Early Respiratory Impairment and Pneumonia after Hybrid Laparoscopically Assisted Esophagectomy-A Comparison with the Open Approach.

Martin Reichert,Emmanuel Schneck,Michael Sander,Markus A Weigand,Matthias Hecker,Andreas Hecker,Florian Uhle,Winfried Padberg,Veronika Grau,Ingolf Askevold,Maike Lang

doi:10.3390/jcm9061896

Abstract

Patients undergoing esophageal cancer surgery are at high risk of developing severe pulmonary complications. Beneficial effects of minimally invasive esophagectomy had been discussed recently, but the incidence of perioperative respiratory impairment remains unclear. This is a retrospective single-center cohort study of patients, who underwent open (OE) or laparoscopically assisted, hybrid minimally invasive abdomino-thoracic esophagectomy (LAE) for cancer regarding respiratory impairment (PaO2/FiO2 ratio (P/FR) < 300 mmHg) and pneumonia. No differences were observed in the cumulative incidence of reduced P/FR between OE and LAE patients. Of note, until postoperative day (POD) 2, P/FR did not differ among both groups. Thereafter, the rate of patients with respiratory impairment was higher after OE on POD 3, 5, and 10 (p ≤ 0.05) and tended being higher on POD 7 and 9 (p ≤ 0.1). Although the duration of LAE procedure was slightly longer (total: p = 0.07, thoracic part: p = 0.004), the duration of surgery (Spearman’s rank correlation coefficient (rsp) = −0.267, p = 0.006), especially of laparotomy (rsp = −0.242, p = 0.01) correlated inversely with respiratory impairment on POD 3 after OE. Pneumonia occurred on POD 5 (1–25) and 8.5 (3–14) after OE and LAE, respectively, with the highest incidence after OE (p = 0.01). In conclusion, respiratory impairment and pulmonary complications occur frequently after esophagectomy. Although early respiratory impairment is independent of the surgical approach, postoperative pneumonia rate is reduced after LAE.

Highlights

Esophageal carcinoma is a common cancer with a growing incidence over the past years and a major cause for cancer-related mortality worldwide [1]
Except for the rate of arterial hypertension, which was more prevalent in the OE group (p = 0.02), preoperative patient characteristics resembled in both groups regarding body mass index, American society of Anesthesiologist’s classification of physical health (ASA) score as well as chronic cardiac and pulmonary diseases
Our study suggests that an early phase of postoperative pulmonary impairment that starts immediately after surgery is inherent to the open thoracic part of the esophagectomy procedure but largely independent of the extent of abdominal trauma

Summary

Introduction

Esophageal carcinoma is a common cancer with a growing incidence over the past years and a major cause for cancer-related mortality worldwide [1]. If the tumor is localized in the thoracic part of the esophagus, the abdomino-thoracic Ivor Lewis procedure for an intrathoracic anastomosis or three-incision McKeown procedure for a cervical anastomosis are adequate surgical techniques for resection [1]. These procedures allow the resection of the tumor-bearing esophagus, mediastinal and perigastric lymph node dissection, and reconstruction of the intestinal passage that is routinely performed as gastric pull-up. Abdomino-thoracic esophagectomies are high-risk surgical procedures, facing high rates of postoperative morbidity and mortality, even in high-volume surgical centers [2,3,4,5,6,7,8,9,10]. Multiple factors were proposed to contribute to the pathogenesis of postoperative pulmonary complications like perioperative atelectasis after single-lung ventilation, post-thoracotomy pain affecting respiratory physiology, as well as intraoperative injury to the thoracic cavity and the lung [10,15,16,17,18,19,20]

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