The Effect of Tidal Volume on Pulmonary Complications following Minimally Invasive Esophagectomy: A Randomized and Controlled Study

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1 The Effect of Tidal Volume on Pulmonary Complications following Minimally Invasive Esophagectomy: A Randomized and Controlled Study Yaxing Shen, MD, Ming Zhong, MD, Lijie Tan, MD Zhongshan Hospital,Fudan University, Shanghai, China The authors had nothing to disclosure

2 Outline Background Methods Results Discussion

3 Pulmonary complications Background Atkins BZ, Shah AS, Hutcheson KA, Mangum JH, Pappas TN, Harpole DH Jr, D'Amico TA. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg, 2004; 78:

4 Background Chest X ray 1 day post-op The operative side Chest X ray 1 day post-op The ventilative side Objective: The role of SLV in PC Low tidal volume and its effect on PC

5 Study design: Methods Registered: Clinicaltrial. gov (No.NCT ) The Ethics Committee of Zhongshan Hospital (No ) A prospective, randomized, controlled trial Time periods: June 2011 and July 2012

6 Patients: Methods The inclusion criteria for MIE were Clinically staged T1-3N0M0 tumors; No previous history of cancer; No previous history of neck or chest surgery; ASA score of I-II. The exclusion criteria for MIE were Preexisting COPD/asthma/interstitial lung disease; Heart/liver or renal dysfunction; Preoperative corticosteroid treatment.

7 Methods Operation Three stage MIE Semi prone position Artificial CO 2 Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR, Schauer PR, Close JM, Fernando HC. Minimally invasive esophagectomy: outcomes in 222 patients. Ann Surg 2003; 238(4):

8 Methods Randomization: MIE patients assigned to PV or CV Thoracic stage Abdominal and cervical stage

9 Methods Perioperative management Combined epidural and general anesthesia Intra-operative monitoring PaO 2 /FiO 2 follow-up (4 time points) Lavage collection: The left lung (2 time points) Mini-BAL IL-1ß.IL-6.IL-8

10 Methods Definition of Pulmonary Complications Therapeutic bronchoscopy due to bronchial secretion; Pneumonia per clinical and radiographic criteria; ALI/ARDS requiring reintubation; Pleural effusion requiring post-op chest drainage; Pulmonary embolism. Wright CD, Kucharczuk JC, O Brien SM, Grab JD, Allen MS. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg. 2009; 137(3):

11 Results

12 Results

13 Results The oxygenation index recorded at the time of intubation, and 18h 48h 72h after the operation.

14 Results The IL changes from the ventilation lung reached significant difference between PV and CV group (Recorded at the intubation and 18h after MIE).

15 Results

16 Results Pulmonary complications Over-all incidence: 17.82% 9.43% versus 27.08% in PV and CV PV CV 2 0 ARDS Pneumonia Pleural Effusion Pulmonary atelactasis

17 Discussion Lung injury due to single lung ventilation In double lung ventilation VT=8ml/kg Fit for single lung ventilation? Sihag S, Wright CD, Wain JC, Gaissert HA, Lanuti M, Allan JS, Mathisen DJ, Morse CR. Comparison of perioperative outcomes following open versus minimally invasive Ivor Lewis oesophagectomy at a single, high-volume centre. Eur J Cardiothorac Surg. 2012; 42(3):

18 Discussion Decreased VT from 8ml/kg to 5ml/kg The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000; 342(18):

19 Discussion SLV in MIE: Semi prone position Artificial Pneumothorax Altered V/Q ratio PEEP Improved post-op OI Richard JC, Bregeon F, Costes N, Bars DL, Tourvieille C, Lavenne F, Janier M, Bourdin G, Gimenez G, Guerin C. Effects of prone position and positive end-expiratory pressure on lung perfusion and ventilation. Crit Care Med. 2008; 36(8): Feng M, Shen Y, Wang H, Tan L, Zhang Y, Khan MA, Wang Q. Thoracolaparoscopic esophagectomy: is the prone position a safe alternative to the decubitus position? J Am Coll Surg. 2012; 214(5):

20 Discussion Inflammatory response: Open esophagectomy 52 pts randomized VT: 9ml/kg or 5ml/kg+5cm H 2 O PEEP Serum samples for ILs Decreased systemic inflammatory response Michelet P, D'Journo XB, Roch A, Doddoli C, Marin V, Papazian L, Decamps I, Bregeon F, Thomas P, Auffray JP. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study.anesthesiology. 2006; 105(5):

21 Discussion Inflammatory response: Intubation and 18hrs following OP Harvested from the ventilative lung

22 Discussion Inflammatory response Makino H, Kunisaki C, Kosaka T, Akiyama H, Morita S, Endo I. Perioperative use of a neutrophil elastase inhibitor in videoassisted thoracoscopic oesophagectomy for cancer. Br J Surg. 2011; 98(7):

23 Discussion Pulmonary complications PV CV 2 0 ARDS Pneumonia Pleural Effusion Pulmonary atelactasis Richard JC, Bregeon F, Costes N, Bars DL, Tourvieille C, Lavenne F, Janier M, Bourdin G, Gimenez G, Guerin C. Effects of prone position and positive end-expiratory pressure on lung perfusion and ventilation. Crit Care Med. 2008; 36(8):

24 Discussion From Open to Minimally invasive Esophagectomy The MIE minimized operative injury The SLV induced ventilative injury The effect of ventilation became evident The regional inflammatory response Predicted pulmonary complications Richard JC, Bregeon F, Costes N, Bars DL, Tourvieille C, Lavenne F, Janier M, Bourdin G, Gimenez G, Guerin C. Effects of prone position and positive end-expiratory pressure on lung perfusion and ventilation. Crit Care Med. 2008; 36(8):

25 Discussion VT Lung Injury Inflammatory Response Pulmonary Complication

26 Discussion Limitations Single center Case volume The comparison of subgroups of PC

27 Thank you & Welcome to Shanghai!

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