Perioperative management and outcomes of minimally invasive esophagectomy: case study of a high-volume tertiary center in Taiwan.

Background: Mortality and complication rates for surgical esophagectomy remain high despite progress in surgical techniques and perioperative care. Minimally invasive surgery and intraoperative goal-directed fluid management are gaining popularity in Taiwan; however, perioperative complications and short-term outcomes have been rarely reported. In this retrospective study, we analyzed the surgical procedures performed as well as the perioperative outcomes and treatments after esophagectomy in a high-volume medical center in Taiwan. The goals of this study are to compare the complications and the following treatment between different surgical procedures and to analyze if any preoperative coexisting disease and anesthesia conduct might be associated with postoperative complications and hospitalization course.

Methods: We retrospectively reviewed the data of all patients who had undergone esophagectomy and reconstruction in 2015. Patient characteristics, type of surgery performed, method of anesthesia, postoperative hospitalization course, and additional surgical interventions were reviewed and analyzed.

Results: In total, 64 patients were included. Among them, 58 patients (90.6%) were reported squamous cell carcinoma, 33 patients (51.6%) received McKeown minimally invasive esophagectomy (MIE), and 20 (31.3%) received Ivor-Lewis MIE. The most common postoperative complications were pulmonary complications (18.7%), such as empyema and pleural effusion, dysrhythmias (14.1%), anastomosis leakage (14.1%), vocal cord paralysis (9.4%), gastric tube stenosis (4.7%), chyle leakage (4.7%), and acute kidney injury (AKI, 4.7%). Twenty-five percent of patients received secondary operative interventions for the aforementioned complications. Postoperative arrhythmia (P=0.042), pulmonary complications (P=0.009), and AKI (P=0.015) were significantly associated with prolonged intensive care unit (ICU) stays. Thirty-day and 90-day mortality rates were 3.1% and 4.7% respectively. Patients with preoperative arrhythmias have a higher risk of developing post-operative dysrhythmia (P=0.013) and lung complications (P=0.036). Patients with an underlying heart disease are at higher risk of post-op AKI (P=0.002) and second surgical intervention (P=0.013). Chronic kidney diseases are associated with post-op dysrhythmia (P=0.013), lung complications (P=0.036) and post-op AKI (P≤0.01). Although McKeown MIE bore a significantly longer surgical time and higher intraoperatively-infused crystalloid than did Ivor Lewis MIE, there were no significant differences regarding postoperative cardiothoracic complications and patient outcomes.

Conclusions: Postoperative outcomes of McKeown MIE and Ivor-Lewis MIE were comparable in our center and short term outcomes were similar to those in previous reports. However, despite neoadjuvant concurrent chemoradiation therapy (CCRT), the use of minimally invasive techniques, and well-controlled anesthesia, the incidence of perioperative complications remains high. Our results suggest that patients with preoperative comorbidity of arrhythmia, heart diseases, and CKD are associated with more common post-operative complications. Furthermore, postoperative dysrhythmias, pulmonary complications, and AKI warrant special anesthetic and surgical care to prevent prolonged ICU stay.