Intraoperative Management of the Patient Undergoing Esophagectomy

Javier H. Campos, M.D.

Professor Vice Chair for Clinical Affairs Director of Cardiothoracic Anesthesia Executive Medical Director of Operating Rooms Department of Anesthesia

Disclosure
Advisory board member of the ET View Medical, Ltd. Paid consultant ET View Medical, Ltd.

Esophageal Cancer
n=17,000 cases per year U.S.
A B

NCI Esophageal Cancer Research Investment

$5.12B $4.97B $4.83B $4.79B $4.75B

$28.8 M

$30.5 M

$21.6 M

$22.3 M

$22.4 M

Fiscal Year

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (NIH)

General Facts
Esophagectomy is associated with a significant risk of: Morbidity of 50% and Mortality of 10% Bailey SH, et al: Ann Thorac Surg 2003; 75: 217-222 High rates of post-operative morbidity
Anastomotic leaks Tachyarrhythmias Pneumonia

Orringer MB, et al. Ann Surg 2007; 246: 363-72

Pulmonary complications 50%

Outline
Perioperative risk factors Airway management Intubation Lung isolation Extubation Inflammatory response to one-lung ventilation (OLV) Fluid management Vasoactive agents Summary

Perioperative Risk Factors After Esophagectomy

Retrospective study in 168 patients ALI 23.8%, ARDS 14.5% Mortality in the ARDS patient was 50% hx smoking Experience of surgeon Duration of operation and OLV Anastomotic leak
Tandom S, et al: Br J Anaesth 2001; 86: 633-638

Comparison of Hospitals with More Than 20 Esophageal Resections Per Year Versus Hospitals with Lower Case Loads

Citation Begg Van Lanscht Kuo Dimick Gilison Birkmeyer Urbach Finlayson Random Combined (8)

Year 1998 2001 2001 2001 2002 2002 2003 2003

Effect OddsRatio .23 .43 .25 .16 .99 .42 .66 .41 .42

Lower Upper Confidence Interval P-Value .03 .30 14 .09 .67 .34 .38 .34 .31 1.74 .64 .45 .31 1.47 .53 1.15 .51 .58 .12 .00 .00 .00 ..95 .00 .14 .00 .00 N Total 503 1892 1193 1136 1076 6337 613 5282 18032
Favors Vol >20 OP/yr Favors Vol < 20 Op/yr

Metzger R, et al: Dis Esophagus 2004;17:310-314

Volume Hospital Esophagectomies (results of 13 publications)

(< 5 per year)

(5-10)

(11-20)

(>20)

Metzger R, et al: Dis Esophagus 2004;17:310-314

Surgical Approaches to Esophagectomy

Transhiatal esophagectomy Abdominal Cervical esophagogastric anastomosis Trans-thoracic
Thoracoabdominal +/- neck Ivor Lewis (R-thoracotomy + abdominal) McKeown (3-hole) in block

Minimal invasive esophagectomy

Transhiatal Dissection

Orringer MG, et al: OP Tech Thorac Cardiovasc Surg 2005: 63-83

Transhiatal Dissection
A B

Orringer MG, et al: OP Tech Thorac Cardiovasc Surg 2005: 63-83

Transhiatal Esophagectomy without Thoracotomy

n=1,950 transhiatal esophagectomies n=4 intraoperative deaths (<1%) due to

mediastinal bleeding
n=6 Postoperatively (<1%) required

thoracotomy for control mediastinal bleeding

Anastomotic leak 13%
Orringer MG, et al: OP Tech Thorac Cardiovasc Surg 2005: 63-83

Transhiatal Esophagectomy: Clinical Experience and Refinements

Orringer MB, et al: Ann Surg 1999;230:392-400

Radical En Bloc Esophagectomy

A

Altork NK, et al: OP Tech Thorac Cardiovasc Surg 2005: 84-98

Esophageal Cancer

Esophagectomy
Need for rapid sequence induction Frequent need for postop ventilation Non-pulmonary surgery Usually R-sided lung collapse

Bronchial Blockers
Advantages Need for rapid sequence induction Awake fiberoptic bronchoscopy Intubated patient/need for postop ventilation Disadvantages Displacement and malposition Inability to good suction Speed of lung collapse
Campos JH: Curr Opin Anaesthesiol 2007; 20:2731.

Double-Lumen Endotracheal Tubes

Advantages Full access to both lungs for ventilation, suctioning, CPAP Less malposition Disadvantages Difficult airways Rapid sequence induction?? Tube size
Campos JH: Curr Opin Anaesthesiol 2007; 20:2731.

Campos JH: Curr Opin Anaesthesiol 2009; 22:4-10

Inflammatory Response in Esophagectomy

Author
Zingg U Dur Cyt Ntw 2010; 21: 50-57

N
29

Surgical Approach
Transthoracic esophagectomy

Inflammatory Response
IL-6, IL-IRA in left ventilated lung and peripheral blood

Outcome cytokine in vent. lung

No correlation with pulmonary complications 4th day increased cytokine Correlate pulmonary complications

DJourno X Eur J Cardiothorac Surg 2010; 37: 1144-1151

97 Group I pulm Group II non-pulm

Transthoracic esophagectomy

IL-6, IL-8,IiL-10, TNF

Inflammatory Response to One-Lung Ventilation

Propofol

Sevoflurane

Propofol

Sevoflurane

Conno ED, et al: Anesthesiology 2009;110:131626

Intraoperative Fluids Administration and Esophagectomy

Bundgaard-Nielsen M, et al: Acta Anaesthesiol Scand 2009; 53: 843-851

Restrictive Fluids Pro:

RCT, 156 pts (Israel) Elective bowel resections Liberal: 12ml/kg/hr (LR) Restrictive: 4ml/kg/hr (LR) Fluid challenges for bleeding or hypotension
Nisanevich V, et al: Anesthesiology 2005; 103: 25-32

Restrictive Fluids Pro:

Outcomes
Significantly less fluid (3.6 vs 1.2) l and < weight gain Less patients with complications Earlier return of bowel function Earlier hospital discharge (8 vs 9 days)

Nisanevich V, et al: Anesthesiology 2005; 103: 25-32

Restrictive Fluids Con:

Prospective, randomized study, France n=70 pts (gastric, hepatic, pancreas, resection) Goal directed therapy (esophageal doppler probe) blood flow velocity 6ml/kg/hr vs 12ml/kg/hr Fluid challenge for P V >13% Outcome
Futier E, et al: Arch Surg 2010; 145: 1193-1200

Restrictive Fluid Con:

Statistically significant outcomes in restrictive

group
More hypovolemic episodes (3.8 vs 1.2) Less overall fluid (3040 vs 5266) mL Lower venous saturation (intraop and postop) More anastomotic leaks (12 vs 4 cases) More sepsis (16 vs 5 cases) More ALI/ARDS
Futier E, et al: Arch Surg 2010; 145: 1193-1200

Perioperative Fluid Management and Pulmonary Complications after Esophagectomy (Lewis Tanner)
n=45 patients (divided according to complications) Pulmonary complications group n=9 intraop fluids 5415 810 cc balance No pulmonary complications n=36 intraop fluids 4174 1033 cc balance

Outcomes: > pneumonia, ALI and ARDS

Casado D, et al: Dis Esoph 2010; 23: 523-528

Preoperative Deficits
Fasting Does NOT change intravascular volume Bowel preparation Can induce intravascular deficit However not routinely used for esophagectomy patient, unless colon interposition is planned

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Intraoperative Deficits
Evaporative losses Third spacing/edema Bleeding Vasodilation

Fluid and Weight Gain

Chappel D, et al: Anesthesiology 2008; 109: 723-740

Perioperative Weight Gain and Mortality of Patients.

Overall Mortality (%)

Perioperative Weight Gain (%)

Chappel D, et al: Anesthesiology 2008; 109: 723-740

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Volume Effect of Colloid is Context Sensitive

Normovolemic hemodilution Volume loading

120

Volume Effect (%)

100 80 60 40 20 0
6% HES 200/0.532 5% human albumin32 6% HES 130/0.431

6% HES 200/0.533

5% human albumin33

Chappel D, et al: Anesthesiology 2008; 109: 723-740

Pulmonary Morbidity Following Esophagectomy is Decreased with a Multimodal Anesthetic Regimen

Restrictive strategy (not fluid balance <4L) n=83 (NR)

n=84 (SR)
Intraop Crystalloid 250 ml/h Additional as needed to maintain UO >0.5 ml/kg/h Colloid 1:1 with blood loss Norepinephrine to maintain MAP?65 mmHg SICU Crystalloid 150 ml/h

Pulmonary complications 26% vs 42%

Buise M, et al: Acta Anaesth Belg 2008; 59: 257-261

Preoperative Fluid Therapy

SR (n=84) Fluids in Crystalloids (ml) Colloids (ml) Packet cells (ml) Fluids out Blood loss (ml) Urine production (ml/kg/hr) Total fluid balance (ml) 1432 92 1.77 0.15 + 5100 277 1129 115 1.17 0.10 + 3683 241* 5630 189 1917 94 589 43 3670 266* 460 77 600 133 NR (n=83)

Buise M, et al: Acta Anaesth Belg 2008; 59: 257-261

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Fluid Management in Esophagectomy

Baseline crystalloid sol. to replace insensible

perspiration and urine output

Replace initial blood loss with crystalloid or

colloid to maintain euvolemic

Albumin if risk of renal injury or hypoalbuminemia

Blood transfusion of threshold reacher

Chappel D, et al: Anesthesiology 2008; 109: 723-740

Hemodynamic Goal Therapy Meta Analysis

RCT adult surgical pts: 26 trials/4188 pts Manipulation of hemodynamics with fluids and/or

inotropes within 8 hrs after surgery (optimization oxygen delivery)

Reduction on: - infection rates

- pneumonia - urinary tract infection

Dalfino L, et al: Critical Care 2011; 15: 1-14

Norepinephrine
Inotropes associated with higher mortality after

esophagectomy
Ferguson MK, et al: World J Surg 1997; 21: 1599: 664

Inotropes correlate with leak-related mortality after

esophagectomy
Whooley BP, et al: Am J Surg 2001; 181: 198-203

Inotropic support associated with development of

ARDS
Tandon S, et al: BR J Anaesth 2001, 86: 633-638

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Early Extubation and Outcomes After Esophagectomy

Author
Chandrashekar MV Br J Anaesth 2003; 90: 474-9 Lanuti M: Ann Thorac Surg 2006; 82: 2037-41

N
76 retrospective (UK) 102 retrospective (MGH)

Operation
Ivor-Lewis Two stage with field lymphadenectomy Transthoracic or Thoraco-abdominal esophagectomy

Outcome
73 extubated in OR 3 remain intubated 7 reintubation (10%) 92 extubate in OR 2 emergent intubation 3 delayed reintubation for ARDS

n=11 n=43 n=34 n=4

n=1 n=6 n=3 n=0

Lanuti M, et al: Ann Thorac Surg 2006; 82: 2037-2041

Summary
Aspiration risk (pre and post) OLV and lung protection Fluid management crystalloids/ colloids Maintain hemodynamic stability (inotropes ??) Early extubation desirable Outcomes worst for postop pulmonary

complications
javier-campos@uiowa.edu http://www.anesth.uiowa.edu/

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