title: Assessment of intra-operative haemodynamic changes associated with transhiatal and transthoracic oesophagectomy.
abstract: OBJECTIVE
  Previous comparisons of the different surgical techniques for oesophagectomy have concentrated on mortality, morbidity and survival. There is limited data regarding the intra-operative physiological ramifications of the transhiatal (TH) versus the transthoracic (TT) approach to oesophageal resection. We carried out an in-depth analysis of the intra-operative haemodynamic changes and assessed the potential implications on perioperative outcomes in a matched cohort of patients undergoing TH and TT oesophagectomy.
  
  
  METHODS
  A retrospective case review study of TT and TH oesophageal resection at a high-volume tertiary referral centre for oesophageal diseases. General demographics and outcomes of the patients were accumulated prospectively in an Institutional Review Board (IRB) approved database. Intra-operative haemodynamic measurements were obtained from anaesthetic records. A total of 40 patients (20 TT+20 TH) were retrospectively identified after matching them for age, co-morbidities, tumour stage and American Society of Anesthesiologists (ASA) status. Main outcome measures included perioperative outcomes, operative time, blood loss, intensive care unit (ICU) and hospital length of stay, incidence and types of dysrhythmias, incidence of intra-operative hypotension and vasopressor usage, as well as perioperative morbidity and 90-day mortality.
  
  
  RESULTS
  Indications for resection included oesophageal cancer (27 patients), high-grade dysplasia (six patients), laryngopharyngoesophageal cancer (three patients), achalasia (two patients) and scleroderma (1 patient). Nine patents with oesophageal cancer had pT3 tumours (TH1, TT8). The mortality was zero in both groups. The total duration of hospitalisation and ICU care was similar in both groups. The mean estimated blood loss was 213 ml (range 100-400 ml) for the TH group and 216 ml (range 80-500 ml) for the TT group. The median operating times for both approaches were similar (398 min TH vs 382 min TT). Intra-operative dysrhythmias were noted in 11 TH and 15 TT patients. Both groups maintained at least 80% of the pre-operative systolic blood pressure (SBP) intra-operatively (TT 89% vs TH 85%) and required vasopressors in comparable quantities. The comparative statistical analysis of intra-operative incidences of hypotensive episodes below 100, 90 and 80 mm Hg showed no significant differences in both groups. However, the TH group experienced a greater frequency of acute hypotension (acute SBP decreases by ≥ 10 mm Hg per 5-min reading) intra-operatively (TH 25% vs TT 16% of operative time), p=0.02. Phenylephrine infusions were required for longer periods in the TH group (TH 52.7% vs TT 33.6% of operation time), p=0.01.
  
  
  CONCLUSIONS
  This study demonstrates that intra-operative haemodynamic changes and perioperative outcomes are similar in both TT and TH approaches for oesophagectomy in a well-matched cohort of patients. Patients undergoing the TH approach demonstrated a higher frequency of intra-operative haemodynamic lability. The approaches to oesophageal resection should be based on matching the operation to the patient's pre-existing conditions and tumour characteristics rather than perceived differences in haemodynamic impact.
authors.affiliation: Section of Thoracic Surgery and Anesthesiology, Virginia Mason Medical Center, Seattle, WA 98101, USA.
authors.forename: Madhan Kumar
authors.initials: MK
authors.lastname: Kuppusamy
authors.forename: Chance D
authors.initials: CD
authors.lastname: Felisky
authors.forename: Felisky D
authors.initials: FD
authors.lastname: Chance
authors.forename: James D
authors.initials: JD
authors.lastname: Helman
authors.forename: Mathew
authors.initials: M
authors.lastname: Deeter
authors.forename: Richard P
authors.initials: RP
authors.lastname: Koehler
authors.forename: Donald E
authors.initials: DE
authors.lastname: Low
mesh_terms: D000328:Adult; D000368:Aged; D001145:Arrhythmias, Cardiac / Q000209:etiology; D004938:Esophageal Neoplasms / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007430:Intraoperative Care; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome