Ann Thorac Surg 2006;82:2037-2041
© 2006 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Feasibility and Outcomes of an Early Extubation Policy After Esophagectomy
Michael Lanuti, MD*,
Pierre E. de Delva, MD,
Abdulrahman Maher, MD,
Cameron D. Wright, MD,
Henning A. Gaissert, MD,
John C. Wain, MD,
Dean M. Donahue, MD,
Douglas J. Mathisen, MD
Division of General Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Accepted for publication July 13, 2006.
* Address correspondence to Dr Lanuti, 55 Fruit Street, Blake 1570, Boston, MA 02114 (Email: mlanuti{at}partners.org).
Presented at the Poster Session of the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
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Abstract
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BACKGROUND: Although early extubation of esophagectomy patients has been found to be feasible, safe, and associated with low morbidity, there is no uniform standard of care among high volume centers. Our objective is to examine a contemporary series of esophagectomies and identify the feasibility and outcome of an early extubation policy.
METHODS: This study is a retrospective review of all patients who underwent esophagectomy between January 2003 and December 2004 at the Massachusetts General Hospital. One hundred and two patients were analyzed from 129 consecutive patients who underwent esophagectomy and subsequently divided in two groups: The early extubation group was extubated in the operating room and the late extubation group was extubated in the intensive care unit (ICU).
RESULTS: Ninety percent were extubated early. Although most patients underwent a transthoracic or thoracoabdominal esophagectomy, the operative approach did not influence failure to extubate. Neoadjuvant therapy was not predictive of extubation failure. Most patients age 70 or greater (86%) were extubated early. There were three nonelective reintubations in the early extubation group secondary to acute respiratory distress syndrome. The median length of stay was 11 days and median ICU stay was one day. The 30-day mortality was 1.9% and the median survival was 28 months.
CONCLUSIONS: Attention to restricted intraoperative fluid balance, limited blood loss, anesthetic technique, and epidural use permit most patients undergoing esophageal resection to be safely extubated immediately postresection in the operating room.
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Introduction
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Esophagectomy remains the primary mode of treatment for localized esophageal cancer and the salvage mode for patients with end-stage benign esophageal disease. Each year in the United States, approximately 13,900 people are diagnosed with esophageal cancer and nearly 4,000 esophageal resections are performed [1]. Advancements in anesthesia management, pain control, surgical technique, and critical care have led to measurable improvements in the outcomes of esophageal resection. Nevertheless, esophageal resection continues to pose an impressive physiologic insult and is associated with significant morbidity and mortality. Many variables have been analyzed to predict outcome for esophagectomy patients. Age and pneumonia remain the dominant variables that predict mortality in multivariate analysis [2]. Moreover, there is increasing evidence that esophagectomies performed at high volume centers are associated with lower morbidity and mortality [3–5].
Pulmonary complications are the most common source of morbidity after esophagectomy. Data show that pulmonary complications occur in 25% to 50% of cases accounting for up to 60% of deaths [6]. Several factors contribute to the development of pulmonary morbidity. These include the use of thoracotomy, atelectasis due to splinting and sedation, single lung ventilation, and the age and comorbidities of the patient. Historically, prophylactic overnight mechanical ventilation was instituted to prevent aspiration, protect the airway, and allow for adequate pain control during the immediate perioperative period. This policy likely contributed to the pulmonary morbidity, with higher rates of ventilator-associated pneumonias, barotrauma, and acute respiratory distress syndrome (ARDS). Efforts to reduce this morbidity have focused on anesthesia protocols that allow for the extubation of patients in the operating theater. Several studies have documented that extubation in the operating room is feasible, safe, and associated with lower morbidity [7–10]. Nevertheless, the timing of extubation after esophagectomy remains a controversial issue with no concordant practice among high-volume centers.
Our objective is to examine a modern series of esophageal resections to identify the feasibility and outcomes of an early extubation policy. A contemporary series was chosen to reflect the most up to date practices of preoperative risk assessment and anesthetic management. Outcomes in terms of morbidity, resource utilization, and in-hospital mortality were analyzed.
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Patients and Methods
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Subjects were selected from the pool of patients that underwent esophagectomy at the Massachusetts General Hospital by the Thoracic Surgical Service between January 1, 2003 and December 31, 2004. Retrospective chart reviews were performed. The study population included all patients with esophageal squamous cell carcinoma, adenocarcinoma, Barrett’s esophagus, and benign esophageal disease that underwent a primary esophagectomy with gastric reconstruction. Patients that underwent repeat esophagectomy or emergent esophagectomy were excluded. Patients were also excluded if their esophageal reconstruction required the use of colon or jejunal interposition as a replacement conduit. Patients who underwent induction chemoradiotherapy were included in this study. The study was inclusive of all surgical techniques, including transthoracic (Ivor Lewis), left thoracoabdominal, modified-McKeown, and transhiatal. Demographic, preoperative, intraoperative, and outcome measures were recorded. Data were obtained from the medical record, including office charts, anesthesia records, and in-hospital chart. This study was approved by the Institutional Review Board (IRB) at the Massachusetts General Hospital. The IRB specifically considered this retrospective chart review, including subject selection and confidentiality, and waived the need for patient consent.
A policy of routine extubation in the operating room after esophagectomy was successfully adopted between 1997 and 2002. The study period for this analysis was chosen at a time when all of the parameters considered essential to achieving a high extubation rate were routinely accepted by the thoracic surgeons and anesthesiologists. These include the routine use of a preinduction thoracic epidural, continuous epidural infusion during the operation to limit the total dose of narcotic and inhaled anesthetic, and use of forced air warming systems to prevent hypothermia. Low dose vasopressors were used to limit total intraoperative fluid requirement while maintaining adequate end organ perfusion. Patients were routinely monitored with electrocardiogram, blood pressure, and pulse oximetry. Peripheral large bore intravenous access and arterial lines were inserted under local anesthesia. Patients were routinely induced with propofol, and succinylcholine. Anesthesia was maintained with a combination of systemic opiates, neuromuscular paralysis, thoracic neuraxial blockade with lidocaine and an inhalational agent (ie, sevoflurane or isoflurane).
No specific criteria for extubation existed although difficult preoperative airway, hypercarbia, excessive bleeding, lengthy operative time, hypothermia, hemodynamic instability, and acidosis were considered relative contraindications to extubation. The decision to extubate was at the discretion of the anesthesiologist and thoracic surgeon. Extubation was likely delayed if two or more of these parameters were present at the completion of the procedure. Patients recovered in an intensive care setting for at least 12 to 24 hours and transferred to the Thoracic Surgery Unit when stable. Perioperative antibiotics were routinely used for at least 24 to 48 hours. All patients had skilled pulmonary physiotherapy, incentive spirometry, and early ambulation. Nasogastric drainage was maintained on average 4 to 7 days or until a Gastrografin (Squibb Diagnostic, Princeton, NJ) swallow was performed 4 to 7 days postoperatively to confirm the absence of anastomotic leak or delayed conduit emptying. Enteral nutrition was instituted early and advanced as tolerated. There was liberal use of bedside flexible bronchoscopy for pulmonary toilet.
Identified patients were divided into two groups: early and late extubation groups. The early extubation group was defined to include patients successfully extubated in the operating room. Patients who were not extubated in the operating room or required immediate reintubation in the operating room were considered part of the late extubation group.
Statistical Analysis
Statistical analysis was performed using SAS version 9.13 statistical software (SAS, Cary, NC). Continuous variables were analyzed with the Student t test and confirmed with the Mann-Whitney U test. Proportions were analyzed with the Fisher exact test. A p value of 0.05 or less was used for statistical significance. Collated variables were collected and presented as mean ± standard error of the mean. Survival was analyzed with the Kaplan-Meier method.
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Results
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There were 129 consecutive patients who underwent esophagectomy for all indications over a two-year period on the Thoracic Surgery Service. After excluding redo-esophagectomy, emergent esophagectomy, and reconstruction with conduit other than stomach, 102 patients were identified for analysis. Preoperative patient characteristics are described in Table 1. Ninety-two patients were successfully extubated in the operating room at the conclusion of the procedure. These patients comprised the early extubation group. Ten patients (9.8%) failed to extubate in the immediate postoperative period. These patients comprise the late extubation group. Two of these patients were extubated in the operating room but needed emergent reintubation and departed the operating room mechanically ventilated. These two patients were reintubated in the operating room due to airway obstruction. Eight patients were selected for prophylactic overnight ventilation. Two patients were selected because of delayed emergence from anesthesia. Two patients extubated late for prolonged length of case (>12 hours) and one extubated late for extenuating comorbidities (severe ischemic heart disease and poor lung function). One patient with obstructive sleep apnea developed significant hypercapnia and had a questionable aspiration event during induction. The etiology of delayed extubation could not be identified in the remaining two patients.
Only three patients, all in the early extubation group, had respiratory failure, which prompted reintubation. One patient developed a hemothorax within 24 hours postoperatively and suffered multisystem organ failure. Another patient had a presumed major aspiration event requiring reintubation on the first postoperative day. The third patient had a prolonged hospitalization from chylothorax and ultimately developed septic shock from toxic mega-colon requiring reintubation approximately three weeks from his original surgery. All required prolonged ventilation and tracheostomy.
Twenty-eight percent of all patients in this study were 70 years or older and comprised 40% of the delayed extubation group. The rate of failure to extubate in this cohort was 13.8% (4 of 29) vs 8.2% (6 of 73) in younger patients (p = 0.39). Esophageal cancer was the most common indication for esophagectomy (97.1%). Adenocarcinoma was the most common malignancy (87%). Overall, 50% (51 of 102) of patients received neoadjuvant chemoradiotherapy with no difference in the failure to extubate rate between the groups. Three patients had benign disease. Two patients had end-stage achalasia and one had a giant leiomyoma of the esophagus.
The distribution of operative approach is demonstrated in Figure 1. Most patients underwent Ivor Lewis (48%) or thoracoabdominal (36%) esophagectomy. All patients that underwent a transhiatal esophagectomy (11%) were extubated early. The failure to extubate rate for transhiatal was 0% compared with 11% (10 of 91) for the other modalities (p = 0.25). There was no difference in long-term survival between transhiatal esophagectomy and the transthoracic modalities (p = 0.90). Modified McKeown esophagectomy (5 of 102) had the highest rate of failure to extubate (20%) although not statistically significant when compared with other modalities (p = 0.43).
Intraoperative factors are presented in Table 2. Ninety-seven percent of patients had thoracic epidural anesthesia prior to induction. One patient without a preinduction thoracic epidural failed to extubate due to respiratory depression from systemic narcotic. This patient received an epidural on postoperative day one and was extubated that evening. The other patients were managed with intravenous narcotics.
The median length of stay was 11 days (6 to 55 days). The median length of ICU care was one day (0 to 26 days). Postoperative outcomes are presented in Table 3. The rate of pneumonia was 14.7%. The respiratory failure rate was 2.9% overall. There was one case of a major aspiration event leading to respiratory failure (1 of 92) in the early extubation group. It occurred greater than 24 hours postoperatively. One in-hospital death occurred in the early extubation group secondary to fatal arrhythmia. This patient had a history of valvular heart disease and sick sinus syndrome. The event occurred on postoperative day eight and was not likely related to early extubation. The 30-day mortality rate was 1.9%. With a mean follow up of 15.6 months, the median survival was 28 months (Fig 2).
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Comment
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Historically, the practice of delayed extubation for esophageal resection had its roots in a number of arguments and observations. Surgeons, anesthesiologists, and critical care specialists reasoned that fluid shifts secondary to extensive perioperative inflammation increased airway edema and the risk of airway obstruction. Postoperative pain caused by thoracotomy and(or) laparotomy compromised pulmonary mechanics. Postoperative bile reflux increased the risk of aspiration pneumonia. Thus, the reasoning went, postoperative "prophylactic" tracheal intubation and mechanical ventilation improved outcomes. However, little data existed to support this complex line of reasoning. Improved surgical technique, decreased length of surgery, less blood loss and associated fluid resuscitation, and improved perioperative pain management with thoracic epidural analgesia, further weakened this line of reasoning. Thus, a paradigm shift occurred and some institutions adopted early extubation as an important change in the perioperative management of esophageal resections [8–10].
Several studies have examined the outcomes of early and late extubation after esophagectomy. In 1993, Caldwell and colleagues [9] reported the outcome of patients undergoing esophagectomy after a change in clinical management from overnight ventilation to early extubation. The analysis yielded no increase in respiratory complications and a decrease in ICU stay. Chandrashekar and colleagues [11] evaluated 76 patients who underwent Ivor Lewis esophagectomy and found that the duration of one-lung ventilation was significantly longer in patients who required reventilation in the operating room or immediately postoperatively. The authors suggested that a history of smoking, chronic obstructive pulmonary disease, and neoadjuvant therapy appeared to be associated with delayed extubation. In contrast, neoadjuvant chemoradiotherapy was performed in 50% of patients in our series and was not significantly associated with delayed extubation postesophagectomy.
Ventilation in the postoperative period is associated with a higher incidence of ARDS and prolonged ICU stay. Tandon and colleagues [12] reported a 14.5% incidence of ARDS in a series of 168 elective esophagectomies. Pulmonary complications occurred in 44%. Those with a recent history of tobacco use were found to be at highest risk. Contemporary series, including patients with neoadjuvant chemoradiotherapy, report lower rates of ARDS (2.6% to 7.6%) [12–16]. Pulmonary complications occurred in 33% of patients in our series with a 2.9% incidence of ARDS. Our rates of ARDS are among the lowest reported in the literature and can perhaps be attributed to a greater than 90% early extubation rate, epidural use in 97% of the patients, and restricted intraoperative fluid management. Recent evidence for postoperative management of bowel resections suggest improved outcome with restricted fluid resuscitation [17]. Furthermore, our anesthesiologists tend to run a maintenance epidural infusion of 2% lidocaine throughout the procedure decreasing the total dose of inhalation agent and narcotic administered. Theoretically, preemptive analgesia with thoracic neuraxial blockade may blunt the overall stress response to the physiologic insult of esophagectomy and therefore improve outcomes. This has been demonstrated in animal models but has not been sufficiently evaluated in human subjects [18].
There has been only one randomized controlled trial evaluating early and late extubation after esophagectomy. In 1998, Bartels and colleagues [19] compared early extubation (within 6 hours) and prolonged ventilation (>24 hours) in patients after transthoracic (n = 104) or transhiatal esophageal (n = 131) resection. The authors concluded that the early extubation group after transthoracic esophagectomy had higher hospital mortality compared with the prolonged ventilation group (9.8% vs 1.9%); however, this did not reach statistical significance. In our study, there was no difference in perioperative mortality in the early and late extubation groups. Bartels and colleagues [19] report that transhiatal esophagectomy was associated with reduced complications when extubated early. Similarly, a recent large prospective study [16] identified surgical procedure as the most important risk factor for postoperative morbidity with the transthoracic technique demonstrating significantly higher risk. Including Ivor Lewis, thoracoabdominal, and modified-McKeown, we performed transthoracic esophageal resections in 89% of the study population with equal mortality and long-term survival compared with transhiatal esophagectomy. No statistical difference in early extubation could be demonstrated when comparing the transhiatal approach with other esophagectomy techniques, although it is noteworthy that none of the patients resected by a transhiatal approach failed extubation.
Aside from the risk of aspiration or excessive blood loss and hemodynamic instability, routine esophagectomy should be extubated early in the operating room. The routine risk of aspiration in the immediate postoperative period does not appear significantly higher than the risk of aspiration during postoperative recovery with a nasogastric tube. Thus, it is hard to justify prophylactic intubation for prevention of aspiration because the risk of aspiration is prevalent throughout the perioperative period and not isolated to the first 12 to 24 postoperative hours. Our low rate of ARDS is more likely due to anesthetic and surgical technique and diligent adherence to aspiration precautions by our nursing staff than by the use of prolonged nasogastric decompression or selective prophylactic intubation and mechanical ventilation. Our rate of failure to extubate (9.8%) is among the lowest in the recent literature (4% to 41%) [7, 9, 11]. We believe our excellent outcomes are, in part, due to this achievement.
There are several limitations in our study design. This is a single, tertiary-care center experience and our results may not be applicable to all patients or hospital settings. Retrospective and unblinded data gathering introduces several biases into our results and analysis. The decision to extubate a patient ultimately resided in the anesthesiologist and was not based on any strict predefined criteria. This introduces further bias into the study. The small number of patients who comprise the delayed extubation group limits our ability to compare the outcomes between the two groups and identify factors predictive of failure to extubate. Therefore, we highlight the feasibility of early extubation as opposed to making statistical comparisons between the groups. Optimally, a prospective study would yield stronger conclusions although it is unlikely that a randomized clinical trial could be justified given the mounting evidence in support of early extubation. A prospective multi-institutional database (ie, Society of Thoracic Surgeons database) specifically configured to record multiple preoperative and intraoperative variables would provide results that could be directly applicable to clinical practice.
An argument could be made to assign subjects who failed extubation in the operating room as respiratory failures after early extubation. It is our opinion that a reintubation occurring in the controlled setting of the operating room constitutes a relatively benign clinical scenario compared with reintubation in the recovery room or on a clinical floor. The outcomes of these patients could be expected to parallel those of the patients selected for prophylactic overnight intubation rather than those patients who were extubated early and failed on a clinical floor. In fact, both patients who where reintubated in the operating room were extubated within 48 hours. Those who were reintubated on the ward required prolonged ventilatory support and tracheostomy. Therefore, respiratory failure in the operating room was assigned as delayed extubation.
In summary, most patients can be extubated safely after esophagectomy. We report one of the lowest failures to extubate rates after esophageal resection regardless of surgical approach. Furthermore, the combination of preoperative risk optimization, relatively standardized intraoperative anesthetic scheme, a policy of early extubation, surgical expertise, and excellent postoperative care has demonstrated one of the lowest rates of ARDS, morbidity, and mortality in the literature. These outcomes and the potential reductions in resource utilization validate our enthusiasm for an early extubation policy and we encourage its growing acceptance.
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Acknowledgments
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Financial support for this study was provided by the Division of Thoracic Surgery at the Massachusetts General Hospital. We would like to acknowledge our data manager, Sheila Cann, for her diligence and dedication toward compiling and maintaining the Thoracic Surgery database.
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References
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- Jemal A, Murray T, Samuels A, et al. Cancer statistics, 2003 CA Cancer J Clin 2003;53:5-26.[Abstract/Free Full Text]
- Akins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity and mortality following esophagectomy Ann Thorac Surg 2004;78:1170-1176.[Abstract/Free Full Text]
- Birkmeyer JD, Siewers AE, Finlayson EVA, et al. Hospital volume and surgical mortality in the United States N Engl J Med 2002;346:1128-1137.[Abstract/Free Full Text]
- Swisher SG, Merriman KW, Deford L, et al. Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer J Thorac Cardiovasc Surg 2000;119:1126-1134.[Abstract/Free Full Text]
- Dimick JB, Wainess RM, Gilbert R, et al. National trends in outcomes for esophageal resection Ann Thorac Surg 2005;79:212-218.[Abstract/Free Full Text]
- Kita T, Mammoto T, Kishi Y. Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma J Clin Anesth 2002;14:252-256.[Medline]
- Yap FHY, Lau JYW, Joynt GM, et al. Early extubation after transthoracic esophagectomy Hong Kong Med J 2003;9:98-102.[Medline]
- Shackford SR, Virgilio RW, Peters RM. Early extubation versus prophylactic ventilation in the high risk patient: a comparison of postoperative management in the prevention of respiratory complications Anesth Analg 1981;60:76-80.[Abstract/Free Full Text]
- Caldwell MT, Murphy PG, Page R, Walsh TN, Hennessy TP. Timing of extubation after oesophagectomy Br J Surg 1993;80:1537-1539.[Medline]
- Desiderio D, Downey R. Critical issues in early extubation and hospital discharge in thoracic oncology surgery J Cardiothorac Vasc Anesth 1998;12:3-6.[Medline]
- Chandrashekar MV, Irving M, Wayman J, Raimes SA, Linsley A. Immediate extubation and epidural analgesia allow safe management in a high dependency unit after two-stage esophagectomyResults of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital. Br J Anaesth 2003;90:474-479.[Abstract/Free Full Text]
- Tandon S, Barchelor A, Bullock R, et al. Perioperative risk factors for acute lung injury after elective esophagectomy Br J Anaesth 1997;79:306-310.[Abstract/Free Full Text]
- Mariette C, Taillier G, Van Seuningen I, et al. Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma Ann Thorac Surg 2004;78:1177-1183.[Abstract/Free Full Text]
- Millikan K, Silverstein J, Hart V, et al. A 15-year review of esophagectomy for carcinoma of the esophagus and cardia Arch Surg 1995;130:617-624.[Abstract]
- Berger A, Scott W, Freedman G, et al. Morbidity and mortality are not increased after induction chemoradiotherapy followed by esophagectomy in patients with esophageal cancer Semin Oncol 2005;32(suppl 9):S16-S20.[Medline]
- Gockel I, Exner C, Junginger T. Morbidity and mortality after esophagectomy for esophageal carcinoma: a risk analysis World J Surg Oncol 2005;3:1-8.[Medline]
- Bardstrup B, Tonnensen H, Beier-Holgersen R, et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimensA randomized assessor-blinded multicenter trial. Ann Surg 2003;238:641-648.[Medline]
- Shavit Y, Weidenfeld J, DeKeyser FG, et al. Effects of surgical stress on brain prostaglandin E2 production and on the pituitary-adrenal axis: attenuation by preemptive analgesia and by central amygdala lesion Brain Res 2005;1047:10-17.[Medline]
- Bartels H, Stein JH, Siewart JR. Early extubation vs. late extubation after esophagus resection: a randomized, prospective study(in German) Langenbecks Arch Suppl Kongressbd 1998;115:1074-1076.
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Abstract
Introduction
= early extubation; 
= late extubation.)