and median American Society of Anesthesiologists score was significantly better in group 3 compared with group 4. Following initiation of the SOCP there was an increase in immediate extubation (8 of 12 in group 1 versus 12 of 12 in group 3) and first-day mobilization (1 of 12 versus 12 of 12 respectively), and a reduction in complications (9 of 12 versus 4 of 12), length of critical care stay (4 (range 2–20) days in group 1 versus 3 (1–5) days in group 3) and length of hospital stay (17 (12–30) to 7 (6–37) days respectively). Patients not on the pathway but who had surgery during the same interval experienced small but non-significant improvements in length of critical care and hospital stay, and in first-day mobilization.
Conclusion
The study demonstrated improvement in short-term outcomes after oesophagectomy following the adoption of an established multidisciplinary standardized postoperative pathway.
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Affiliation(s)
- S R Preston
- Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - S R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
| | - C R Baker
- Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - Y Soon
- Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - S Singh
- Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK
| | - D E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington, USA
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25
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Early Results: Morbidity, Mortality, and the Treatment of Complications. Updates Surg 2012. [DOI: 10.1007/978-88-470-2330-7_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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26
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Casado D, López F, Martí R. Perioperative fluid management and major respiratory complications in patients undergoing esophagectomy. Dis Esophagus 2010; 23:523-8. [PMID: 20459444 DOI: 10.1111/j.1442-2050.2010.01057.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageal surgery is often related to a high morbidity and mortality rate despite an improvement in postoperative care. Fluid administration has been described to be a factor that contributes to the development of postoperative respiratory complications after esophageal surgery. The aim was to study the relation between intraoperative and postoperative fluid administration and the development of respiratory complications after esophageal surgery. Patients undergoing esophageal surgery for cancer were selected from a prospective nonrandomized computer database. All of the patients underwent esophagectomy according to the Lewis-Tanner approach. Single-lung ventilation was used in all of the patients during the thoracic approach. The patients were divided in two groups with respect to the development of respiratory complications. Variables studied were American Society of Anesthesiologist Score, sex, preoperative chemoradiotherapy, albumin, smoking history, time until extubation, epidural analgesia, and fluid administration intraoperatively and 5 days postoperatively. Forty-five patients were included in the study. Respiratory complications were observed in nine patients (20%). None of the variables studied except fluid administration (P= 0.005 - odds ratio = 1.001 -95% confidence interval) were shown as a risk factor for the development of respiratory complications on the multivariate analysis. Fluid administration intraoperatively and postoperatively has shown to be a contributing factor for the development of respiratory complications after esophageal surgery.
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Affiliation(s)
- D Casado
- Department of Surgery, Hospital Clínico Universitario, Valencia, Spain
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27
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Peri-operative and complication management for adenocarcinoma of the oesophagus and oesophagigastric junction. Recent Results Cancer Res 2010. [PMID: 20676878 DOI: 10.1007/978-3-540-70579-6_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
Surgical resection of oesophageal cancer still offers the only chance of cure for this disease. Nevertheless, oesophageal surgery may be accompanied by relevant mortality and morbidity, the causes of which can be both directly related to surgical technique as well as a large spectrum of non-surgical complications. In the last few years, improvements in patient selection and technical advances, as well as elaborated peri- and post-operative management, have helped to reduce these threats.The following article addresses important aspects of patient selection and evaluation, pre-operative preparation, anaesthesia, operative prophylaxis of complications, immediate post-operative care and complication management. All these factors are important contributions to improve the outcome in this challenging medical condition. Nowadays, experienced centres report operative mortality rates of around 5% for radical transthoracic resections (Low et al. 2007; Or-ringer et al. 2007; Ando et al. 2000; Karl et al. 2000; Whooley et al. 2003), down from rates of up to 30 or 40% in previous decades (Earlam and Cunha-Melo 1980). Many factors have contributed to these improvements; some authors claim large volume centres have a tendency to improve results, mostly due to more aggressive management of post-operative complications (Forshaw et al. 2006; van Lanschot et al. 2001; Smith et al. 2008). The following article summarizes the factors that have been identified in the past decades to influence the outcome of major surgery for the resection of adenocarcinoma of the oesophagus.
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Iscimen R, Brown DR, Cassivi SD, Keegan MT. Intensive Care Unit Utilization and Outcome After Esophagectomy. J Cardiothorac Vasc Anesth 2010; 24:440-6. [DOI: 10.1053/j.jvca.2008.02.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2007] [Indexed: 11/11/2022]
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Abstract
PURPOSE OF REVIEW The most frequent complications of oesophageal surgery are respiratory and these are associated with increased critical care stay, hospital stay and mortality. This review focuses on the risk factors associated with the development of respiratory complications after oesophageal surgery. RECENT FINDINGS An acceptable operative mortality, increased and improved quality of life can be gained in appropriately selected patients. When induction therapy is scheduled, smoking cessation is advised. The preoperative treatment of airway pathogens can reduce postoperative complications and this may be particularly relevant in patients who have received induction chemoradiotherapy. Nonrandomized studies suggest that thoracic epidural analgesia improves outcome. Minimally invasive surgery is increasingly used and appears safe but direct comparisons to open surgery in terms of respiratory complications are awaited. Few randomized studies are available to guide anaesthetic management but anaesthetists should aim to avoid hypoxaemia, hypotension, aspiration and limit blood and fluid administration. Postoperative aspiration is common and steps to reduce it are recommended. SUMMARY The multifactorial nature of respiratory complications after oesophageal surgery may mean that a number of interventions are needed to have a detectable influence on outcome, much like a care bundle strategy.
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Toh Y, Oki E, Minami K, Okamura T. Evaluation of the feasibility and safety of immediate extubation after esophagectomy with extended radical three-field lymph node dissection for thoracic esophageal cancers. Esophagus 2009. [DOI: 10.1007/s10388-009-0198-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
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Zausig YA, Weigand MA, Graf BM. [Perioperative fluid management: an analysis of the present situation]. Anaesthesist 2009; 55:371-90. [PMID: 16508741 DOI: 10.1007/s00101-006-0988-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Optimal perioperative fluid management is still controversial. Besides well known perioperative hypovolaemia, hypervolaemia has an influence on perioperative morbidity and mortality, particularly with regard to the patient's medical history, a reduced cardiac and pulmonal function and the operation itself. The concepts of preoperative, intraoperative and postoperative fluid administration are neither adequately validated, nor sufficiently integrated into a perioperative concept. At the present, moderate fluid administration to improve preoperative and postoperative outcome is safe in minor or medium surgical procedures. High-risk surgical patients benefit from a time-oriented or/and goal-oriented monitored fluid therapy. In the past only little attention has been concentrated on postoperative fluid management, but may be stimulated by the new concepts of fast track surgery.
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Affiliation(s)
- Y A Zausig
- ZARI - Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Universitätsklinikum, Georg-August-Universität, Göttingen, Germany.
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Abstract
Esophageal resection is a formidable operation associated with high morbidity and mortality. Anesthetic management may contribute to the containment of respiratory failure and anastomotic leakage by the use of thoracic epidural analgesia, protective ventilation strategies, prevention of tracheal aspiration, and judicious fluid management.
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Affiliation(s)
- Ju-Mei Ng
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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35
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D’Journo XB, Michelet P, Avaro JP, Trousse D, Giudicelli R, Fuentes P, Doddoli C, Thomas P. Complications respiratoires de l’œsophagectomie pour cancer. Rev Mal Respir 2008; 25:683-94. [DOI: 10.1016/s0761-8425(08)73798-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Van Houdenhoven M, Nguyen DT, Eijkemans MJ, Steyerberg EW, Tilanus HW, Gommers D, Wullink G, Bakker J, Kazemier G. Optimizing intensive care capacity using individual length-of-stay prediction models. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R42. [PMID: 17389032 PMCID: PMC2206463 DOI: 10.1186/cc5730] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2006] [Revised: 02/16/2007] [Accepted: 03/27/2007] [Indexed: 01/04/2023]
Abstract
Introduction Effective planning of elective surgical procedures requiring postoperative intensive care is important in preventing cancellations and empty intensive care unit (ICU) beds. To improve planning, we constructed, validated and tested three models designed to predict length of stay (LOS) in the ICU in individual patients. Methods Retrospective data were collected from 518 consecutive patients who underwent oesophagectomy with reconstruction for carcinoma between January 1997 and April 2005. Three multivariable linear regression models for LOS, namely preoperative, postoperative and intra-ICU, were constructed using these data. Internal validation was assessed using bootstrap sampling in order to obtain validated estimates of the explained variance (r2). To determine the potential gain of the best performing model in day-to-day clinical practice, prospective data from a second cohort of 65 consecutive patients undergoing oesophagectomy between May 2005 and April 2006 were used in the model, and the predictive performance of the model was compared with prediction based on mean LOS. Results The intra-ICU model had an r2 of 45% after internal validation. Important prognostic variables for LOS included greater patient age, comorbidity, type of surgical approach, intraoperative respiratory minute volume and complications occurring within 72 hours in the ICU. The potential gain of the best model in day-to-day clinical practice was determined relative to mean LOS. Use of the model reduced the deficit number (underestimation) of ICU days by 65 and increased the excess number (overestimation) of ICU days by 23 for the cohort of 65 patients. A conservative analysis conducted in the second, prospective cohort of patients revealed that 7% more oesophagectomies could have been accommodated, and 15% of cancelled procedures could have been prevented. Conclusion Patient characteristics can be used to create models that will help in predicting LOS in the ICU. This will result in more efficient use of ICU beds and fewer cancellations.
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Affiliation(s)
- Mark Van Houdenhoven
- Department of Operating Rooms, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Duy-Tien Nguyen
- Department of Operating Rooms, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Marinus J Eijkemans
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Hugo W Tilanus
- Department of Surgery, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Diederik Gommers
- Department of Anesthesiology, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Gerhard Wullink
- Department of Operating Rooms, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Jan Bakker
- Department of Intensive Care, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - Geert Kazemier
- Department of Operating Rooms, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
- Department of Surgery, Erasmus University Medical Center, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Michelet P, Jaber S, Eledjam JJ, Auffray JP. Prise en charge anesthésique de l'œsophagectomie: avancées et perspectives. ACTA ACUST UNITED AC 2007; 26:229-41. [PMID: 17270381 DOI: 10.1016/j.annfar.2006.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 11/21/2006] [Indexed: 01/06/2023]
Abstract
Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation.
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Affiliation(s)
- P Michelet
- Département d'anesthésie-réanimation, hôpital Sainte-Marguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
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Abstract
PURPOSE OF REVIEW To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy. RECENT FINDINGS Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery. SUMMARY Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.
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González-González JJ, Sanz-Alvarez L, Marqués-Alvarez L, Navarrete-Guijosa F, Martínez-Rodríguez E. [Complications of surgical resection of esophageal cancer]. Cir Esp 2006; 80:349-60. [PMID: 17192218 DOI: 10.1016/s0009-739x(06)70987-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Esophageal resection has undergone refinements over recent years, with improved outcomes. However, in-hospital mortality remains above 10% in developed countries and is below 5% in only a select group of hospitals. Morbidity remains high even in high-volume hospitals. We reviewed risk factors in esophageal resection. Pulmonary complications occur mainly in older patients and in those with pulmonary dysfunction, especially %FEV1 or hypoxia. Liver cirrhosis, squamous cell cancer, low patient volume, and cervical anastomoses also increase complication rates. Neoadjuvant chemoradiotherapy, which may be effective in squamous cell tumors, can also increase morbidity. The main cause of morbidity and mortality are pleuropulmonary complications. Also significant are anastomotic leak and esophageal conduit necrosis. A complex procedure such as esophageal resection is better served in specialized teams.
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Affiliation(s)
- Juan José González-González
- Servicio de Cirugía General. Instituto Universitario de Oncología. Hospital Universitario Central de Asturias. Oviedo. Asturias. España.
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Lanuti M, de Delva PE, Maher A, Wright CD, Gaissert HA, Wain JC, Donahue DM, Mathisen DJ. Feasibility and outcomes of an early extubation policy after esophagectomy. Ann Thorac Surg 2006; 82:2037-41. [PMID: 17126107 DOI: 10.1016/j.athoracsur.2006.07.024] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 07/12/2006] [Accepted: 07/13/2006] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although early extubation of esophagectomy patients has been found to be feasible, safe, and associated with low morbidity, there is no uniform standard of care among high volume centers. Our objective is to examine a contemporary series of esophagectomies and identify the feasibility and outcome of an early extubation policy. METHODS This study is a retrospective review of all patients who underwent esophagectomy between January 2003 and December 2004 at the Massachusetts General Hospital. One hundred and two patients were analyzed from 129 consecutive patients who underwent esophagectomy and subsequently divided in two groups: The early extubation group was extubated in the operating room and the late extubation group was extubated in the intensive care unit (ICU). RESULTS Ninety percent were extubated early. Although most patients underwent a transthoracic or thoracoabdominal esophagectomy, the operative approach did not influence failure to extubate. Neoadjuvant therapy was not predictive of extubation failure. Most patients age 70 or greater (86%) were extubated early. There were three nonelective reintubations in the early extubation group secondary to acute respiratory distress syndrome. The median length of stay was 11 days and median ICU stay was one day. The 30-day mortality was 1.9% and the median survival was 28 months. CONCLUSIONS Attention to restricted intraoperative fluid balance, limited blood loss, anesthetic technique, and epidural use permit most patients undergoing esophageal resection to be safely extubated immediately postresection in the operating room.
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Affiliation(s)
- Michael Lanuti
- Division of General Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Michelet P, D'Journo XB, Roch A, Papazian L, Ragni J, Thomas P, Auffray JP. Perioperative Risk Factors for Anastomotic Leakage After Esophagectomy. Chest 2005; 128:3461-6. [PMID: 16304300 DOI: 10.1378/chest.128.5.3461] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Anastomotic leakage after esophagectomy is associated with high postoperative morbidity and mortality. The most important predisposing factors for anastomotic leaks are ischemia of the gastric conduit and low blood oxygen content. The aim of this study was to evaluate the influence of thoracic epidural analgesia (TEA) on the incidence of anastomotic leakage after esophagectomy. DESIGN Retrospective study. SETTING A thoracic surgery and anesthesia department in a teaching hospital. PATIENTS Two hundred seven patients who underwent one-stage esophagectomy between 1998 and 2003. INTERVENTIONS The effects of perioperative factors and postoperative complications on the incidence of anastomotic leakage were analyzed. Leakage was defined as an anastomotic disruption detected by an ionic x-ray contrast study and confirmed by upper endoscopy in the postoperative period. Analyzed factors included effective TEA placed before the surgical procedure. MEASUREMENTS AND RESULTS Anastomotic leakage occurred in 23 patients (11%). This complication was associated with a significant increase in length of stay in the ICU and in the hospital (mean, 19 +/- 16 days vs 9 +/- 7 days [+/- SD], p = 0.008; and 43 +/- 27 days vs 23 +/- 11 days, respectively; p < 0.001). Mortality in patients presenting anastomotic leakage was 26%, compared with 5.4% in the remainder (p = 0.002). Factors independently associated with the incidence of leakage included estimated blood loss per milliliter during the surgical procedure (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.001 to 1.007), the cervical location for anastomosis (OR, 5.4; 95% CI, 1.3 to 22.9), and the development of an ARDS in the postoperative period (OR, 4.1; 95% CI, 2.6 to 176.5). Ninety-three patients benefited from an effective TEA for 4.4 +/- 0.8 days. The use of TEA was independently associated with a decrease in the incidence of anastomotic leakage (OR, 0.13; 95% CI, 0.02 to 0.71). CONCLUSIONS The results of this retrospective study suggest that TEA is associated with a decrease in occurrence of anastomotic leakage.
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Rudin A, Flisberg P, Johansson J, Walther B, Lundberg CJF. Thoracic Epidural Analgesia or Intravenous Morphine Analgesia After Thoracoabdominal Esophagectomy: A Prospective Follow-up of 201 Patients. J Cardiothorac Vasc Anesth 2005; 19:350-7. [PMID: 16130063 DOI: 10.1053/j.jvca.2005.03.013] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Thoracoabdominal esophagectomy is a major surgical procedure that carries significant postoperative morbidity and mortality. Because the choice of analgesic technique may influence outcome, the impact of thoracic epidural or intravenous analgesia was investigated after esophagectomy. DESIGN Prospective observational study during January 1996 until January 2002. SETTING University hospital. PARTICIPANTS All patients undergoing thoracoabdominal esophagectomy during the 6-year period. INTERVENTIONS Patients were prospectively monitored during a 6-year period. Duration of surgery, intraoperative blood loss, fluid administration, postoperative intubation time, intensive care unit (ICU) stay, pain relief and related side effects, postoperative complications, hospital stay, and in-hospital and long-term mortality were compared in relation with the analgesic technique. MEASUREMENTS AND MAIN RESULT Thoracic epidural analgesia with bupivacaine/morphine was used in 166 patients, and intravenous morphine analgesia was used in 35 patients. Postoperative intubation time and ICU stay were similar in both groups. Patients with epidural analgesia experienced less pain. Sedation, respiratory depression, hallucinations, and confusion were more common in the intravenous morphine group. Postoperative weight did not differ between the groups, despite fluid replacement that was higher in the epidural group during the first 24 hours. The in-hospital mortality rate was 0.5%. CONCLUSIONS No differences in morbidity/mortality rates depending on analgesic treatment were observed in patients undergoing thoracoabdominal esophagectomy. Thoracic epidural analgesia provided better pain relief with fewer opioid-related side effects than intravenous morphine analgesia. However, postoperative epidural analgesia was associated with more technical difficulties.
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MESH Headings
- Abdomen/surgery
- Adult
- Aged
- Aged, 80 and over
- Analgesia, Epidural/adverse effects
- Analgesia, Epidural/methods
- Analgesia, Patient-Controlled/methods
- Analgesics, Opioid/administration & dosage
- Analgesics, Opioid/adverse effects
- Analgesics, Opioid/therapeutic use
- Anesthetics, Local/administration & dosage
- Bupivacaine/administration & dosage
- Esophagectomy/adverse effects
- Esophagectomy/mortality
- Female
- Fluid Therapy/methods
- Follow-Up Studies
- Humans
- Infusions, Intravenous/adverse effects
- Infusions, Intravenous/methods
- Intubation, Intratracheal/methods
- Length of Stay
- Male
- Middle Aged
- Morphine/administration & dosage
- Morphine/adverse effects
- Morphine/therapeutic use
- Postoperative Complications/etiology
- Postoperative Complications/prevention & control
- Prospective Studies
- Thoracic Surgical Procedures/methods
- Treatment Outcome
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Affiliation(s)
- Asa Rudin
- Department of Anesthesiology and Intensive Care, Lund University Hospital, Sweden.
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Abstract
PURPOSE OF REVIEW To evaluate the developments in the treatment of advanced esophageal cancer during the past year. RECENT FINDINGS Esophagectomy remains the treatment of choice for resectable esophageal malignancies even in locally advanced disease. Transthoracic en bloc esophagectomy with extended mediastinal lymphadenectomy seems to be superior to transmediastinal resection. Hospital and surgeon volume are the major factors that determine postoperative mortality. Promising short-term results were obtained in larger series with minimally-invasive esophagectomy, but concerns about oncologic appropriateness and the widespread applicability of this approach remain. Although neoadjuvant chemotherapy or radiochemotherapy is widely practiced, only responders appear to benefit. Positron emission tomography with fluorodeoxyglucose has been identified as a promising tool for response evaluation early after the onset of neoadjuvant treatment. Adjuvant chemotherapy or radiochemotherapy may be beneficial in a subgroup of patients after complete tumor resection. SUMMARY The transthoracic approach should be preferred for esophagectomy in locally advanced tumors. The surgeon's experience is the most important determinant of outcome after esophagectomy. Individualized indications for multimodality treatment appear possible.
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Shah M, Pearce A. Oesophagectomy and elective postoperative ventilation. Br J Anaesth 2004; 92:907-8; author reply 908. [PMID: 15145839 DOI: 10.1093/bja/aeh561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Rocker M, Havard TJ, Wagle A. Early extubation after two-stage oesophagectomy. Br J Anaesth 2003; 91:760; author reply 760. [PMID: 14570813 DOI: 10.1093/bja/aeg631] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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