Update on anesthetic management for esophagectomy Ju-Mei Ng

Transcription

1 Update on anesthetic management for esophagectomy Ju-Mei Ng Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women s Hospital, Boston, Massachusetts, USA Correspondence to Ju-Mei Ng, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women s Hospital, 75 Francis Street, Boston, MA 02115, USA Tel: ; fax: ; jng1@partners.org Current Opinion in Anesthesiology 2011, 24:37 43 Purpose of review The article highlights the current important issues surrounding the anesthetic care of patients presenting for esophagectomy. Recent findings With the decline in mortality from esophagectomy in high-volume centers over the last 30 years, focus may now be on decreasing morbidity. Improving the blood supply of the esophageal anastomosis, methods to reduce the incidence of pulmonary complications and optimizing fluid management in these patients are areas in which anesthetic care may contribute. There are also the potential benefits of minimally invasive techniques, which are increasingly being utilized. Summary The incorporation of thoracic epidural analgesia, goal-directed fluid management therapy, protective ventilation during one-lung anesthesia and strategies to improve perfusion of the gastric graft are some aspects which anesthetic care may impact. Keywords anesthesia, esophagectomy, operative management Curr Opin Anesthesiol 24:37 43 ß 2011 Wolters Kluwer Health Lippincott Williams & Wilkins Introduction Whereas overall mortality from esophagectomy has declined over the last 30 years to 8 11%, morbidity may reach 40 50% [1,2]. Anastomotic and cardiopulmonary complications contribute the majority of perioperative morbidity and mortality. Improvement in outcome may be achieved by appropriate risk assessment and patient selection, choice of surgical techniques and their execution, and optimizing perioperative care. Perioperative management of the esophagectomy patient has been previously addressed [3]. This review will concentrate on anastomotic leak (the most common surgical complication) and pulmonary morbidity, and the anesthetic factors that may influence these outcomes, including fluid management, the use of vasopressors and maintenance of conduit perfusion, and thoracic epidural analgesia (TEA). The impact of minimally invasive techniques will also be discussed, and recent studies that may affect outcome highlighted. Anastomotic complications and perfusion of the gastric conduit The incidence of cervical anastomotic complications varies from 15 to 37% [1,2]. Thoracic anastomoses have a lower leak rate but higher morbidity and mortality. Briel et al. [4] documented a conduit ischemia or anastomotic leak rate of up to 10% that accounted for 37% of all hospital deaths after esophagectomy. The configuration of the reconstructions (neoesophagus) predisposes to inadequate blood supply to the furthest position of the conduit, with relative ischemia of the conduit at the anastomotic site. This ischemia is thought to play a role in the sequelae of esophagogastric and esophagocolonic anastomotic leaks in 3 25% of cases [5]. Wound-tissue oxygenation is dependent on vascular anatomy, vasomotor control and arterial tissue oxygen pressure. The fundamental principal is maintenance of adequate perfusion to the anastomosis. Various variables may contribute to anastomotic complications (including technical aspects and patient comorbidities), and some methods are being investigated to improve blood supply in order to reduce the leak rate and subsequent morbidity [6]. Proposed mechanism/technique for improvement of conduit microvascular blood flow include the following: (1) Interaction with local gastric vasomotor tone: (i) Thoracic epidural anesthesia, (ii) Prostaglandins. (2) Reduction of venous congestion: (i) Pharmacological, for example topical or intravenous nitroglycerin, (ii) Surgical interventions, for example venous blood letting ß 2011 Wolters Kluwer Health Lippincott Williams & Wilkins DOI: /ACO.0b013e f7

2 38 Thoracic anesthesia (3) Supercharging the anastomosis of arteries and veins. (4) Ischemic preconditioning of the conduit: (i) Preoperative disruption of conduit blood supply prior to definitive procedure by angiographic embolization, surgery or infusion of vasoactive substances. Further studies of these strategies are needed to establish their efficacy and safety for routine use. Thoracic epidural analgesia Thoracic epidural analgesia is associated with a decreased occurrence of anastomotic leakage [7], improved microcirculation of the distal gastric tube in an experimental model [8] and microvascular perfusion of the gastric conduit in the anastomotic area after esophagectomy [9]. However, aggressive bolus dosing of the epidural with local anesthetic was found to decrease flux at the anastomotic end of the gastric tube when systolic arterial pressure decreased by 30% of baseline [10]. Gastric flux returned to baseline with an epinephrine infusion. As TEA has many other advantages in esophagectomy patients, it is important to incorporate it into the care of these patients, maximize its potential benefits while being attentive to its shortcomings. Measured bolus dosing with a more dilute concentration of local anesthetic, avoidance of hypovolemia and the judicious use of vasopressors are commonly used methods to achieve this goal. Perfusion pressure It is believed that the use of vasopressors may be deleterious to the perfusion of gastrointestinal anastomoses [11] and associated with an increased risk of gastrointestinal anastomotic leakage [12]. Animal studies have demonstrated that vasopressor-induced constriction of the splanchnic vessels may lead to shunting of the microcirculation and local hypoxia [13,14]. Specific to gastric graft perfusion in esophagectomy, the administration of a norepinephrine infusion to restore blood pressure was associated with severe graft hypoperfusion [11] and systemic arterial hypotension induced by local anesthetic bolus decreased flux at the anastomosis [10]. In the study by Theodorou et al. [11] norepinephrine was administered in a hemorrhage model, which naturally adversely affects microcirculation. On the contrary, when the blood pressure decrease caused by local anesthetic bolus was restored by an epinephrine infusion, flux at the anastomotic end of the gastric tube was restored [10]. Systemic arterial hypotension compromises gastric tube tissue perfusion and must be avoided. The use of vasoconstrictive substances under normovolemic conditions has no detrimental effect on gastric microvascular blood flow [15 ], and the intraoperative use of short-acting Key points Anesthetic care may contribute to reduction in morbidity by the incorporation of thoracic epidural analgesia, goal-directed fluid management and protective ventilation during one-lung anesthesia. The fundamentals for maintenance of perfusion pressure to the conduit and prevention of aspiration are emphasized. Modification of the inflammatory response may be key to improving outcome. vasopressors, phenylephrine or ephedrine, has no association with postoperative anastomotic leak [12]. Vasopressors can be safely used to maintain systemic perfusion pressure during esophagectomy when hypovolemia is excluded. This may be beneficial for gastric conduit tissue perfusion when the blood pressure decrease is due to surgical manipulation or epidural administration. However, occult hypovolemia should always be excluded, as it is uncommon for prolonged vasopressor requirement in elective esophagectomy. Minimally invasive esophagectomy Minimally invasive esophagectomy (MIE) is being increasingly used for surgical management of esophageal cancer. The techniques vary from entirely minimally invasive to hybrid procedures in which either the thoracic or the abdominal part of the operation is performed endoscopically. Two recent meta-analyses observed trends in favor of MIE for major morbidity, pulmonary complications, length of ICU/hospital stay and blood loss [16,17]. However, case-control studies were included, with inherent selection and design bias. Nevertheless, studies collectively point towards improved short-term outcomes after MIE with comparable cancer outcomes. It is also uncertain if the inflammatory response associated with esophagectomy is reduced by the use of a more minimally invasive approach. A recent study suggests that laparoscopic-assisted gastric tube reconstruction attenuated postoperative systemic inflammatory response (SIR) [18]. More controlled prospective studies are needed to establish superiority of MIE over the open procedure. This may not be viable as more centers embark on minimally invasive approaches and large numbers of patients would be required to study the end points of interest. The only prospective multicenter study of 99 MIE reported a 2% 30-day mortality, 4.9% incidence of pneumonia and 7.8% anastomotic leak [19]. Results appear promising. The anesthetic implications of MIE [20] include longer operative times, with perhaps longer duration of one-lung ventilation (OLV), possibly prone positioning during

3 Update on anesthetic management for esophagectomy Ng 39 thoracoscopic mobilization of the esophagus and use of TEA. Fluid management The task of balancing perfusion pressure and oxygen delivery to vital organs and the gut mucosa, and the prevention of excessive fluid accumulation that may delay recovery of gastrointestinal function, impair wound and/or anastomotic healing, coagulation, cardiac and respiratory function is challenging [21 25]. There is a growing literature comparing liberal with restrictive fluid management, many demonstrating better outcomes in fluid-restricted patients [21 23,26,27]. Patients who received restricted fluid regimen in major gastrointestinal surgery showed better gastrointestinal recovery time [21 23], reduced overall morbidity [21 23,27] and improved respiratory parameters [22,26]. In an experimental model, intraoperative crystalloid fluid overload compromised anastomotic stability of small bowel anastomoses [28]. This study showed a direct negative impact of fluid overload on function and structure of the ileo-ileal anastomosis, which may have deleterious effects on anastomotic healing and postoperative complications. The two studies specific to esophagectomy were relatively small, nonrandomized case series [26,29]. Kita et al.[26] found that restricting intraoperative fluids reduced postoperative pulmonary complications and shortened the recovery period. Neal et al.[29] reported a reduction in esophagectomy-related morbidity with standardized multimodal management that included TEA, early extubation and more accurately avoidance of excessive volume infusion (mean crystalloid infusion of 4 l). A positive perioperative fluid balance was associated with adverse surgical outcomes in patients after transthoracic esophagectomy or esophagogastrectomy [30]. The exact definition of volume restriction, different fluid regimens and end points used in studies make it difficult to derive guidelines regarding perioperative fluid therapy. Avoidance of fluid overload seems to be the key to better postoperative outcome. The potential for acute lung injury (ALI) during OLV and high incidence of pulmonary complications during esophagectomy makes it imperative that fluid therapy be optimized to avoid exacerbation of ALI. Perhaps goal-directed therapy, with individual maximization of flow-related hemodynamic parameters, which showed reduced hospital stay, postoperative nausea and vomiting, and faster gastrointestinal recovery in various major surgery [31], should be applied during esophagectomy. As the esophageal Doppler, which has acquired a strong evidence base of outcome data [32], is impractical in esophagectomy, another minimally invasive hemodynamic monitoring method should be employed. The pulse contour cardiac output system to evaluate lung water postesophagectomy was found to be a useful parameter of respiratory function and predictive of pulmonary complications [33,34]. Arterial pressure variationguided fluid management has been reviewed recently [35 ]. Results are encouraging although further studies are required to draw any conclusions. The FloTrach/ Vigileo system (Edwards Lifesciences, Irving, CA) was an accurate predictor of intravascular hypovolemia and improved hemodynamic stability postoperatively in two small studies involving esophagectomy patients [36,37]. Another study in major abdominal surgery concluded that it was not a reliable predictor of fluid responsiveness [38]. Potential limits to its usefulness or accuracy during esophagectomy include lung compliance and intrathoracic pressure variations during positioning changes, laparoscopy and intra-abdominal pressure, the open chest, ventilatory settings [tidal volume and positive end-expiratory pressure (PEEP)] during two and OLV, and its use restricted to the intraoperative period if patients are extubated at the end of surgery. Moreover, no outcome data are available. The impact of goaldirected therapy and ideal device for the monitoring of preload dependence during esophagectomy still remains to be investigated. The choice of crystalloids versus colloids as intraoperative fluid therapy and its effect on intestinal anastomotic healing is debatable. Goal-directed therapy during major abdominal surgery showed better recovery of gastrointestinal function and decreased complications [31]. Interestingly, the treatment group received more colloids compared to controls. This was not the aim of the study, but rather a result of the study design. Colloids appeared to have benefits on intestinal anastomotic healing when compared to similar volume crystalloid infusion in an experimental model [39 ]. In animal models, goaldirected colloid therapy, not goal-directed crystalloid therapy or restricting crystalloids, increased intestinal microcirculatory blood flow and tissue oxygen tension after abdominal surgery [40,41]. Another study in the rat model found no difference in anastomotic healing indices between colloid and saline replacement therapy [42]. Perhaps only a goal-directed approach with the appropriate fluid according to type of fluid loss/deficit can improve outcome [43]. Pulmonary morbidity Pulmonary complications are frequent and are the most common cause of postoperative death in esophageal cancer patients [44 46]. Various patient factors (age, performance status, lung function) and perioperative

4 40 Thoracic anesthesia events (duration of surgery and OLV, fluid management, anastomotic leak) have been found to influence pulmonary morbidity and/or ALI [44 49]. The cause appears to be multifactorial, and it may take a combination of different approaches to achieve a reduction in overall pulmonary complications [50 ]. One-lung ventilation Robust inflammatory responses accompany esophagectomy, and may be related to the development of ALI [51 53]. OLV results in an inflammatory response; the period of OLV and surgical manipulation aggravates the alveolar injury and increases leukocyte recruitment in the dependent lung. Alveolar recruitment and accompanying reexpansion/reperfusion lung injury adds further insult [54 56]. The clinical significance of each independent factor on perioperative morbidity after esophagectomy is unclear, but lung protective ventilatory strategies should be employed. These include 5 6 ml/kg tidal volume, optimizing PEEP (setting PEEP above the lower inflection point), limiting plateau and peak inspiratory pressures to less than 25 cmh 2 O and less than 35 cmh 2 O, respectively [57]. Protective ventilation (tidal volume of 5 ml/kg and 5 cmh 2 O of PEEP) during OLV in a piglet model resulted in reduced inflammatory cytokines in the plasma and lung tissue [58] and a similar result was found in the bronchoalveolar lavage fluid of patients during OLV with tidal volume of 5 ml/kg compared to 10 ml/ kg [59]. Utilizing smaller tidal volumes and PEEP during OLV was associated with a decrease in the proinflammatory response after esophagectomy, improved lung function, and earlier extubation [48]. Type of anesthetic Volatile anesthetic have been shown to produce dose and time-dependent immunomodulatory effects; however, studies comparing volatiles with propofol during thoracic surgery and OLV are conflicting. Desflurane [60] and sevoflurane [61] produced attenuated pulmonary inflammatory responses compared to propofol, with a reduction on overall number of adverse events [61]. However, the duration of surgery and OLV was longer in the propofol group, and this has been shown to be a risk factor for pulmonary morbidity [44,47]. On the contrary, sevoflurane was found to cause a greater proinflammatory response than propofol during thoracic surgery [62]. Although the patient population was similar, differences in the time of exposure and OLV, specimen collection method, site(s) and timing, and laboratory techniques do limit comparison of results. Furthermore, the inflammatory response associated with OLV in transthoracic esophagectomy is complex, with a more pronounced response on the ventilated side and the time courses of both sides significantly different [63 ]. Pulmonary complications or anastomotic leakage were also not related to the cytokine concentrations. Therefore the contribution of type of anesthetic to the inflammatory response during esophagectomy and clinical outcome remains unknown. Thoracic epidural analgesia In esophagectomy, TEA provides superior pain relief [64,65], reduces pulmonary complications [66,67], and plays a central role in a multimodal approach or standardized perioperative clinical pathway, which has shown improved outcomes [29,68,69]. No epidural analgesia was an independent risk factor for pneumonia and TEA was the key factor that facilitated immediate or early postoperative tracheal extubation [67]. There are no specific comparative studies of TEA in open versus MIE, although it was found to reduce the risk of in-hospital death during MIE in one study [70]. It would therefore appear rational to continue utilizing TEA in MIE. Prevention of tracheal aspiration Following esophagectomy, patients are prone to episodes of reflux into the remaining proximal esophagus and pharynx as many of the mechanisms that prevent acid reflux are disrupted or absent [71 73]. The lower esophageal sphincter is excised, the stomach is denervated and paralysis of the recurrent laryngeal nerve is often observed [74]. Routine postoperative nasogastric decompression of the gastric conduit for protection against aspiration and to decrease the risk of anastomotic leak from distensioninduced gastric conduit ischemia may itself lead to impaired hypopharyngeal function, patient discomfort, a predisposition to sinusitis, pharyngitis and pneumonia, and may directly lead to perforation [73,75 77]. Gastric conduit decompression after esophagectomy can be achieved safely with a pharyngostomy tube [78] or transcervically [79]. This method has been found to be durable, promote patient comfort and mobility, and has a low incidence of complications. Recent investigations Results of some recent studies of interest are given in the following sections. Cardiovascular morbidity Arrhythmias are common perioperatively. Although majority are benign, symptomatic arrhythmias may be associated with worse outcome [80 82]. Atrial fibrillation has been linked with pulmonary complications and anastomotic leakage with subsequent hemodynamic instability [80]. In a randomized controlled trial of 80 patients undergoing transthoracic esophagectomy, prophylactic administration of intravenous amiodarone significantly reduced the incidence of atrial fibrillation [83 ]. However, this did not relate to reduced ICU or hospital

5 Update on anesthetic management for esophagectomy Ng 41 stay. The incidence of myocardial infarction after esophagectomy is 1 2% [44,45]. Results from the POISE trial [84] and a recent meta-analysis [85] do not support the use of beta-blockers for the prevention of cardiovascular outcome in low or intermediate-risk noncardiac surgery. Inflammatory response The inflammatory response elicited during esophagectomy has been implicated in the development of postoperative complications, particularly respiratory morbidity. Modification of this inflammatory response with a perioperative administration of steroids, prostaglandin E 1, or a protease inhibitor may be useful. A reduction in hypercytokinemia, improved postoperative oxygenation and shortened SIR were reported [86 88]. There was no difference in morbidity or mortality. A metaanalysis involving the administration of intravenous methylprednisolone to decrease the inflammatory response to esophageal resection found quality problems with seven of the eight trials [89]. Larger prospective randomized studies are required. Conclusion Utilization of TEA, goal-directed fluid therapy, maintenance of perfusion pressure, protective ventilation during OLV, and prevention of aspiration are some approaches to reduce pulmonary complications and prevent anastomotic leak. Future research should focus on the modification of the inflammatory response in an effort to improve outcome. References and recommended reading Papers of particular interest, published within the annual period of review, have been highlighted as: of special interest of outstanding interest Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 112). 1 Chang AC, Ji H, Birkmeyer NJ, et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008; 85: Connors RC, Reuben BC, Neumayer LA, Bull DA. Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients. J Am Coll Surg 2007; 205: Ng JM. Perioperative anesthetic management for esophagectomy. Anesthesiol Clin 2008; 26: Briel JW, Tamhankar AP, Hagen JA, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 2004; 198: ; discussion Reavis KM. The esophageal anastomosis: how improving blood supply affects leak rate. J Gastrointest Surg 2009; 13: Enestvedt CK, Thompson SK, Chang EY, Jobe BA. Clinical review: healing in gastrointestinal anastomoses, part II. Microsurgery 2006; 26: Michelet P, D Journo XB, Roch A, et al. Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural analgesia. Chest 2005; 128: Lazar G, Kaszaki J, Abraham S, et al. Thoracic epidural anesthesia improves the gastric microcirculation during experimental gastric tube formation. Surgery 2003; 134: Michelet P, Roch A, D Journo XB, et al. Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy. Acta Anaesthesiol Scand 2007; 51: Al-Rawi OY, Pennefather SH, Page RD, et al. The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy. Anesth Analg 2008; 106: Theodorou D, Drimousis PG, Larentzakis A, et al. The effects of vasopressors on perfusion of gastric graft after esophagectomy. An experimental study. J Gastrointest Surg 2008; 12: Zakrison T, Nascimento BA Jr, Tremblay LN, et al. Perioperative vasopressors are associated with an increased risk of gastrointestinal anastomotic leakage. World J Surg 2007; 31: Krejci V, Hiltebrand LB, Sigurdsson GH. Effects of epinephrine, norepinephrine, and phenylephrine on microcirculatory blood flow in the gastrointestinal tract in sepsis. Crit Care Med 2006; 34: Guzman JA, Dikin MS, Kruse JA. Lingual, splanchnic, and systemic hemodynamic and carbon dioxide tension changes during endotoxic shock and resuscitation. J Appl Physiol 2005; 98: Klijn E, Niehof S, de Jonge J, et al. The effect of perfusion pressure on gastric tissue blood flow in an experimental gastric tube model. Anesth Analg 2010; 110: Demonstrates that the short-term use of vasoconstrictors has no acute detrimental effect on the impaired microvascular blood flow in the gastric conduit. 16 Nagpal K, Ahmed K, Vats A, et al. Is minimally invasive surgery beneficial in the management of esophageal cancer? A meta-analysis Surg Endosc 2010; 24: A recent meta-analysis of 12 studies reporting a trend towards improved shortterm outcomes with the minimally invasive approach compared to open esophagectomy. 17 Biere SS, Cuesta MA, van der Peet DL. Minimally invasive versus open esophagectomy for cancer: a systematic review and meta-analysis. Minerva Chir 2009; 64: Tsujimoto H, Ono S, Sugasawa H, et al. Gastric tube reconstruction by laparoscopy-assisted surgery attenuates postoperative systemic inflammatory response after esophagectomy for esophageal cancer. World J Surg 2010 [Epub ahead of print]. 19 Luketich J, Pennathur A, Catalano PJ, et al. Results of a phase II multicenter study of minimally invasive esophagectomy (Eastern Cooperative Oncology Group Study E2202). J Clin Oncol 2009; 27 (Suppl):15s. 20 Bussieres JS. Open or minimally invasive esophagectomy: are the outcomes different? Curr Opin Anaesthesiol 2009; 22: Lobo DN, Bostock KA, Neal KR, et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 2002; 359: Brandstrup B, Tonnesen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238: Nisanevich V, Felsenstein I, Almogy G, et al. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology 2005; 103: Joshi GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg 2005; 101: Holte K, Sharrock NE, Kehlet H. Pathophysiology and clinical implications of perioperative fluid excess. Br J Anaesth 2002; 89: Kita T, Mammoto T, Kishi Y. Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma. J Clin Anesth 2002; 14: Khoo CK, Vickery CJ, Forsyth N, et al. A prospective randomized controlled trial of multimodal perioperative management protocol in patients undergoing elective colorectal resection for cancer. Ann Surg 2007; 245: Marjanovic G, Villain C, Juettner E, et al. Impact of different crystalloid volume regimes on intestinal anastomotic stability. Ann Surg 2009; 249: Neal JM, Wilcox RT, Allen HW, Low DE. Near-total esophagectomy: the influence of standardized multimodal management and intraoperative fluid restriction. Reg Anesth Pain Med 2003; 28: Wei S, Tian J, Song X, Chen Y. Association of perioperative fluid balance and adverse surgical outcomes in esophageal cancer and esophagogastric junction cancer. Ann Thorac Surg 2008; 86: Bundgaard-Nielsen M, Holte K, Secher NH, Kehlet H. Monitoring of perioperative fluid administration by individualized goal-directed therapy. Acta Anaesthesiol Scand 2007; 51:

6 42 Thoracic anesthesia 32 Abbas SM, Hill AG. Systematic review of the literature for the use of oesophageal Doppler monitor for fluid replacement in major abdominal surgery. Anaesthesia 2008; 63: Oshima K, Kunimoto F, Hinohara H, et al. Evaluation of respiratory status in patients after thoracic esophagectomy using PiCCO system. Ann Thorac Cardiovasc Surg 2008; 14: Sato Y, Motoyama S, Maruyama K, et al. Extravascular lung water measured using single transpulmonary thermodilution reflects perioperative pulmonary edema induced by esophagectomy. Eur Surg Res 2007; 39: Cannesson M. Arterial pressure variation and goal-directed fluid therapy. J Cardiothorac Vasc Anesth 2010; 24: Informative review of the physiology and methods used to measure dynamic parameters of fluid responsiveness. 36 Kobayashi M, Ko M, Kimura T, et al. Perioperative monitoring of fluid responsiveness after esophageal surgery using stroke volume variation. Expert Rev Med Devices 2008; 5: Kobayashi M, Koh M, Irinoda T, et al. Stroke volume variation as a predictor of intravascular volume depression and possible hypotension during the early postoperative period after esophagectomy. Ann Surg Oncol 2009; 16: Lahner D, Kabon B, Marschalek C, et al. Evaluation of stroke volume variation obtained by arterial pulse contour analysis to predict fluid responsiveness intraoperatively. Br J Anaesth 2009; 103: Marjanovic G, Villain C, Timme S, et al. Colloid vs. crystalloid infusions in gastrointestinal surgery and their different impact on the healing of intestinal anastomoses. Int J Colorectal Dis 2010; 25: Experimental data showing that volume overload groups had worse indices of intestinal anastomotic healing, and that colloids were preferable to crystalloids during high volume fluid load. This adds to the growing evidence for the benefits of a less liberal fluid regimen for surgical patients. 40 Hiltebrand LB, Kimberger O, Arnberger M, et al. Crystalloids versus colloids for goal-directed fluid therapy in major surgery. Crit Care 2009; 13:R Kimberger O, Arnberger M, Brandt S, et al. Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon. Anesthesiology 2009; 110: Hotz B, Hotz HG, Arndt M, et al. Fluid resuscitation with human albumin or hydroxyethyl starch are there differences in the healing of experimental intestinal anastomoses? Scand J Gastroenterol 2010; 45: Chappell D, Jacob M, Hofmann-Kiefer K, et al. A rational approach to perioperative fluid management. Anesthesiology 2008; 109: Law S, Wong KH, Kwok KF, et al. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg 2004; 240: Whooley BP, Law S, Murthy SC, et al. Analysis of reduced death and complication rates after esophageal resection. Ann Surg 2001; 233: Ferguson MK, Durkin AE. Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 2002; 123: Tandon S, Batchelor A, Bullock R, et al. Peri-operative risk factors for acute lung injury after elective oesophagectomy. Br J Anaesth 2001; 86: Michelet P, D Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology 2006; 105: Misthos P, Katsaragakis S, Theodorou D, et al. The degree of oxidative stress is associated with major adverse effects after lung resection: a prospective study. Eur J Cardiothorac Surg 2006; 29: McKevith JM, Pennefather SH. Respiratory complications after oesophageal surgery. Curr Opin Anaesthesiol 2010; 23: Concise recent review of the contributors to respiratory morbidity and possible approaches to improve outcome. 51 Kooguchi K, Kobayashi A, Kitamura Y, et al. Elevated expression of inducible nitric oxide synthase and inflammatory cytokines in the alveolar macrophages after esophagectomy. Crit Care Med 2002; 30: Tsukada K, Hasegawa T, Miyazaki T, et al. Predictive value of interleukin-8 and granulocyte elastase in pulmonary complication after esophagectomy. Am J Surg 2001; 181: Cree RT, Warnell I, Staunton M, et al. Alveolar and plasma concentrations of interleukin-8 and vascular endothelial growth factor following oesophagectomy. Anaesthesia 2004; 59: Misthos P, Katsaragakis S, Milingos N, et al. Postresectional pulmonary oxidative stress in lung cancer patients. The role of one-lung ventilation. Eur J Cardiothorac Surg 2005; 27: ; discussion Kozian A, Schilling T, Rocken C, et al. Increased alveolar damage after mechanical ventilation in a porcine model of thoracic surgery. J Cardiothorac Vasc Anesth 2010; 24: Tsai JA, Lund M, Lundell L, Nilsson-Ekdahl K. One-lung ventilation during thoracoabdominal esophagectomy elicits complement activation. J Surg Res 2009; 152: Slinger P. Pro: low tidal volume is indicated during one-lung ventilation. Anesth Analg 2006; 103: Theroux MC, Fisher AO, Horner LM, et al. Protective ventilation to reduce inflammatory injury from one lung ventilation in a piglet model. Paediatr Anaesth 2010; 20: Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg 2005; 101: ; table of contents. 60 Schilling T, Kozian A, Kretzschmar M, et al. Effects of propofol and desflurane anaesthesia on the alveolar inflammatory response to one-lung ventilation. Br J Anaesth 2007; 99: De Conno E, Steurer MP, Wittlinger M, et al. Anesthetic-induced improvement of the inflammatory response to one-lung ventilation. Anesthesiology 2009; 110: Abou-Elenain K. Study of the systemic and pulmonary oxidative stress status during exposure to propofol and sevoflurane anaesthesia during thoracic surgery. Eur J Anaesthesiol 2010; 27: Zingg U, Forberger J, Frey DM, et al. Inflammatory response in ventilated left and collapsed right lungs, serum and pleural fluid, in transthoracic esophagectomy for cancer. Eur Cytokine Netw 2010; 21: This study demonstrates the complexity of the inflammatory response during transthoracic esophagectomy, and emphasizes the difficulties involved in comparing studies and isolating the contributors to this reaction. 64 Flisberg P, Tornebrandt K, Walther B, Lundberg J. Pain relief after esophagectomy: thoracic epidural analgesia is better than parenteral opioids. J Cardiothorac Vasc Anesth 2001; 15: Rudin A, Flisberg P, Johansson J, et al. Thoracic epidural analgesia or intravenous morphine analgesia after thoracoabdominal esophagectomy: a prospective follow-up of 201 patients. J Cardiothorac Vasc Anesth 2005; 19: Popping DM, Elia N, Marret E, et al. Protective effects of epidural analgesia on pulmonary complications after abdominal and thoracic surgery: a metaanalysis. Arch Surg 2008; 143: Cense HA, Lagarde SM, de Jong K, et al. Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic esophageal cancer resection. J Am Coll Surg 2006; 202: Brodner G, Pogatzki E, Van Aken H, et al. A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 1998; 86: Low DE, Kunz S, Schembre D, et al. Esophagectomy: it s not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007; 11: Zingg U, McQuinn A, DiValentino D, et al. Minimally invasive versus open esophagectomy for patients with esophageal cancer. Ann Thorac Surg 2009; 87: Kauer WK, Stein HJ, Bartels H, Siewert JR. Intratracheal long-term ph monitoring: a new method to evaluate episodes of silent acid aspiration in patients after esophagectomy and gastric pull up. J Gastrointest Surg 2003; 7: de Souza DG, Gaughen CL. Aspiration risk after esophagectomy. Anesth Analg 2009; 109: Shackcloth MJ, McCarron E, Kendall J, et al. Randomized clinical trial to determine the effect of nasogastric drainage on tracheal acid aspiration following oesophagectomy. Br J Surg 2006; 93: Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78: ; discussion Lum Cheong RS, Cornwell EE 3rd. Suppurative sinusitis in critically ill patients: a case report and review of the literature. J Natl Med Assoc 1992; 84: Nguyen NT, Slone J, Wooldridge J, et al. Minimally invasive esophagectomy without the use of postoperative nasogastric tube decompression. Am Surg 2009; 75: Sato T, Takayama T, So K, Murayama I. Is retention of a nasogastric tube after esophagectomy a risk factor for postoperative respiratory tract infection? J Infect Chemother 2007; 13:

7 Update on anesthetic management for esophagectomy Ng Rueth NM, Lee N, Groth SS, et al. Pharyngostomy tubes for gastric conduit decompression. J Thorac Cardiovasc Surg 2010; 140: Schuchert MJ, Pettiford BL, Landreneau JP, et al. Transcervical gastric tube drainage facilitates patient mobility and reduces the risk of pulmonary complications after esophagectomy. J Gastrointest Surg 2008; 12: Murthy SC, Law S, Whooley BP, et al. Atrial fibrillation after esophagectomy is a marker for postoperative morbidity and mortality. J Thorac Cardiovasc Surg 2003; 126: Amar D, Burt ME, Bains MS, Leung DH. Symptomatic tachydysrhythmias after esophagectomy: incidence and outcome measures. Ann Thorac Surg 1996; 61: Stippel DL, Taylan C, Schroder W, et al. Supraventricular tachyarrhythmia as early indicator of a complicated course after esophagectomy. Dis Esophagus 2005; 18: Tisdale JE, Wroblewski HA, Wall DS, et al. A randomized, controlled study of amiodarone for prevention of atrial fibrillation after transthoracic esophagectomy. J Thorac Cardiovasc Surg 2010; 140: Prospective randomized trial showing the effectiveness of amiodarone in the prophylaxis of atrial fibrillation after esophagectomy. 84 Devereaux PJ, Yang H, Yusuf S, et al. Effects of extended-release metoprolol succinate in patients undergoing noncardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: Bangalore S, Wetterslev J, Pranesh S, et al. Perioperative beta blockers in patients having noncardiac surgery: a meta-analysis. Lancet 2008; 372: Nakazawa K, Narumi Y, Ishikawa S, et al. Effect of prostaglandin E1 on inflammatory responses and gas exchange in patients undergoing surgery for oesophageal cancer. Br J Anaesth 2004; 93: Farrokhnia E, Makarem J, Khan ZH, et al. The effects of prostaglandin E1 on interleukin-6, pulmonary function and postoperative recovery in oesophagectomised patients. Anaesth Intensive Care 2009; 37: Kawahara Y, Ninomiya I, Fujimura T, et al. Prospective randomized controlled study on the effects of perioperative administration of a neutrophil elastase inhibitor to patients undergoing video-assisted thoracoscopic surgery for thoracic esophageal cancer. Dis Esophagus 2010; 23: Engelman E, Maeyens C. Effect of preoperative single-dose corticosteroid administration on postoperative morbidity following esophagectomy. J Gastrointest Surg 2010; 14: