Introduction
Surgical resection is actually the only curative option for resectable esophageal cancer in association with radio-chemotherapy. However, it is a high-risk procedure with significant postoperative morbidity and mortality. Minimal invasive esophagectomy and enhanced recovery after surgery program, as ERAS® have been developed this last decade, with the aim to reduce postoperative morbidity and mortality. Minimal invasive surgery, including laparoscopic and thoracoscopic approach instead of laparoscopy and thoracotomy, was introduced at the CHUV in 2015.
The aim of the present study is to analyze anaesthetic procedure and management of minimal invasive esophagectomy since its implementation in our institution.
Methods
This monocentric retrospective study concerns all adult patients who have undergone minimally invasive esophagectomy in the visceral surgery department of the CHUV from December 2015 to December 2018. First outcome of the study will be the analysis of the anaesthetic technique, fluid and ventilation management and postoperative analgesic efficacy. Second outcome will be the analysis of postoperative complications, length of stay and mortality.
Results
Of the 80 patients, all underwent minimal invasive procedure without conversion to open (laparotomy or thoracoscopy). Medium age was 62.5 (range 40-82), 81.25 % were male. Median Charlson comorbidity score was 3 (range 0-11). Total surgical and anesthesia median time was respectively 275.5 (range 192-405) and 391 minutes (range 305-596). Predominant complications were pulmonary complications (42 patients, 52.5%) and anastomotic leak (34 patients, 42.5%). Others complications were per-operative hypothermia (18 patients, 22.5%), cardiac complications (17 patients, 21.25%), thrombo-embolism disease (8 patients, 10%) and sepsis (13 patients, 16.25%). Acute renal injury with dialysis occurred in two patients following respiratory and cardiac complications and one patient presented a hepatic failure following respiratory infection.
Median length of stay was 15.5 days (range 9-149) and mortality rate at 30 days was 7.5%. Comparison of anesthesia-related factors between Dindo-Clavien stade I-II and stade III-V complications do not show any statistical significance except for length of stay (13.16 days VS 35.79 days, p = 6.94x10-7).
Conclusion
Esophagectomy remains a high-risk operation with significant perioperative morbidity and mortality and requires a multidisciplinary approach. Complication rate was high in our group of patients with mostly respiratory issues and surgical leaks. It leaves potential for further improvements in the care of this high-risk procedure. While ERAS protocols have been successfully implemented in a variety of surgical disciplines, its use in esophageal surgery is still evolving and appears to be promising in achieving further marginal gains. Prevention of pulmonary complications could be made with tobacco cessation and respiratory rehabilitation. The use of scores could be useful to improve patient’s selection for surgery.