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The impact of tidal volume on pulmonary complications following minimally invasive esophagectomy: A randomized and controlled study

2013; Elsevier BV; Volume: 146; Issue: 5 Linguagem: Inglês

10.1016/j.jtcvs.2013.06.043

1097-685X

Yaxing Shen, Ming Zhong, Wei Wu, Hao Wang, Mingxiang Feng, Lijie Tan, Qun Wang,

Esophageal Cancer Research and Treatment

BackgroundMinimally invasive esophagectomy (MIE) has been advantageous for lowering pulmonary complications compared with open approaches.1Wright C.D. Kucharczuk J.C. O’Brien S.M. Grab J.D. Allen M.S. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model.J Thorac Cardiovasc Surg. 2009; 137: 587-595Abstract Full Text Full Text PDF PubMed Scopus (282) Google Scholar However, pulmonary complications remain the most common morbidity after surgical resection of esophageal cancer.2Law S. Wong K.H. Kwok K.F. Chu K.M. Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer.Ann Surg. 2004; 240: 791-800Crossref PubMed Scopus (336) Google Scholar, 3Ferguson M.K. Celauro A.D. Prachand V. Prediction of major pulmonary complications after esophagectomy.Ann Thorac Surg. 2011; 91: 1494-1500Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar The aim of this prospective, randomized, controlled, clinical trial was designed to see whether low tidal volume (VT) could further minimize pulmonary complications after MIE.MethodsBetween June 2011 and July 2012, a total of 101 patients who underwent MIE received left-lung ventilation during thoracoscopic esophagectomy. All patients received left-lung ventilation during thoracoscopic esophagectomy. Patients were randomly assigned to a low VT (5 mL/kg + 5 cm H2O positive end-expiratory pressure) preserved ventilation (PV) group (n = 53) and a conventional VT (8 mL/kg) controlled ventilation (CV) group (n = 48) in the thoracic stage. Alveolar lavage fluid was harvested from the ventilated lung at intubation and at 18 hours after surgery for analysis of interleukin (IL)-1ß, IL-6, and IL-8 levels. Clinical characteristics, including patient demographics, operation features, and changes in oxygenation index, were recorded and analyzed. Pulmonary complications were identified and statistically compared between the 2 groups.ResultsThe clinical characteristics and operation features were comparable between the 2 groups. IL-1ß, IL-6, and IL-8 expressions in preoperative alveolar lavage fluid were similar between the 2 groups. Significantly lower IL expressions were observed in the PV group than those in the CV group at 18 hours after MIE (IL-1ß, 25.42 ± 31.01 vs 94.96 ± 118.24 pg/mL; IL-6, 30.86 ± 75.78 vs 92.99 ± 72.90 pg/mL; IL-8, 258.75 ± 188.24 vs 403.95 ± 151.44 pg/mL; all P < .05). The 18-hour postoperative oxygenation index was lower in the CV group than that in the PV group (292.85 ± 28.74 vs 326.35 ± 34.43; P = .046). Pulmonary complications were observed in 18 cases of our series, occurring more frequently on the ventilation side (right, 6 cases; and left, 12 cases). All patients were cured by conservative therapy without severe sequelae. The occurrence of pulmonary complications in the PV group was lower than that in the CV group (9.43% vs 27.08%; P = .021).ConclusionsLung injury due to intraoperative single-lung ventilation may contribute to pulmonary complications after MIE. Low VT ventilation could decrease ventilation-associated lung inflammation, thus minimizing pulmonary complications after MIE. Further studies, based on a larger volume of populations, are required to confirm these findings. Minimally invasive esophagectomy (MIE) has been advantageous for lowering pulmonary complications compared with open approaches.1Wright C.D. Kucharczuk J.C. O’Brien S.M. Grab J.D. Allen M.S. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model.J Thorac Cardiovasc Surg. 2009; 137: 587-595Abstract Full Text Full Text PDF PubMed Scopus (282) Google Scholar However, pulmonary complications remain the most common morbidity after surgical resection of esophageal cancer.2Law S. Wong K.H. Kwok K.F. Chu K.M. Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer.Ann Surg. 2004; 240: 791-800Crossref PubMed Scopus (336) Google Scholar, 3Ferguson M.K. Celauro A.D. Prachand V. Prediction of major pulmonary complications after esophagectomy.Ann Thorac Surg. 2011; 91: 1494-1500Abstract Full Text Full Text PDF PubMed Scopus (117) Google Scholar The aim of this prospective, randomized, controlled, clinical trial was designed to see whether low tidal volume (VT) could further minimize pulmonary complications after MIE. Between June 2011 and July 2012, a total of 101 patients who underwent MIE received left-lung ventilation during thoracoscopic esophagectomy. All patients received left-lung ventilation during thoracoscopic esophagectomy. Patients were randomly assigned to a low VT (5 mL/kg + 5 cm H2O positive end-expiratory pressure) preserved ventilation (PV) group (n = 53) and a conventional VT (8 mL/kg) controlled ventilation (CV) group (n = 48) in the thoracic stage. Alveolar lavage fluid was harvested from the ventilated lung at intubation and at 18 hours after surgery for analysis of interleukin (IL)-1ß, IL-6, and IL-8 levels. Clinical characteristics, including patient demographics, operation features, and changes in oxygenation index, were recorded and analyzed. Pulmonary complications were identified and statistically compared between the 2 groups. The clinical characteristics and operation features were comparable between the 2 groups. IL-1ß, IL-6, and IL-8 expressions in preoperative alveolar lavage fluid were similar between the 2 groups. Significantly lower IL expressions were observed in the PV group than those in the CV group at 18 hours after MIE (IL-1ß, 25.42 ± 31.01 vs 94.96 ± 118.24 pg/mL; IL-6, 30.86 ± 75.78 vs 92.99 ± 72.90 pg/mL; IL-8, 258.75 ± 188.24 vs 403.95 ± 151.44 pg/mL; all P < .05). The 18-hour postoperative oxygenation index was lower in the CV group than that in the PV group (292.85 ± 28.74 vs 326.35 ± 34.43; P = .046). Pulmonary complications were observed in 18 cases of our series, occurring more frequently on the ventilation side (right, 6 cases; and left, 12 cases). All patients were cured by conservative therapy without severe sequelae. The occurrence of pulmonary complications in the PV group was lower than that in the CV group (9.43% vs 27.08%; P = .021). Lung injury due to intraoperative single-lung ventilation may contribute to pulmonary complications after MIE. Low VT ventilation could decrease ventilation-associated lung inflammation, thus minimizing pulmonary complications after MIE. Further studies, based on a larger volume of populations, are required to confirm these findings.