Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study.
BACKGROUND
Esophagectomy induces a systemic inflammatory response whose extent has been recognized as a predictive factor of postoperative respiratory morbidity. The aim of this study was to determine the effectiveness of a protective ventilatory strategy to reduce systemic inflammation in patients undergoing esophagectomy.


METHODS
The authors prospectively investigated 52 patients undergoing planned esophagectomy for cancer. Patients were randomly assigned to a conventional ventilation strategy (n = 26; tidal volume of 9 ml/kg during two-lung and one-lung ventilation; no positive end-expiratory pressure) or a protective ventilation strategy (n = 26; tidal volume of 9 ml/kg during two-lung ventilation, reduced to 5 ml/kg during one-lung ventilation; positive end-expiratory pressure 5 cm H2O throughout the operative time).


RESULTS
Plasmatic levels of interleukin (IL)-1beta, IL-6, IL-8, and tumor necrosis factor alpha were measured perioperatively and postoperatively. Pulmonary function and postoperative evolution were also evaluated. Patients who received protective strategy had lower blood levels of IL-1beta, IL-6, and IL-8 at the end of one-lung ventilation (0.24 [0.15-0.40] vs. 0.56 [0.38-0.89] pg/ml, P < 0.001; 91 [61-117] vs. 189 [127-294] pg/ml, P < 0.001; and 30 [22-45] vs. 49 [29-69] pg/ml, P < 0.05, respectively) and 18 h postoperatively (0.18 [0.13-0.30] vs. 0.43 [0.34-0.54] pg/ml, P < 0.001; 54 [36-89] vs. 116 [78-208] pg/ml, P < 0.001; 16 [11-24] vs. 35 [28-53] pg/ml, P < 0.001, respectively). Protective strategy resulted in higher oxygen partial pressure to inspired oxygen fraction ratio during one-lung ventilation and 1 h postoperatively and in a reduction of postoperative mechanical ventilation duration (115 +/- 38 vs. 171 +/- 57 min, P < 0.001).


CONCLUSIONS
A protective ventilatory strategy decreases the proinflammatory systemic response after esophagectomy, improves lung function, and results in earlier extubation.
Michelet
Pierre
P
Réanimation Polyvalente, Hôpital Sainte-Marguerite, 13274 Marseille Cedex 9, France. pierre.michelet@mail.ap-hm.fr
D'Journo
Xavier-Benoît
XB
Roch
Antoine
A
Doddoli
Christophe
C
Marin
Valerie
V
Papazian
Laurent
L
Decamps
Isabelle
I
Bregeon
Fabienne
F
Thomas
Pascal
P
Auffray
Jean-Pierre
JP
D000368:Aged; D004938:Esophageal Neoplasms / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects*; D005260:Female; D006801:Humans; D018836:Inflammation Mediators / Q000097:blood; D053583:Interleukin-1beta / Q000097:blood; D015850:Interleukin-6 / Q000097:blood; D016209:Interleukin-8 / Q000097:blood; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D018746:Systemic Inflammatory Response Syndrome / Q000097:blood / Q000209:etiology / Q000517:prevention & control*; D013990:Tidal Volume; D014409:Tumor Necrosis Factor-alpha / Q000097:blood
D018836:Inflammation Mediators; D053583:Interleukin-1beta; D015850:Interleukin-6; D016209:Interleukin-8; D014409:Tumor Necrosis Factor-alpha