title: The effect of on-demand vs deep neuromuscular relaxation on rating of surgical and anaesthesiologic conditions in patients undergoing thoracolaparoscopic esophagectomy (DEPTH trial): study protocol for a randomized controlled trial.
abstract: BACKGROUND
  Deep muscle relaxation has been shown to facilitate operating conditions during laparoscopic surgery. Minimally invasive esophageal surgery is a high-risk procedure in which the use of deep neuromuscular block (NMB) may improve conditions in the thoracic phase as well. Neuromuscular antagonists can be given on demand or by continuous infusion (deep NMB). However, the positioning of the patient often hampers train-of-four (TOF) monitoring. A continuous infusion thus may result in a deep NMB at the end of surgery. The use of neostigmine not only is insufficient for reversing deep NMB but also may be contraindicated for this procedure because of its cholinergic effects. Sugammadex is an effective alternative but is rather expensive. This study aims to evaluate the use of deep versus on-demand NMB on operating, anaesthesiologic conditions, and costs in patients undergoing a two- or three-phase thoracolaparoscopic esophageal resection.
  
  
  METHODS
  We will conduct a single-center randomized controlled double-blinded intervention study. Sixty-six patients undergoing a thoracolaparoscopic esophageal resection will be included. Patients will receive either continuous infusion of rocuronium 0.6 mg/kg per hour (group 1) or continuous infusion of NaCl 0.9 % 0.06 ml/kg per hour (group 2). In both groups, on-demand boluses of rocuronium can be given (open-label design). The primary aim of this study is to compare the surgical rating scale (SRS) during the abdominal phase. Main secondary aims are to evaluate SRS during the thoracic phase, to evaluate anesthesiologic conditions, and to compare costs (in euros) associated with use of rocuronium, sugammadex, and duration of surgery.
  
  
  CONCLUSIONS
  This study is the first to evaluate the benefits of deep neuromuscular relaxation on surgical and anaesthesiologic conditions during thoracolaparoscopic esophageal surgery. This surgical procedure is unique because it consists of both an abdominal phase and a thoracic phase taking place in different order depending on the subtype of surgery (a two- or three-stage transthoracic esophagectomy). In addition, possible benefits associated with deep NMB, such as decrease in operating time, will be weighed against costs.
  
  
  BACKGROUND
  European Clinical Trials Database (EudraCT) number: 2014-002147-18 (obtained 19 May 2014) ClinicalTrials.gov: NCT02320734 (obtained 18 Dec. 2014).
authors.affiliation: Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. d.p.veelo@amc.uva.nl.
authors.forename: Denise P
authors.initials: DP
authors.lastname: Veelo
authors.affiliation: Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. s.s.gisbertz@amc.uva.nl.
authors.forename: Suzanne S
authors.initials: SS
authors.lastname: Gisbertz
authors.affiliation: Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. r.a.hannivoort@amc.uva.nl.
authors.forename: Rebekka A
authors.initials: RA
authors.lastname: Hannivoort
authors.affiliation: Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. s.vandieren@amc.uva.nl.|Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. s.vandieren@amc.uva.nl.
authors.forename: Susan
authors.initials: S
authors.lastname: van Dieren
authors.affiliation: Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. b.f.geerts@amc.uva.nl.
authors.forename: Bart F
authors.initials: BF
authors.lastname: Geerts
authors.affiliation: Department of Surgery, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. m.i.vanbergehenegouwen@amc.uva.nl.
authors.forename: Mark I
authors.initials: MI
authors.lastname: van Berge Henegouwen
authors.affiliation: Department of Anaesthesiology, Academic Medical Center, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands. m.w.hollmann@amc.uva.nl.
authors.forename: Markus W
authors.initials: MW
authors.lastname: Hollmann
mesh_terms: D000732:Androstanols / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D002985:Clinical Protocols; D003362:Cost-Benefit Analysis; D004311:Double-Blind Method; D004334:Drug Administration Schedule; D016527:Drug Costs; D016629:Esophagectomy / Q000009:adverse effects / Q000191:economics / Q000379:methods*; D006801:Humans; D007263:Infusions, Parenteral; D010535:Laparoscopy / Q000009:adverse effects / Q000191:economics; D016343:Monitoring, Intraoperative / Q000379:methods; D009126:Muscle Relaxation / Q000187:drug effects*; D009426:Netherlands; D009466:Neuromuscular Blocking Agents / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D012107:Research Design; D000077123:Rocuronium; D013906:Thoracoscopy / Q000009:adverse effects / Q000191:economics; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000732:Androstanols; D009466:Neuromuscular Blocking Agents; D000077123:Rocuronium