Anaesthesia for oesophagectomy Stephen H. Pennefather
Purpose of review To review the current anaesthetic management of patients undergoing transthoracic oesophagectomy. Recent findings Oesophageal adenocarcinoma is increasing rapidly in the West. The perioperative mortality for oesophagectomy remains high. A relationship has been established between volume and outcome for oesophageal surgery. There is little evidence from randomized clinical studies to guide the management of patients undergoing oesophagectomy. The profile of patients presenting for oesophagectomy is changing. There is emerging evidence that anaesthetic management influences outcome. At present there are no clear advantages for minimal access surgery. Summary Although nonsurgical treatments are being developed, at present surgery remains the mainstay of potentially curative treatment. Accurate risk stratification would greatly facilitate the assessment of strategies to reduce operative mortality. Anaesthetic research has the potential to further improve the safety of patients undergoing oesophageal surgery.
Introduction
Keywords anaesthesia, oesophagectomy, operative and postoperative management, preoperative assessment
Surgical treatment
Curr Opin Anaesthesiol 20:15–20. ß 2007 Lippincott Williams & Wilkins. The Cardiothoracic Centre, Liverpool, UK Correspondence to Dr S.H. Pennefather, Consultant Anaesthetist, The Cardiothoracic Centre, Thomas Drive, Liverpool L14 3PE, UK Tel: +44 151 2281616; fax: +44 151 2882640; e-mail:
[email protected] Current Opinion in Anaesthesiology 2007, 20:15–20 Abbreviations DLT IHD PCI
double lumen tube ischaemic heart disease percutaneous coronary intervention
ß 2007 Lippincott Williams & Wilkins 0952-7907
Worldwide more than 90% of oesophageal cancers are squamous cell carcinomas [1]. Oesophageal adenocarcinoma is the most rapidly increasing cancer in the USA [2] and has now overtaken squamous cell carcinoma as the predominant cell type for oesophageal cancer in the West. This increasing incidence of oesophageal adenocarcinoma has been attributed to gastro-oesophageal reflux and its sequel Barrett’s oesophagus [3], increased obesity [4], low fruit and vegetable intake [5] and reduced Helicobacter pylori infections [6] and perhaps a currently unidentified risk factor [2]. Oesophageal cancer is now the seventh most common malignancy worldwide. The prognosis for patients with oesophageal carcinoma is poor. In the West about 30% of patients are considered potentially curable at presentation. The 5-year survival rate after surgery, the mainstay of curative treatment, is about 25%. Nonsurgical treatments that are being developed and are appropriate for a few selected patients include endoscopic mucosal resection, photodynamic therapy and chemoradiotherapy.
On 14 March 1913, Franz Torek performed the first successful oesophageal resection on a 67-year-old woman. The anaesthetic was administered by Dr Carl Eggers, a thoracic surgeon, using the newly developed technique of tracheal intubation [7]. No attempt was made at reconstruction. Gastric interpositions to re-establish continuity after oesophageal resection were first performed in Boston during the1940s [8]. Historically, and in the experience of some present day anaesthetists, oesophageal resections are associated with a high mortality rate. Between 1960 and 1979 the operative mortality was 29% [9], but had decreased to 13% by 1988 [10]. A number of centres now report operative mortalities below 5%. This probably underestimates the current mortality in the West. Two recent large reports may more accurately reflect current mortality. The British Oesophagogastric Cancer Group reported a mortality of 13.7% between 1999 and 2002 [11]. The mortality at US Veteran Affairs Medical Centres between 1991 and 2001 was 9.8% [12]. Numerous reports have documented a relationship between volume and outcome for oesophageal surgery with lower mortality rates when the procedures are done by high-volume surgeons [13,14] or in high-volume hospitals [15–18]. Volumebased referrals are now used as a method of quality improvement and as a justification for regionalization of oesophageal services in a number of countries. The regionalization of oesophageal services will concentrate 15
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16 Thoracic anaesthesia
anaesthetic experience. Although anaesthetic expertise influences outcome [19], a relationship between anaesthetic volume and outcome has not been established.
sion occurs and plans for thoracic epidural analgesia should take into account the current platelet count.
Patient selection There is very little evidence from randomized clinical studies to guide the management of patients with oesophageal cancer. The surgical approach to the oesophagus and the extent of both longitudinal and radial excision are controversial and dependent on the opinion of individual surgeons and the culture of the institution. Some clinicians argue that lymph node involvement is a marker of spread and the prognosis is not affected by extensive lymph node resection whereas others argue that extensive lymph node resection improves prognosis. Extensive lymph node resection frequently results in upstage migration and enables more accurate prognostication. Interpreting the literature is hampered by an East–West divide in oesophageal cancer management. Eastern management philosophy is typified by Japan where most oesophageal cancers are squamous in type. The Japanese philosophy of radical resections and extensive lymphadenectomies may not be appropriate for the typical Western patient with an adenocarcinoma. This review will concentrate on the Western management of oesophageal cancer.
Minimal access surgery Various different combinations of thoracoscopy, laparoscopy, mediastinoscopy and open incisions have been studied [20]. At present the most popular is thorascopic oesophagectomy, laparotomy and cervical oesophagogastrostomy [21]. Studies have not demonstrated any clear advantages for minimal access surgery [21].
Neoadjuvant chemotherapy There have been at least 11 randomized trials published that have evaluated the role of preoperative chemotherapy. Most have been underpowered or have had methodological faults. There are, however, two high-quality trials comparing surgery and chemotherapy with surgery alone. The results of these two trials were diametrically opposite. The American Intergroup study [22] showed neoadjuvant chemotherapy to be of no benefit. The larger Medical Research Council [23] study using the same chemotherapeutic agents (cisplatinum and 5FU) showed an improvement in 2-year survival from 34% to 43%. Reconciling the difference between these two studies is difficult, perhaps the intensive chemotherapy and resulting delayed surgery adversely affected outcome in the American Intergroup study. A recent metaanalysis of preoperative chemotherapy for oesophageal cancers showed a significant late survival advantage for chemotherapy [24]. There is growing opinion that neoadjuvant chemotherapy is effective in improving survival [25]. Anaesthetists need to strike a balance between allowing sufficient time for the patient to recover from chemotherapy and delaying tumour resection. Bone marrow suppres-
Selecting patients for potentially curative surgery is important, but not easy. Although patients with potentially resectable disease should be offered surgery, surgery should not be undertaken on patients unable to survive the trauma of this operation. Anaesthetists rarely make decisions about the resectability of oesophageal tumours and a detailed discussion of the criteria for determining resectability is beyond the scope of this article. Determining operability is not an exact science and is largely based on the anaesthetist and the surgeon’s judgement. Retrospective analyses have shown age [12,26–31], tumor stage [26], pulmonary dysfunction [26,28,31,32], history of smoking [33,34], diabetes mellitus [12], cardiac dysfunction [32], impaired general health [29,32], reduced preoperative performance [27,28,35] and hepatic dysfunction [32] to be indicators of mortality. In a retrospective analysis Bartels et al. [32] found, in descending order, that general health, cardiac function, hepatic function and respiratory function influenced postoperative mortality. They developed a scoring system using these parameters that predicted risk prospectively. The development of a risk stratification system, comparable to those used for cardiac surgery, for patients undergoing oesophagectomy would greatly facilitate the assessment of strategies to reduce operative mortality.
Preoperative anaesthetic assessment In the West the changing epidemiology of oesophageal cancer is changing the profile of patients presenting for oesophagectomy. Although a history of tobacco abuse remains common, the prevalence of obesity, gastrooesophageal reflux and ischaemic heart disease (IHD) has increased. The prevalence of alcohol abuse and pulmonary sepsis as a result of repeated aspirations has decreased. The population is aging. At present 25% of candidates for potential curative therapies are American Society of Anesthesiologists (ASA) grade III or IV [36]. The prevalence of IHD in Western patients with oesophageal cancer is high and increasing. No studies have specifically addressed revascularization in patients with oesophageal cancer. For patients with stable symptoms some guidance can be derived from other studies. McFalls et al. [37] randomized 510 patients scheduled for major vascular surgery with a stenosis of one or more major coronary arteries of over 70% to revascularization or no revascularization. (Patients with severe aortic stenosis, left main stem disease or a left ventricular ejection fraction of <20% were excluded). There was no significant difference between groups in perioperative myocardial infarction rate or mortality 2.7 years after
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Anaesthesia for oesophagectomy Pennefather 17
randomization. In this study 59% of the patients in the revascularization group underwent percutaneous coronary interventions (PCIs). The wisdom of prophylactic coronary stenting prior to oesophageal surgery is questionable. PCIs have not been shown to improve prognosis in patients with IHD except when undertaken for acute myocardial infarction [38]. Patients scheduled for oesophagectomy who have recently undergone PCIs present a dilemma for the anaesthetist. All PCIs render the endoluminal surface thrombogenic [39], the risk of delayed thrombosis is increased with bare metal stents and highest in patients treated with drug eluting stents [40]. The risk of coronary thrombosis is further increased when destabilized plaque and coronary stents are exposed to the prothrombotic postoperative milieu [41]. The risks are highest when noncardiac surgery is performed within 42 days of the coronary stenting [42]. Current guidelines recommend administering aspirin and clopidogrel for at least 3 months after PCIs [43]. Anaesthetists are faced with a dilemma: should these antiplatelet agents be stopped before the operation or continued throughout the operative period? Continuing the dual antiplatelet therapy increases the risk of bleeding [44] and effectively excludes the use of epidural analgesia. Stopping antiplatelet therapy is a major predictor of potentially catastrophic stent occlusion [45] and is associated with an unacceptably high incidence of major cardiac complications [46]. During the perioperative management of patients with IHD undergoing oesophagectomy consideration should be given to administering aspirin [47] and a statin [48]. Although perioperative b-blockade is recommended for patients at increased cardiac risk undergoing oesophagectomy [49], this recommendation needs to be viewed in the context of later trials [50,51] and a metaanalysis [52] which did not shown clear benefits for perioperative b-blockade. Whilst awaiting the outcome of the perioperative ischaemia study anaesthetists should consider administering perioperative b-blockers to patients with high-risk scores for IHD [53], particularly if they are not scheduled to receive a thoracic epidural. Withdrawal of chronically administered b-blockers can have serious adverse effects [54] and the intravenous route should be utilized until oral intake can be resumed.
Operative and postoperative management There is some evidence that anaesthetic management contributes directly to the mortality after oesophagectomy [19,33]. The 1996/1997 British national confidential enquiry into perioperative deaths found problems with double lumen tubes (DLTs), a feature of 30% of the deaths after oesophagectomy [19] and precipitated an editorial calling for the routine use of fibreoptic bronchoscopy in patients undergoing one-lung ventilation [55].
Gastro-oesophageal reflux (GOR) is a risk factor for the development of oesophageal cancer. Food collected proximal to an oesophageal obstruction may not clear after an overnight fast. Most patients undergoing oesophageal surgery are thus at risk of aspiration at induction. Anaesthetic techniques to reduce the risk of aspiration at induction are well known and should be used on patients undergoing an oesophagectomy. Tracheal aspiration may occur after intubation. A prospective study of patients undergoing thoracotomy showed GOR in 28% and tracheal acid aspiration, measured above the tracheal cuff, in 8% of patients [56]. Inadequate tracheal cuff inflation or intraoperative cuff deflation and DLT repositioning are potentially disastrous. An adequately inflated DLT tracheal cuff may also allow leakage of fluid past the cuff in up to half of patients undergoing thoracic surgery in the lateral position [57]. This aspiration may contribute to the development of postoperative pulmonary complications and can be reduced by the use of a water-based gel lubricant on the tracheal cuff of the DLT to block channels formed by folds in these cuffs [57]. Tracheal acid aspiration also occurs after surgery. A prospective study, measuring tracheal pH for 48 h postoesophagectomy in awake, spontaneously breathing patients, showed that tracheal aspiration of gastric acid was very common, with multiple tracheal aspirations occurring in all patients studied [58]. Consideration should be given to measures to reduce tracheal aspiration: avoiding laryngeal injury at intubation, semirecumbent nursing and applying continuous low-grade suction to a double lumen nasogastric tube [58]. Gastro-oesophageal anastomotic leak is a frequent complication of oesophageal surgery with a high mortality [59]. Anastomotic leaks are usually attributable to technical error or gastric conduit ischaemia. Most patients undergo immediate reconstruction using tubularized stomach based on a blood supply from the right gastroepiploic artery. The left gastric, left gastroepiploic and short gastric arteries are divided. The distal end of this newly formed gastric tube is vascularized by an intramural plexus of vessels supplied from branches of the right gastroepiploic artery. The blood flow at the distal end of the newly fashioned gastric tube is decreased [60,61]. A relationship between low distal gastric tube blood flow and anastomotic leak has been shown [60]. The stomach receives its innervation through branches of the vagus and T6–T10 sympathetic nerves [62]. A sympathetic block induced by a thoracic epidural may increase gastric tube blood flow. Conversely an epidural mediated decrease in blood pressure may reduce gastric tube blood flow. In a prospective study using a laser Doppler technique to measure blood flow it has been shown that thoracic epidural induced hypotension decreases intraoperative gastric tube blood flow and that vasoconstrictor induced hypertension increases distal gastric tube perfusion (R.D. Page, S.H. Pennefather and G.N. Russell, unpublished observation).
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18 Thoracic anaesthesia
The accurate diagnosis of a leak after oesophagectomy is difficult and many patients present with sepsis or acute respiratory distress syndrome (ARDS) [63]. Routine contrast swallow is often inaccurate [63,64]. Contrast swallow computed tomography (CT) examination [63] and flexible gastroscopy may be more useful [64,65]. Anastomotic leaks remain undiagnosed in up to 50% of patients. It may be appropriate to assume that any patient developing sepsis or ARDS immediately after an oesophagectomy has a leak until proved otherwise [63]. A retrospective analysis found the development of ARDS after oesophagectomy to be associated with intraoperative hypoxaemia and haemodynamic instability. Haemodynamic instability was indicated by intraoperative fluid administration, hypotension and inotropes use [33]. The authors postulated that recurrent episodes of intraoperative hypotension and hypoxaemia may have caused a series of tissue ischaemia and reperfusion injuries releasing proinflammatory mediators and activating leukocytes leading to lung injury [33]. Alternatively the intraoperative hypotension and hypoxaemia may have impaired distal gastric tube tissue oxygenation and the lung injury could have been secondary to gastric tube ischaemia or necrosis. The observation that lung injury was significantly (P ¼ 0.005) related to the experience of the surgeon and that an anastomotic leak was diagnosed in 42% of the patients with lung injury support the latter hypothesis.
Timing of extubation There is considerable institutional variation in the duration of postoperative ventilation after transthoracic oesophagectomy. Postoperative ventilation has not been shown to reduce respiratory complications after abdominal surgery in elective high-risk patients [66]. Elective postoperative ventilation can cause morbidity by barotrauma [67], aspiration and sedation-related side effects. Since 1993 early extubation has been advocated to reduce morbidity and cost after oesophagectomy [68]. Early extubation is facilitated by thoracic epidural analgesia [69–72]. There is a growing volume of literature showing that early extubation is safe [68,69,71,72] and associated with reduced intensive care stay [69,71,72]. Costs may be reduced [69,72]. There is, however, one study showing early extubation to be associated with a nonsignificant increase in mortality [73].
to provide postoperative analgesia for patients undergoing oesophagectomy. For patients not receiving epidural analgesia, thoracic paravertebral blocks are increasingly used as part of a multimodal therapy. In nonrandomized studies comparing intravenous opioids with epidural analgesia, patients receiving epidural analgesia had better analgesia [77,78], fewer respiratory complications [79], spent less time in intensive care [79,80] and had a lower mortality rate [34,69,79]. Pain management, particularly afferent neural blockade by epidural analgesia, can decrease perioperative stress [81,82] and influence the postoperative immune response [83,84]. An extensive dural block produced by dual epidural catheters, however, has not been shown to significantly alter the postoperative immune response in patients undergoing radical oesophagectomy [84].
Nutrition There is a wide consensus that, after surgery, early enteral feeding preserves gut integrity, maintains immunocompetence and reduces clinical infections. After oesophagectomy the anastomosis raises particular concerns in relation to enteral feeding and parenteral nutrition is widely used. Two randomized studies have compared enteral with parenteral nutrition. Both found enteral nutrition to be as safe as parenteral nutrition [85,86]. A further two randomized studies compared enteral feeding with no feeding [87,88], both studies were undertaken in well nourished patients. Surprisingly, no benefit from early feeding was found in either study. Enteral feeding was found to have a cost. Postoperative mobility, vital capacity and forced expiratory volume in 1 s (FEV1) were lower in the fed group than the unfed group. Perhaps immediate postoperative enteral feeding should not be routinely undertaken in well nourished patients undergoing oesophagectomy [87].
Conclusion The incidence of oesophageal adenocarcinoma is increasing rapidly. Surgery remains the mainstay of potentially curative treatment. The evidence base for the management of patients undergoing oesophagectomies is weak. There is accumulating evidence that the intraoperative anaesthetic management of patients undergoing oesophagectomies influences outcome. Anaesthetic research has an important role in further improving the safety of patients undergoing oesophageal surgery.
Postoperative analgesia
References and recommended reading
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