Advertisement

Updates in Surgery

, Volume 68, Issue 2, pp 185–190 | Cite as

Intra-operative hypotensive episodes may be associated with post-operative esophageal anastomotic leak

  • Uberto FumagalliEmail author
  • Alessandra Melis
  • Jana Balazova
  • Valeria Lascari
  • Emanuela Morenghi
  • Riccardo Rosati
Original Article

Abstract

This study aims to report the hypotensive episodes (HEs) during esophagectomy and their influence on the occurrence of anastomotic leak. Eighty-four patients underwent esophagectomy with gastric pull-up. Pre-, intra-, and post-operative data were prospectively collected. HEs were defined by systolic pressure decreasing more than 30 % of the basal value for more than 5 min. Nineteen patients had intra-operative HEs (22.6 %). HEs were significantly more frequent in patients undergoing prone esophagectomy (P = 0.001) and those with an epidural catheter (EC) (P = 0.04) used during surgery. Among them, 15 were treated with vasopressors. There were six severe post-operative anastomotic leaks, which required surgery; leaks were significantly more common in patients with intra-operative HEs (21 vs 3.1 %; P = 0.02), especially those treated with vasopressive agents (20 vs 0 %; P = 0.008). Intra-operative use of EC can, in certain conditions, significantly influence gastric blood flow due to HEs. A higher incidence of severe leak occurred in patients experiencing intra-operative HEs. Several factors can lead to intra-operative HEs, and the perioperative use of an EC should be carefully evaluated.

Keywords

Esophagectomy Thoracic epidural analgesia Anastomotic leak Intra-operative fluid management Anastomotic healing Hypothension 

Notes

Acknowledgments

The study and publication were not funded by any funding agency in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

Conflict of interest

All the authors declare they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Research involving human participants and/or animals

This article does not contain any "studies" with human participants or animals performed by any of the authors; all the clinical procedures analyzed in the present paper represent standard clinical care.

Informed consent

Informed consent was obtained from all individual participants included in the study.

References

  1. 1.
    Hii MW, Smithers BM, Gotley DC et al (2013) Impact of postoperative morbidity on long-term survival after oesophagectomy. Br J Surg 100:95–104CrossRefPubMedGoogle Scholar
  2. 2.
    Dorcaratto D, Grande L, Pera M (2013) Enhanced recovery in gastrointestinal surgery: upper gastrointestinal surgery. Dig Surg. 30:70–78CrossRefPubMedGoogle Scholar
  3. 3.
    Lassen K, Soop M, Nygren J et al (2009) Consensus review of optimal perioperative care in colorectal surgery: enhanced Recovery After Surgery (ERAS) Group recommendations. Arch Surg 144:961–969CrossRefPubMedGoogle Scholar
  4. 4.
    Tang J, Humes DJ, Gemmil E et al (2013) Reduction in length of stay for patients undergoing oesophageal and gastric resections with implementation of enhanced recovery packages. Ann R Coll Surg Engl 95:323–328CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Fumagalli U, Bersani M, Russo A et al (2013) Volume and outcomes after esophageal cancer surgery: the experience of the Region of Lombardy-Italy. Updates Surg 65:271–275CrossRefPubMedGoogle Scholar
  6. 6.
    Flisberg P, Törnebrandt K, Walther B et al (2001) Pain relief after esophagectomy: thoracic epidural analgesia is better than parenteral opioids. J Cardiothorac Vasc Anesth 15:282–287CrossRefPubMedGoogle Scholar
  7. 7.
    Lee L, Li C, Robert N et al (2013) Economic impact of an enhanced recovery pathway for oesophagectomy. Br J Surg 100:1326–1334CrossRefPubMedGoogle Scholar
  8. 8.
    Findlay JM, Gillies RS, Millo J et al (2014) Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg 259:413–431CrossRefPubMedGoogle Scholar
  9. 9.
    Michelet P, Roch A, D’Journo X-B et al (2007) Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy. Acta Anaesthesiol Scand 51:587–594CrossRefPubMedGoogle Scholar
  10. 10.
    Al-Rawi OY, Pennefather SH, Page RD et al (2008) The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy. Anesth Analg 106:884–887CrossRefPubMedGoogle Scholar
  11. 11.
    Michelet P, D’Journo X-B, Roch A et al (2005) Perioperative risk factors for anastomotic leakage after esophagectomy: influence of thoracic epidural analgesia. Chest 128:3461–3466CrossRefPubMedGoogle Scholar
  12. 12.
    Rutegård M, Lagergren P, Rouvelas I et al (2012) Intrathoracic anastomotic leakage and mortality after esophageal cancer resection: a population-based study. Ann Surg Oncol 19:99–103CrossRefPubMedGoogle Scholar
  13. 13.
    Markar SR, Arya S, Karthikesalingam A et al (2013) Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Ann Surg Oncol 20:4274–4281CrossRefPubMedGoogle Scholar
  14. 14.
    Kassis ES, Kosinski AS, Ross P et al (2013) Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 96:1919–1926CrossRefPubMedGoogle Scholar
  15. 15.
    Tabatabai A, Hashemi M, Mohajeri G et al (2009) Incidence and risk factors predisposing anastomotic leak after transhiatal esophagectomy. Ann Thorac Med. 4:197–200CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Junemann-Ramirez M, Awan MY, Khan ZM et al (2005) Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume centre. Eur J Cardiothorac Surg 27:3–7CrossRefPubMedGoogle Scholar
  17. 17.
    Mitchell JD (2006) Anastomotic leak after esophagectomy. Thorac Surg Clin. 16:1–9CrossRefPubMedGoogle Scholar
  18. 18.
    Lázár G, Kaszaki J, Abrahám S et al (2003) Thoracic epidural anesthesia improves the gastric microcirculation during experimental gastric tube formation. Surgery. 134:799–805CrossRefPubMedGoogle Scholar
  19. 19.
    Weimann A, Braga M, Harsanyi L et al (2006) ESPEN guidelines on enteral nutrition: surgery including organ transplantation. Clin Nutr. 25:224–244CrossRefPubMedGoogle Scholar
  20. 20.
    Jie B, Jiang Z-M, Nolan MT et al (2012) Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition. 28:1022–1027CrossRefPubMedGoogle Scholar
  21. 21.
    Bartels K, Fiegel M, Stevens Q et al (2015) Approaches to perioperative care for esophagectomy. J Cardiothorac Vasc Anesth 29:472–480CrossRefPubMedGoogle Scholar
  22. 22.
    Dindo D, Demartines N, Clavien P-A (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Kapral S, Gollmann G, Bachmann D et al (1999) The effects of thoracic epidural anesthesia on intraoperative visceral perfusion and metabolism. Anesth Analg 88:402–406PubMedGoogle Scholar
  24. 24.
    Johansson K, Ahn H, Lindhagen J et al (1988) Effect of epidural anaesthesia on intestinal blood flow. Br J Surg 75:73–76CrossRefPubMedGoogle Scholar
  25. 25.
    Steinbrook RA (1998) Epidural anesthesia and gastrointestinal motility. Anesth Analg 86:837–844PubMedGoogle Scholar
  26. 26.
    Zuegel N, Bruer C, Breitschaft K et al (2002) Influence of thoracic epidural analgesia on the early postoperative stage after gastrointestinal surgery. Chirurg 73:262–268CrossRefGoogle Scholar
  27. 27.
    Zakrison T, Nascimento BA, Tremblay LN et al (2007) Perioperative vasopressors are associated with an increased risk of gastrointestinal anastomotic leakage. World J Surg 31:1627–1634CrossRefPubMedGoogle Scholar
  28. 28.
    Pathak D, Pennefather SH, Russell GN et al (2013) Phenylephrine infusion improves blood flow to the stomach during oesophagectomy in the presence of a thoracic epidural analgesia. Eur J Cardiothorac Surg 44:130–133CrossRefPubMedGoogle Scholar
  29. 29.
    Freise H, Van Aken HK (2011) Risks and benefits of thoracic epidural anaesthesia. Br J Anaesth 107:859–868CrossRefPubMedGoogle Scholar
  30. 30.
    Richards ER, Kabir SI, McNaught C-E et al (2013) Effect of thoracic epidural anaesthesia on splanchnic blood flow. Br J Surg 100:316–321CrossRefPubMedGoogle Scholar
  31. 31.
    Cerantola Y, Grass F, Cristaudi A et al (2011) Perioperative nutrition in abdominal surgery: recommendations and reality. Gastroenterol Res Pract. 2011:739347CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2016

Authors and Affiliations

  • Uberto Fumagalli
    • 1
    • 5
    Email author
  • Alessandra Melis
    • 1
  • Jana Balazova
    • 2
  • Valeria Lascari
    • 2
  • Emanuela Morenghi
    • 3
  • Riccardo Rosati
    • 1
    • 4
  1. 1.General and Minimally Invasive SurgeryHumanitas Clinical and Research HospitalRozzanoItaly
  2. 2.Anesthesiology and Critical CareHumanitas Clinical and Research HospitalRozzanoItaly
  3. 3.Biostatistic UnitHumanitas Clinical and Research HospitalRozzanoItaly
  4. 4.Digestive SurgeryUniversity Vita e SaluteMilanItaly
  5. 5.Esophagogastric SurgeryHumanitas Clinical and Research HospitalRozzanoItaly

Personalised recommendations