title: Immediate extubation and epidural analgesia allow safe management in a high-dependency unit after two-stage oesophagectomy. Results of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital.
abstract: BACKGROUND
  The perioperative management of two-stage oesophagectomy has not been standardized and the prevailing practice regarding the timing of extubation after the procedure varies. This audit has evaluated the outcome, in particular the respiratory morbidity and mortality, after immediate extubation in patients who have had thoracic epidural analgesia.
  
  
  METHODS
  All the patients who underwent two-stage oesophagectomy by a single specialist upper gastrointestinal surgeon were recorded both retrospectively (1993-1999) and prospectively (1999-2001). Physical characteristics, comorbid factors, anaesthetic management and postoperative events were recorded on a computer database. Analysis was undertaken to evaluate the morbidity and mortality, in particular the need for reventilation and transfer to the ITU.
  
  
  RESULTS
  Seventy-six patients underwent two-stage oesophagectomy between 1993 and 2001. Seventy-three (96%) patients were extubated in theatre and transferred to a high-dependency bed. Three were ventilated electively and extubated within 36 h and made an uncomplicated recovery. Seven (10%) of the immediately extubated patients subsequently needed admission to the ICU and reventilation. Sixty-seven patients had effective epidural analgesia and nine needed i.v. morphine by patient-controlled analgesia. The 30-day or in-hospital mortality was 2.6% (2 of 76). A further two patients died within 90 days, but after discharge. Respiratory complications were responsible for half of the overall morbidity (44.7%). Respiratory failure occurred in 6.5% (5 of 76) and acute respiratory distress syndrome in 2.6% (2 of 76). Both the in-hospital deaths occurred in patients requiring reventilation and resulted from respiratory complications. The following factors were found to be significant in the reventilated patients: duration of one-lung ventilation; forced expiratory volume in the first second; and ratio of forced expiratory volume in the first second/forced vital capacity.
  
  
  CONCLUSIONS
  Immediate extubation after two-stage oesophagectomy in patients with thoracic epidural analgesia is safe and associated with low morbidity and mortality. Patients can be managed in a high-dependency unit, thus avoiding the need for intensive care. This has cost-saving and logistical implications.
authors.affiliation: Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne, UK.
authors.forename: M V
authors.initials: MV
authors.lastname: Chandrashekar
authors.forename: M
authors.initials: M
authors.lastname: Irving
authors.forename: J
authors.initials: J
authors.lastname: Wayman
authors.forename: S A
authors.initials: SA
authors.lastname: Raimes
authors.forename: A
authors.initials: A
authors.lastname: Linsley
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural; D020878:Device Removal; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods* / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006767:Hospitals, District; D006769:Hospitals, General; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D007902:Length of Stay; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D009367:Neoplasm Staging; D011182:Postoperative Care / Q000379:methods*; D011183:Postoperative Complications; D012121:Respiration, Artificial; D012189:Retrospective Studies