British Journal of Anaesthesia, 2004, Vol. 92, No. 6 907-908
© 2004 The Board of Management and Trustees of the British Journal of Anaesthesia
Correspondence |
Oesophagectomy and elective postoperative ventilation
1 London, UK 2 Carlisle, UK
Editor—Further to the editorial1 by Sherry, which describes representative world mortality rates of 8–10% after oesophagectomy, a number of units undertaking this form of surgery in the UK will have felt encouraged by the substantially lower mortality rate in their own institution. It is a short step to imagining that the lower mortality rate is attributable to a particular component of their management. In the UK, data from the cardiothoracic surgeons self-reported database for 2001–2002 indicate that 587 oesophagectomies were undertaken with an overall mortality rate of 4.7%. Data from the website of the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland2 indicate a crude in-hospital postoperative mortality for oesophagectomy of 7–8%, and 11% after oesophagogastric junction surgery.
The audit by Chandrashekar and colleagues,3 and correspondence in this journal from another unit,4 both stress that their good results are obtained by early extubation and suggest that postoperative ventilation may be a deleterious factor. We believe that they are incorrect. Chandrashekar’s audit of 76 patients over 8 yr undergoing two stage (Ivor Lewis) oesophagectomy mainly managed by thoracic epidural, extubation at the end of surgery, and HDU care resulted in 30-day or in-hospital mortality rate of 2.6%. In our unit in the period January 2000–May 2003, we have undertaken 177 oesophagectomies (open transhiatal 55%, left thoracoabdominal 20%, 2-stage 10%, 3-stage 8%). Most (>90%) have been artificially ventilated electively overnight after surgery. Our 30-day mortality was 0.5% and in-hospital mortality was 1.1%. These research grade audit data are similar to the mortality rates evident here over the last 15–20 yr during which the policy of elective postoperative ventilation has been in use. In our experience, there is no evidence of a deleterious effect of postoperative ventilation for a period of 15–20 h and we would not change our policy. We are particularly concerned that the main stated reason for early extubation is to reduce the demand for an ICU bed. Here we would not undertake the operation unless the correct level of postoperative care was available.
To conduct a formal study into whether postoperative ventilation per se affected outcome would require enrolment of all patients undergoing oesophagectomy in the whole country in a given year. In our view, if there are 
2000 procedures per year in the UK, it is unfortunate that there is not a single database from which it might be possible to extract evidence for good practice in perioperative management. We do not know whether transhiatal oesophagectomy, in which there is no period of one-lung ventilation or surgical handling of the lung, has a better outcome than transthoracic surgery. A review of the literature5 comparing transhiatal (2675 patients) with the Ivor Lewis approach (2808 patients), showed similar rates of respiratory complications and wound infection, with an overall mortality of 6.3% in the transhiatal surgery group, and 9.5% in the Ivor Lewis group. A prospective study in 220 patients6 found no statistically significant difference in mortality between the two surgical approaches but a lower morbidity rate in the transhiatal group. Does neo-adjuvant chemotherapy have an adverse effect? For any given patient, the outcome may be influenced by the type of anaesthesia, inspired oxygen, fluid policy in quantity or type, blood transfusion, body temperature maintenance, length of surgery, one-lung ventilation, duration of one-lung ventilation, inotrope policy, level of postoperative intervention and care, postoperative ventilation, and method of analgesia. These components cannot be examined by individual units because of the numbers treated. In our view, The Royal College of Anaesthetists should take a lead in designing and promoting a national anaesthetic datasheet for this type of surgery.
M. Shah
A. Pearce
London, UK
Editor—The correspondence from the unit at Guy’s Hospital, London describes in some detail the excellent results they have produced for elective oesophageal surgery, though in fact less than half of their series underwent a thoracotomy.
The theme of our paper was that good outcome results could be obtained after thoracotomy without the need for postoperative ventilation and admission to ITU. We have not stated that this is better than a policy of elective ventilation, though we have pointed out that there are theoretical reasons for avoiding prolonged ventilation if this is possible. The main aim of our paper has been to demonstrate that results equal to the best reported from units with a policy of elective postoperative ventilation can be achieved with early extubation.
Shah and Pearce state that they would not undertake the operation unless the correct level of postoperative care was available. They miss the point that the correct level of care can be at an HDU level with ITU back-up if required. This is at no detriment to the patient and is potentially a better use of a valuable resource.
S. Raimes
A. Linsley
Carlisle, UK
References
1 Sherry KM. How can we improve the outcome of oesophagectomy? Br J Anaesth 2001; 86: 611–13
2 The Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland. www.augis.org
3 Chandrashekar MV, Irving M, Wayman J, Raimes SA, Linsley A. 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. Br J Anaesth 2003; 90: 474–9
4 Rocker M, Havard TJ, Wagle A. Early extubation after two-stage oesophagectomy. Br J Anaesth 2003; 91: 760
5 Rindani R, Martin CJ, Cox MR. Transhiatal versus Ivor-Lewis oesophagectomy: is there a difference? Aust N Z J Surg 1999; 69: 187–94[CrossRef][Web of Science][Medline]
6 Hulscher JBF, van Sandick JW, de Boer AGEM, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. New Engl J Med 2002; 347: 1662–9
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