Approaches to Perioperative Care for Esophagectomy

Bartels, Karsten; Fiegel, Matthew; Stevens, Quinn; Ahlgren, Bryan; Weitzel, Nathaen

doi:10.1053/j.jvca.2014.10.029

Cited by 20 publications

(13 citation statements)

References 77 publications

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“…Few observations also suggest restrictive fluid management for patients undergoing esophagectomy [4, 16, 17]. To date, this recommendation is based on very limited evidence.…”

Section: Discussionmentioning

confidence: 99%

“…While nowadays restrictive intraoperative fluid management is accepted as favourable in esophageal surgery as well as in other major abdominal operations [4], very little evidence exists supporting this regimen, and even less concerning the early postoperative phase. Small studies were able to establish a correlation between intraoperative fluid overload and increased postoperative pulmonary morbidity as well as an increased number of surgical complications after esophageal surgery [5–7].…”

Section: Introductionmentioning

confidence: 99%

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Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients

et al. 2017

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BackgroundRestrictive intraoperative fluid management is increasingly recommended for patients undergoing esophagectomy. Controversy still exists about the impact of postoperative fluid management on perioperative outcome.MethodsWe retrospectively examined 335 patients who had undergone esophagectomy for esophageal cancer at the University Hospital Freiburg between 1996 and 2014 to investigate the relation between intra- and postoperative fluid management and postoperative morbidity after esophagectomy.ResultsPerioperative morbidity was 75%, the in-hospital mortality 8%. A fluid balance above average on the operation day was strongly associated with a higher rate of postoperative mortality (21% vs 3%, p < 0.001) and morbidity (83% vs 66%, p = 0.001). Univariate analysis for risk factors for adverse surgical outcome (Clavien ≥ III) identified ASA-score (p = 0.002), smoking (p = 0.036), reconstruction by colonic interposition (p = 0.036), cervical anastomosis (p = 0.017), blood transfusion (p = 0.038) and total fluid balance on the operation day and on POD 4 (p = 0.001) as risk factors.Multivariate analysis confirmed only ASA-score (p = 0.001) and total fluid balance (p = 0.001) as independent predictors of adverse surgical outcome.ConclusionIntra- and postoperative fluid overload is strongly associated with increased postoperative morbidity. Our results suggest restrictive intra- and especially postoperative fluid management to optimize the outcome after esophagectomy.

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“…Few observations also suggest restrictive fluid management for patients undergoing esophagectomy [4, 16, 17]. To date, this recommendation is based on very limited evidence.…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients

et al. 2017

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“…This is likely because, in the planning stages of our study, several conditions were different than during the period when the study was implemented. For example, the approach to one of the most morbid thoracic procedures – esophagectomy - was changed from being performed commonly in an open to a minimally-invasive/thoracoscopic approach [20]. More severe pain from a thoracotomy incision has been associated with higher incidences of pulmonary complications after thoracic surgery [1].…”

Section: Discussionmentioning

confidence: 99%

Heated humidified high-flow nasal cannula oxygen after thoracic surgery — A randomized prospective clinical pilot trial

Brainard

Scott

Sullivan

et al. 2017

Journal of Critical Care

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Background Thoracic surgery patients are at high-risk for adverse pulmonary outcomes. Heated humidified high-flow nasal cannula oxygen (HHFNC O2) may decrease such events. We hypothesized that patients randomized to prophylactic HHFNC O2 would develop fewer pulmonary complications compared to conventional O2 therapy. Methods and Patients Fifty-one patients were randomized to HHFNC O2 vs. conventional O2. The primary outcome was a composite of postoperative pulmonary complications. Secondary outcomes included oxygenation and length of stay. Continuous variables were compared with t-test or Mann-Whitney-U test, categorical variables with Fisher’s Exact test. Results There were no differences in postoperative pulmonary complications based on intention to treat [two in HHFNC O2 (n=25), two in control (n=26), p=0.680], and after exclusion of patients who discontinued HHFNC O2 early [one in HHFNC O2 (n=18), two in control (n=26), p=0.638]. Discomfort from HHFNC O2 occurred in 11/25 (44%); 7/25 (28%) discontinued treatment. Conclusions Pulmonary complications were rare after thoracic surgery. Although HHFNC O2 did not convey significant benefits, these results need to be interpreted with caution, as our study was likely underpowered to detect a reduction in pulmonary complications. High rates of patient-reported discomfort with HHFNC O2 need to be considered in clinical practice and future trials.

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“…This means that the incision is performed in an area which has not been subject to previous radiotherapy (if used) and, in the event of a leak, a cervical drain is technically easier to insert. 7 The transdiaphragmatic (or thoracolaparotomy) approach involves an incision from the thoracotomy site to the umbilicus, dividing the diaphragm surgically ( Fig. 2).…”

Section: Surgical Approaches and Anaesthetic Considerationsmentioning

confidence: 99%

“…17 The risk of developing respiratory complications can be minimized by adequate analgesia, reversal of muscular block, normothermia, and haemodynamic stability. 7 Extubation at the end of surgery has been shown to be safe for most patients. 13 Pneumonia is a common and potentially serious complication, which is associated with a higher risk of death both perioperatively and at 5 yr follow-up.…”

Section: Respiratorymentioning

confidence: 99%