Editorial II

How can we improve the outcome of oesophagectomy?

K.M. Sherry

Approximately 2000 oesophagectomies are performed in England each year with a 30-day mortality of between 9.5 and 10.5%.1 Most surgeons that perform oesophagectomies within the UK have a practice of fewer than 40 patients per year, many less than 20 patients per year. This then is a low volume but high-risk operation. Long term survival after surgery for oesophageal cancer remains gloomy with fewer than 25% of patients surviving for 5 yr.2 3 There is a need to identify perioperative factors implicated in a poor post-operative outcome so those patients vulnerable to complications can be targeted for more intensive monitoring and treatment. In order to provide sufficient patient numbers for analysis, most studies of perioperative risk for oesophagectomy have been performed on retrospective data acquired over several years. It is widely recognized that pulmonary complications following oesophagectomy are associated with patient death, either as a primary condition or secondary to complications such as cardiovascular disorders or sepsis, and so post-operative pulmonary complications are viewed as a legitimate surrogate marker for outcome. Tandon and colleagues,4 in this issue of the British Journal of Anaesthesia, have used retrospective data from an oesophageal cancer database established within their unit and anaesthetic charts to determine perioperative factors associated with acute lung injury, and more particularly adult respiratory distress syndrome, following oesophagectomy for cancer. In doing this they have advanced our understanding of the operative risks. They have reconfirmed some known risks and identified others, some of which are particularly relevant to the anaesthetic management of oesophagectomy patients.

Within the UK, large centres have reported their hospital mortality as between 5 and 8.8%,2 3 5 6 all below the 10% national average and leading to a supposition that centres, or individuals, with a lower volume of cases may have increased the average by their poorer results. Dalrymple-Hay and colleagues2 gave weight to this supposition by noting an improvement in the in-hospital mortality of a single surgeon over time. Three studies using the American Medicare database,7 the Surveillance, Epidemiology and End Results (SEER)–Medicare linked database8 and the Californian Office of Statewide Health Planning and Development figures9 confirm that it is the volume of oesophagectomies performed in a centre and, hence, its experience with this operation, not the size of a hospital or its specialization in cancer surgery, that affects patient outcome. Two of these studies,8 9 determined that hospitals with six or more oesophagectomies per year had a 30-day mortality of between 3.4 and 4.8%, compared with 16 and 17.3% in hospitals with five or fewer. However, higher volume centres also had very variable results, the hospitals that performed more than six oesophagectomies each year had 30-day mortality figures between 0 and 14%,8 indicating factors other than the hospital volume contribute to outcome. Tandon and colleagues4 identified that the experience of the surgeon was associated with a reduction in the development of acute lung injury post-operatively. The impact of the surgeon’s experience has been measured in factors including reduced single-lung operating time and reduced blood loss.10 The impact from the concurrent increasing experience of the acute care team, anaesthetists, intensive care doctors, nurses, physiotherapists, etc., and their contribution by improvements in the management of the patient before, during, and after the operation, is not easily quantifiable, although is probably also important. What is evident is that it is those centres, surgeons, and teams with the most experience of oesophageal surgery, not the size or type of hospital, that achieve the best results following oesophagectomy and that oesophageal surgery should be concentrated in tertiary referral centres.

There are three conditions that are implicated in early post-oesophagectomy death that might be influenced by anaesthetic management; pulmonary disorders, anastomotic breakdown, and cardiovascular disease.

Pulmonary disorders

Combined data, mostly from retrospective studies, suggests that approximately 25% of patients suffer from post-operative pulmonary complications following oesophagectomy.11 12 Retrospective studies rely on clinical detection and recording, and may underestimate the true incidence. A prospective study by Crozier and colleagues13 of 20 oesophagectomy patients reported post-operative pulmonary complications, as diagnosed by a temperature greater than 38°C on post-operative day 1, and radiographic evidence of pulmonary infiltrates, in 50% of patients. Post-operative mortality or respiratory problems have been associated with pre-operative pulmonary dysfunction,14 15 reduced vital capacity,16 and a history of smoking.4 To date there has been little investigation of operative factors that may be implicated in post-operative pulmonary complications. Tandon and colleagues4 in their analysis of 146 patients have now linked post-operative adult respiratory distress syndrome to an operative hypoxaemia index, that is the amount of hypoxaemia during one-lung ventilation, standardized for time during one-lung ventilation. This is an important finding as hypoxaemia during one-lung ventilation is very much in the province of anaesthetic management. It is upper gastrointestinal surgeons that undertake most oesophageal surgery in the UK, possibly 80%,1 and in centres with low numbers of oesophagectomies the anaesthetic management falls mostly to those with little regular practice of one-lung anaesthesia, unless they are also thoracic anaesthetists. Deficiencies in the management of double lumen tubes during one-lung anaesthesia for oesophageal operations were highlighted in the 1996/1997 Report of the National Confidential Enquiry into Perioperative Deaths.1 This noted, in particular, deficiencies in the recognition and management of badly positioned tubes, and in the prompt and appropriate management of hypoxaemia. What then constitutes sufficient frequency of use of one-lung ventilation to gain proficiency in the technique? Even the most experienced thoracic anaesthetists continue to have problems with double lumen tube positioning. There is also a need to keep up to date with investigations into appropriate ventilation strategies for one-lung ventilation, for example the use of pressure controlled ventilation17 and ‘best’ positive end expiratory pressure.18 Having gained proficiency in one-lung ventilation, what frequency of use is required to maintain it? There is no answer to this other than opinion, but surely, it should be counted in the number of double lumen tubes used per week, not the number per month or year. Those with an infrequent use of double lumen tubes need to review their competency and consider ways in which they can increase their experience. Alternatively, should anaesthetists with infrequent use of double lumen tubes avoid their use during oesophagectomy operations and place more reliance on lung retraction? Again, there is little information. It could be expected that two-lung ventilation in those with an open chest would produce ventilation/perfusion mismatch and severe pulmonary shunt, with most ventilation going to the non-dependant lung and most perfusion to the dependant lung. However, Tachibana and colleagues19 compared one-lung ventilation with two-lung ventilation in 30 patients undergoing transthoracic oesophagectomy and found greater pulmonary shunting in those having one-lung ventilation. Presumably, during two-lung ventilation lung retraction compensated for the mismatch by directing a proportion of ventilation to the unretracted dependant lung. Tsui and colleagues20 in a study of 42 oesophagectomy patients found that two-lung high frequency positive pressure ventilation produced fewer severe hypoxic episodes (defined as a SaO2 <80% at a FIO2 of 1.0) and lower peak and mean airway pressures when compared with one-lung ventilation. There is clearly a need for further investigations into ventilation strategies during oesophagectomy operations.

Anastomotic leaks

Anastomotic leaks after oesophagectomy are reported in 10–15% of cases11 12 and are implicated in mediastinitis, systemic sepsis, adult respiratory distress syndrome, and death. However, diagnosis is primarily on clinical recognition and some leaks may not be detected. Tanomkiat and Galassi21 in a prospective radiological study of 114 patients who had undergone oesophageal surgery found anastomotic leaks in 32% of cases. Ischaemia has been shown to occur in the gastric tube during oesophagectomy operations,22 23 and is believed to contribute to anastomotic leak. Studies on pre-operative optimization in patients undergoing major surgery have shown that by managing the circulation to increase cardiac output, outcome can be improved.24 25 Would pre-operative optimization or perhaps more intensive operative monitoring and circulatory control, reduce ischaemia in the gastric tube, prevent anastomotic leaks, and improve outcome? The nearest we have to an answer is from Kusano and colleagues26 who undertook an observational study of oxygen delivery in 115 patients undergoing oesophagectomy. They found that oxygen delivery and consumption measured at 6 h post-operatively was higher in survivors than non-survivors, although not different on or after post-operative day 1. Moreover, oxygen delivery was lower at 6 h after operation in those patients who developed either an anastomotic leak or severe pneumonia.

Cardiovascular complications

Cardiovascular complications, including myocardial infarction and dysrhythmia, have been reported in approximately 11% of patients following oesophagectomy12 and are implicated in adverse outcome. There is little direct information on the incidence of myocardial ischaemia in patients undergoing oesophagectomy. However, we know from Groves and colleagues27 that a similar group, those patients undergoing thoracotomy, had a 24% incidence of post-operative myocardial ischaemia and that myocardial ischaemia was associated with adverse outcome. There is some information on dysrhythmia. A prospective study by Ritchie and colleagues28 noted up to 60% of patients developed cardiac dysrhythmia after oesophagectomy that was not affected by prophylactic digitalization. Amar and colleagues29 reported that 13% of patients developed supraventricular tachycardia (heart rates between 135 and 180 beats min–1) after oesophagectomy and that supraventricular tachycardia was associated with higher intensive care unit admission rate, longer hospital stay, and a higher 30-day mortality. Mangano and colleagues30 assessed the effects of atenolol given on the morning of surgery and on subsequent post-operative days for a maximum of 7 days, to patients with a history of ischaemic heart disease or those with two or more risk factors for ischaemic heart disease undergoing all types of non-cardiac surgery. They showed a reduction in mortality and in the incidence of cardiovascular complications, mainly because of a reduction in cardiac deaths over the first 6–8 months. Detailed perioperative assessment of myocardial ischaemia and the effects of strategies for myocardial protection in those patients undergoing oesophagectomy are areas that deserve closer investigation.

Although current mortality and morbidity figures following oesophagectomy are high, there is good reason to hope for improvement, particularly if oesophageal surgery is concentrated in large volume centres. Centres concentrating on oesophageal surgery offer the opportunity to develop greater team experience and to pursue research into management strategies that may improve outcome after oesophagectomy.

Kathleen M. Sherry

Department of Anaesthetics

Northern General Hospital NHS Trust

Herries Road

Sheffield S5 7AU

UK

References

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