Minimally Invasive Esophagectomy In the Modern Era: Is Regional Anesthesia Still the Answer?

Abstract

In 1913, Franz Torek successfully resected a midesophageal squamous cell carcinoma in a 67-year-old woman through a left transpleural approach under ether anesthetic.1Torek F. The first successful case of resection of the thoracic portion of the esophagus for carcinoma–Preliminary report.JAMA. 1913; 60: 1533Crossref Scopus (19) Google Scholar,2Torek F. The operative treatment of carcinoma of the oesophagus.Ann Surg. 1915; 61: 385-405Crossref PubMed Google Scholar The procedure involved removing the diseased esophageal segment through a cervical incision, creation of a proximal esophagostomy that was tunneled and externalized on the upper anterior chest wall, and a feeding gastrostomy, the latter being performed as a first stage to improve nutritional status and enhance the patient's “powers of resistance.” Later, continuity was established by way of a large external rubber tube serving as a conduit for food to pass from the proximal esophagostomy to the stomach. Although the patient died of unrelated causes at age 80, this one success was never replicated.3Torek F. The causes of failure in the operative treatment of carcinoma of the oesophagus.Ann Surg. 1929; 90: 496-506Crossref PubMed Google Scholar Despite subsequent advancements in the surgical treatment of diseases of the esophagus, resection of intrathoracic esophageal pathology has remained an Achilles’ heel to many surgeons. To the earliest pioneers of thoracic surgery, the development of operative techniques to combat these diseases was slow due to the many constraints inherent to the esophagus, notably its anatomic location within the mediastinum, inadequate anastomotic techniques of the time, and the dangerous risk of early and rapidly fatal postoperative infection. Important progress came in 1946, when Ivor Lewis reported his 2-phase approach to the mid-esophagus through a right thoracotomy,4Lewis I. Surgical treatment of carcinoma of the oesophagus; with special reference to a new operation for growths of the middle third.Br J Surg. 1946; 34: 18-31Crossref PubMed Scopus (387) Google Scholar followed 3 decades later by McKeown's 3-phase technique that included a cervical anastomosis.5McKeown KC. Total three-stage oesophagectomy for cancer of the oesophagus.Br J Surg. 1976; 63: 259-262Crossref PubMed Scopus (179) Google Scholar Nearly 75 years later, Ivor Lewis’ operation remains a mainstay of surgical treatment, with modern-day operative mortality from open surgery ranging roughly from 8% to 13%,6Connors RC Reuben BC Neumayer LA Bull DA Comparing outcomes after transthoracic and transhiatal esophagectomy: A 5-year prospective cohort of 17,395 patients.J Am Coll Surg. 2007; 205: 735-740Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar,7Chang AC Ji H Birkmeyer NJ et al.Outcomes after transhiatal and transthoracic esophagectomy for cancer.Ann Thorac Surg. 2008; 85: 424-429Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar a far cry from the average 72% mortality figure reported by Ochsner and DeBakey in 1941.8Ochsner A DeBakey M. Surgical aspects of carcinoma of the esophagus: Review of the literature and report of four cases.J Thorac Surg. 1941; 10: 401-445Abstract Full Text PDF Google Scholar The complexity and risks of these procedures mainly are due to aggressive and extensive surgical resection of the esophagus and associated lymph nodes, with anastomosis of a mobilized gastric conduit. Postoperative pulmonary complications and gastric conduit anastomotic failure remain primary causes of postoperative morbidity and mortality.6Connors RC Reuben BC Neumayer LA Bull DA Comparing outcomes after transthoracic and transhiatal esophagectomy: A 5-year prospective cohort of 17,395 patients.J Am Coll Surg. 2007; 205: 735-740Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar,7Chang AC Ji H Birkmeyer NJ et al.Outcomes after transhiatal and transthoracic esophagectomy for cancer.Ann Thorac Surg. 2008; 85: 424-429Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar,9Ferguson MK Celauro AD Prachand V Prediction of major pulmonary complications after esophagectomy.Ann Thorac Surg. 2011; 91: 1494-1501Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar The integration of regional anesthesia techniques, most notably thoracic epidural analgesia (TEA), a recognized gold standard, have been critical in improving patient outcomes and decreasing complications associated with these open procedures.10Cense HA Lagarde SM de Jong K et al.Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic esophageal cancer resection.J Am Coll Surg. 2006; 202: 395-400Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar In recent years, a minimally invasive approach to Ivor Lewis’ operation appears to offer further advantages. Minimally invasive techniques that include thoracoscopy and laparoscopy have been adopted in the last decade with favorable outcomes, including reductions in both morbidity and mortality.11Takeuchi H Miyata H Ozawa S et al.Comparison of short-term outcomes between open and minimally invasive esophagectomy for esophageal cancer using a nationwide database in Japan.Ann Surg Oncol. 2017; 24: 1821-1827Crossref PubMed Scopus (104) Google Scholar, 12Wang H Shen Y Feng M et al.Outcomes, quality of life, and survival after esophagectomy for squamous cell carcinoma: A propensity score-matched comparison of operative approaches.J Thorac Cardiovasc Surg. 2015; 149 (1006-1015.e4)Abstract Full Text Full Text PDF Scopus (57) Google Scholar, 13van Workum F Berkelmans GH Klarenbeek BR et al.McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: Systematic review and meta-analysis.J Thorac Dis. 2017; 9: S826-S833Crossref PubMed Scopus (36) Google Scholar These new findings lead us to question the value of the anesthesiologist's proudly held gold standard in the anesthetic and perioperative management of these patients. In the current issue of the Journal of Cardiothoracic and Vascular Anesthesia, Tankard et al. have presented data on the impact of regional anesthesia (all types included in the analysis) on outcomes after minimally invasive Ivor Lewis esophagectomy (MIE).14Tankard KA Brovman EY Allen K Urman RD The impact of regional anesthesia on outcomes after minimally invasive Ivor Lewis esophagectomy.J Cardiothorac Vasc Anesth. 2020; 34: 3052-3058Abstract Full Text Full Text PDF Scopus (1) Google Scholar Using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP), the authors compared 398 patients from multiple institutions who underwent MIE under general anesthesia with (n = 108) or without (n = 290) regional anesthesia. Multivariate regression was used to study the primary outcome of 30-day mortality, and secondary outcomes that included operative reexploration, failure to wean from mechanical ventilation, reintubation, and hospital length of stay, among others. The authors found no significant differences in any of the outcomes between the 2 groups. Should these findings and what they indicate be surprising? After all, anesthesiologists have come to embrace regional techniques as game-changers in patients undergoing open thoracotomy and thoracoabdominal procedures. The reduction in postoperative pulmonary complications, many associated with unmodifiable risk factors such as underlying lung disease, as well as the ability to get older, more frail patients with marginal cardiorespiratory reserves through major surgeries, have, in many cases, enabled definitive treatment over palliation. The question anesthesiologists now must ask is whether the favorable outcomes associated with TEA in higher-risk, open thoracoabdominal surgeries translate into a further need for regional anesthesia techniques when minimally invasive surgical approaches increasingly are embraced.15Bartels K Fiegel M Stevens Q et al.Approaches to perioperative care for esophagectomy.J Cardiothorac Vasc Anesth. 2015; 29: 472-480Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar What if a minimally invasive surgery requires conversion to an open procedure? The selection of an appropriate regional anesthetic is dependent on a thorough understanding of the surgical insult, particularly when there are several operative methods to consider.16Drinhaus H Lambertz R Schröder W Annecke T Analgesia during and after esophagectomy: The surgical approach matters.Ann Thorac Surg. 2018; 106: 1259Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar In the case of esophageal resection, anesthesiologists all are aware of the transhiatal and multiple transthoracic approaches, each demanding alternative ventilatory and analgesic considerations. Although pathology and disease location dictate the surgical approach to a large extent, surgeon preference is also a dominant factor. Interestingly, the 2014 Society of Thoracic Surgeons Practice Guidelines on the Role of Multimodality Treatment for Cancer of the Esophagus and Gastroesophageal Junction do not address the surgical approach.17Little AG Lerut AE Harpole DH et al.The Society of Thoracic Surgeons practice guidelines on the role of multimodality treatment for cancer of the esophagus and gastroesophageal junction.Ann Thorac Surg. 2014; 98: 1880-1885Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar The Ivor Lewis 2-field surgery typically is recommended for esophageal lesions below the carina,18Reed CE. Technique of Open Ivor Lewis Esophagectomy.Oper Tech Thorac Cardiovasc Surg. 2009; 14: 160-175Abstract Full Text Full Text PDF Scopus (17) Google Scholar while McKeown's 3-field procedure adds a left cervical incision, allowing for resection of esophageal lesions above the carina. Importantly, after adjustment for tumor staging and patient characteristics, transthoracic and transhiatal techniques have demonstrated similar 30-day mortality and long-term survival rates.6Connors RC Reuben BC Neumayer LA Bull DA Comparing outcomes after transthoracic and transhiatal esophagectomy: A 5-year prospective cohort of 17,395 patients.J Am Coll Surg. 2007; 205: 735-740Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar,7Chang AC Ji H Birkmeyer NJ et al.Outcomes after transhiatal and transthoracic esophagectomy for cancer.Ann Thorac Surg. 2008; 85: 424-429Abstract Full Text Full Text PDF PubMed Scopus (199) Google Scholar Both Ivor Lewis and McKeown techniques are amendable MIE approaches using multiple small incisions for the required 5 laparoscopic and 3 thoracoscopic ports, with the latter preserving its open cervical incision. A hybrid technique also has been described, with combined minimally invasive and open approaches.19Voron T Lintis A Piessen G Hybrid esophagectomy.J Thorac Dis. 2019; 11: S723-S727Crossref PubMed Scopus (8) Google Scholar Although MIE traditionally has used videoscopic assistance, robotic techniques currently are being integrated to increase exposure with a 3-dimensional field visualization.20Gong L Jiang H Yue J et al.Comparison of the short-term outcomes of robot-assisted minimally invasive, video-assisted minimally invasive, and open esophagectomy.J Thorac Dis. 2020; 12: 916-924Crossref PubMed Scopus (5) Google Scholar Regardless of the chosen method, the bottom line when adopting new surgical approaches is patient outcomes. From a surgical standpoint and despite early skepticism, MIE meets this standard, with potential added benefits including fewer respiratory complications, less blood loss, less pain, earlier oral intake, and enhanced recovery of quality of living.21Wang Q Wu Z Zhan T et al.Comparison of minimally invasive Ivor Lewis esophagectomy and left transthoracic esophagectomy in esophageal squamous cell carcinoma patients: A propensity score-matched analysis.BMC Cancer. 2019; 19: 500Crossref PubMed Scopus (4) Google Scholar Biere et al. were among the first to report a significant reduction in postoperative pulmonary infections,22Biere SS van Berge Henegouwen MI Maas KW Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: A multicentre, open-label, randomised controlled trial.Lancet. 2012; 379: 1887-1892Abstract Full Text Full Text PDF PubMed Scopus (920) Google Scholar with subsequent studies confirming this finding.11Takeuchi H Miyata H Ozawa S et al.Comparison of short-term outcomes between open and minimally invasive esophagectomy for esophageal cancer using a nationwide database in Japan.Ann Surg Oncol. 2017; 24: 1821-1827Crossref PubMed Scopus (104) Google Scholar,23Sihag S Wright CD Wain JC et al.Comparison of perioperative outcomes following open versus minimally invasive Ivor Lewis oesophagectomy at a single, high-volume centre.Eur J Cardiothoracic Surg. 2012; 42: 430-437Crossref PubMed Scopus (73) Google Scholar,24Tapias LF Mathisen DJ Wright CD et al.Outcomes with open and minimally invasive Ivor Lewis esophagectomy after neoadjuvant therapy.Ann Thorac Surg. 2016; 101: 1097-1103Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Tankard et al. addressed mortality as a primary outcome as it relates to the use of regional anesthetic techniques and found no differences.14Tankard KA Brovman EY Allen K Urman RD The impact of regional anesthesia on outcomes after minimally invasive Ivor Lewis esophagectomy.J Cardiothorac Vasc Anesth. 2020; 34: 3052-3058Abstract Full Text Full Text PDF Scopus (1) Google Scholar Likewise, secondary outcomes metrics, including failure to wean from mechanical ventilation and reintubation, demonstrated repeatedly to be improved with TEA in open procedures, were no different between groups. A limitation of their study was, with the exception of epidural anesthesia, failure of the NSQIP dataset to differentiate among the various types of regional blocks, such that paravertebral blocks were combined with chest wall and other types of regional techniques in the analysis. Most patients in the regional plus general anesthesia group received epidural anesthesia (n = 90), 17 received nonspecific regional, while 16 received both, resulting in an important degree of heterogeneity and an inability to determine superiority of one type of regional technique over the other. The implementation of enhanced recovery after surgery protocols has played an important role in the recovery of patients post-esophagectomy.25Schmidt HM El Lakis MA Markar SR et al.Accelerated recovery within standardized recovery pathways after esophagectomy: A prospective cohort study assessing the effects of early discharge on outcomes, readmissions, patient satisfaction, and costs.Ann Thorac Surg. 2016; 102: 931-939Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar, 26Markar SR Karthikesalingam A Low DE Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: Systematic review and pooled analysis.Dis Esophagus. 2015; 28: 468-475Crossref PubMed Scopus (59) Google Scholar, 27Markar SR Schmidt H Kunz S et al.Evolution of standardized clinical pathways: Refining multidisciplinary care and process to improve outcomes of the surgical treatment of esophageal cancer.J Gastrointest Surg. 2014; 18: 1238-1246Crossref PubMed Scopus (46) Google Scholar, 28Low DE Allum W De Manzoni G et al.Guidelines for perioperative care in esophagectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J Surg. 2019; 43: 299-330Crossref PubMed Scopus (118) Google Scholar The use of TEA in MIE has been put into question, as some believe it could negate some of the goals of enhanced recovery after surgery protocols. In robot-assisted McKeown MIE, TEA was found in 1 study to be inadequate in nearly 50% of patients.29Kingma BF Visser E Marsman M et al.Epidural analgesia after minimally invasive esophagectomy: Efficacy and complication profile.Dis Esophagus. 2019; 32 (doy116)Crossref PubMed Scopus (6) Google Scholar Despite the potential benefits the sympathectomy and vasodilatation associated with neuraxial techniques might have in improving microcirculatory blood flow, with a possible reduction in anastomotic leaks,30Lázár G Kaszaki J Ábrahám S et al.Thoracic epidural anesthesia improves the gastric microcirculation during experimental gastric tube formation.Surgery. 2003; 134: 799-805Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar,31Michelet P D'Journo XB Roch A et al.Perioperative risk factors for anastomotic leakage after esophagectomy: Influence of thoracic epidural analgesia.Chest. 2005; 128: 3461-3466Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar the advantages of care pathways for MIE patients might override this desirable effect. The 2019 Enhanced Recovery After Surgery Guidelines for Perioperative Care in Esophagectomy recognized the impact of TEA on postoperative outcomes and gave a strong recommendation for its utilization with open and minimally invasive techniques, while acknowledging that the evidence was only moderate.28Low DE Allum W De Manzoni G et al.Guidelines for perioperative care in esophagectomy: Enhanced Recovery After Surgery (ERAS) Society recommendations.World J Surg. 2019; 43: 299-330Crossref PubMed Scopus (118) Google Scholar Meanwhile, these guidelines also address the use of paravertebral blocks as an alternate to TEA. The retrospective nature of the study by Tankard et al., and the extraction of NSQIP data from multiple institutions, did raise questions about individual practices, including choice of anesthetic modality, and care pathways that are not likely to be uniform across institutions, as noted by the authors.14Tankard KA Brovman EY Allen K Urman RD The impact of regional anesthesia on outcomes after minimally invasive Ivor Lewis esophagectomy.J Cardiothorac Vasc Anesth. 2020; 34: 3052-3058Abstract Full Text Full Text PDF Scopus (1) Google Scholar Furthermore, because the study included all forms of esophageal disease, not just malignancy, perioperative care was likely heterogenous from the standpoint of adjuvant therapies. So where should anesthesiologists focus attention when addressing postoperative analgesia in MIE patients? The study by Tankard et al. perhaps raised more questions than it answers, but such is the nature of scientific inquiry.14Tankard KA Brovman EY Allen K Urman RD The impact of regional anesthesia on outcomes after minimally invasive Ivor Lewis esophagectomy.J Cardiothorac Vasc Anesth. 2020; 34: 3052-3058Abstract Full Text Full Text PDF Scopus (1) Google Scholar The benefits of TEA and paravertebral blocks will continue to be challenged as anesthesiologists integrate more techniques into the armamentarium. Ultrasound-guided fascial plane blocks have become increasingly popular in both thoracic and abdominal surgery. Bilateral continuous transversus abdominis plane blocks recently have been investigated, including a small retrospective study of esophagectomy patients, which demonstrated outcomes comparable to TEA with a variety of surgical approaches.16Drinhaus H Lambertz R Schröder W Annecke T Analgesia during and after esophagectomy: The surgical approach matters.Ann Thorac Surg. 2018; 106: 1259Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar,32Levy G Cordes MA Farivar AS et al.Transversus abdominis plane Bbock improves perioperative outcome after esophagectomy versus epidural.Ann Thorac Surg. 2018; 105: 406-412Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar,33Kendall MC Castro-Alves LJ. Epidural analgesia versus transversus abdominis plane block for esophagectomy: Are they equivalent?.Ann Thorac Surg. 2018; 106: 638-639Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar The use of erector spinae plane blocks in both thoracic and more recently epigastric surgery may prove applicable to esophagectomy as well.34De Cassai A Tonetti T Galligioni H Ori C Erector spinae plane block as a multiple catheter technique for open esophagectomy: A case report.Brazilian J Anesthesiol (English Ed). 2019; 69: 95-98Google Scholar,35Abu Elyazed MM Mostafa SF Abdelghany MS Eid GM Ultrasound-guided erector spinae plane block in patients undergoing open epigastric hernia repair: A prospective randomized controlled study.Anesth Analg. 2019; 129: 235-240Crossref PubMed Scopus (27) Google Scholar De Cassai et al. reported a single case report of open esophagectomy in which 3 erector spinae plane blocks were able to cover the required thoracic and abdominal regions.34De Cassai A Tonetti T Galligioni H Ori C Erector spinae plane block as a multiple catheter technique for open esophagectomy: A case report.Brazilian J Anesthesiol (English Ed). 2019; 69: 95-98Google Scholar Finally, the serratus anterior fascial plane block was reported in a case series of 37 MIE patients, with contraindications for TEA or unplanned conversion to thoracotomy with laparoscopy, in which the authors reported only limited rescue opioids required for pain control.36Barbera C Milito P Punturieri M et al.Serratus anterior plane block for hybrid transthoracic esophagectomy: A pilot study.J Pain Res. 2017; 10: 73-77Crossref PubMed Scopus (22) Google Scholar More than a century ago, valiant attempts at esophageal resection were fraught with hazard and exceedingly high mortality, as the esophagus posed what seemed to be an insurmountable anatomic adversary. Access to the thoracic esophagus in particular was difficult, because of anesthetic considerations, and the raging mediastinal infections that ensued. Today, Ivor Lewis’ groundbreaking surgery has been adapted to a minimally invasive approach with favorable outcomes, and perhaps fewer complications. The question anesthesiologists must now ask is whether the anesthetic approach to open esophageal surgeries lends itself to newer, less invasive procedures. Traditional thinking has led anesthesiologists to believe in the virtues of neuraxial and regional blockade, including blunting of the systemic inflammatory response, pain control, and a reduced risk of postoperative pulmonary complications, sources of major morbidity in this patient population. Do the findings from Tankard et al.’s study mean that anesthesiologists should relegate epidural and regional techniques only to traditional open thoracoabdominal approaches?14Tankard KA Brovman EY Allen K Urman RD The impact of regional anesthesia on outcomes after minimally invasive Ivor Lewis esophagectomy.J Cardiothorac Vasc Anesth. 2020; 34: 3052-3058Abstract Full Text Full Text PDF Scopus (1) Google Scholar The answer to this question is a resounding no! The findings from this study are clearly relevant, but without greater context, anesthesiologists must be satisfied with the fact that they raised further questions worthy of future investigation, preferably in larger-scale randomized controlled trials. Just as surgical techniques continue to evolve, so too must approaches to the perioperative management of these patients. Evidence-based medicine always will be needed to maximize care, including perioperative optimization, meticulous surgical technique, and perioperative anesthetic management. When considering patients undergoing esophagectomy, for example, there is ample evidence supporting more restrictive fluid strategies, protective ventilation, adequate pain control, and the implementation of enhanced recovery protocols. Tankard et al. have opened up a discussion on the role of regional anesthesia in MIE, even if they were unable to demonstrate any obvious benefit.14Tankard KA Brovman EY Allen K Urman RD The impact of regional anesthesia on outcomes after minimally invasive Ivor Lewis esophagectomy.J Cardiothorac Vasc Anesth. 2020; 34: 3052-3058Abstract Full Text Full Text PDF Scopus (1) Google Scholar What their study did do, however, is give pause for thought, allowing us to reconsider standard practices as they apply to open esophagectomy procedures, and question their validity with newer, less invasive surgical techniques. One specifically unanswered question from this study was that of any opioid-sparing effect, a relevant subject with the existing opioid crisis. Importantly, the findings suggested that just as surgeons have been able to improve outcomes by adapting a minimally invasive approach to the Ivor Lewis esophagectomy, so too must anesthesiologists tailor anesthetic techniques to meet the mutual goal of improving patient outcomes, even if it comes down to eliminating the historical gold standard. But not so fast … there still remains much to be learned before abandoning a tried-and-true adjunct. None.