Enhanced recovery after surgery is well established in specialties such as colorectal surgery. It is achieved through the introduction of multiple evidence-based perioperative measures that aim to diminish postoperative organ dysfunction while facilitating recovery. This review aims to present consensus recommendations for the optimal perioperative management of patients undergoing thoracic surgery (principally lung resection). A systematic review of meta-analyses, randomized controlled trials, large non-randomized studies and reviews was conducted for each protocol element. Smaller prospective and retrospective cohort studies were considered only when higher-level evidence was unavailable. The quality of the evidence base was graded by the authors and used to form consensus recommendations for each topic. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society and the European Society for Thoracic Surgery. Recommendations were developed for a total of 45 enhanced recovery items covering topics related to preadmission, admission, intraoperative care and postoperative care. Most are based on good-quality studies. In some instances, good-quality data were not available, and subsequent recommendations are generic or based on data extrapolated from other specialties. In other cases, no recommendation can currently be made because either equipoise exists or there is a lack of available evidence. Recommendations are based not only on the quality of the evidence but also on the balance between desirable and undesirable effects. Key recommendations include preoperative counselling, nutritional screening, smoking cessation, prehabilitation for high-risk patients, avoidance of fasting, carbohydrate loading, avoidance of preoperative sedatives, venous thromboembolism prophylaxis, prevention of hypothermia, short-acting anaesthetics to facilitate early emergence, regional anaesthesia, nausea and vomiting control, opioid-sparing analgesia, euvolemic fluid management, minimally invasive surgery, early chest drain removal, avoidance of urinary catheters and early mobilization after surgery. These guidelines outline recommendations for the perioperative management of patients undergoing lung surgery based on the best available evidence. As the recommendation grade for most of the elements is strong, the use of a systematic perioperative care pathway has the potential to improve outcomes after surgery.

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Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS)

Purpose
Perioperative intravenous ketamine may be a useful addition in pain management regimens. Previous systematic reviews have included all methods of ketamine administration, and heterogeneity between studies has been substantial. This study addresses this issue by narrowing the inclusion criteria, using a random effects model, and performing subgroup analysis to determine the specific types of patients, surgery, and clinical indications which may benefit from perioperative ketamine administration.

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A systematic review of intravenous ketamine for postoperative analgesia

Background:Esophagectomy induces a systemic inflammatory response whose extent has been recognized as a predictive factor of postoperative respiratory morbidity. The aim of this study was to determine the effectiveness of a protective ventilatory strategy to reduce systemic inflammation in patients

Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study.

RESULTS High-flow nasal oxygen therapy was not inferior to BiPAP: the treatment failed in 87 of 414 patients with high-flow nasal oxygen therapy (21.0%) and 91 of 416 patients with BiPAP (21.9%) (absolute difference, 0.9%; 95% CI, −4.9% to 6.6%; P = .003). No significant differences were found for intensive care unit mortality (23 patients with BiPAP [5.5%] and 28 with high-flow nasal oxygen therapy [6.8%]; P = .66) (absolute difference, 1.2% [95% CI, -2.3% to 4.8%]. Skin breakdown was significantly more common with BiPAP after 24 hours (10% vs 3%; 95% CI, 7.3%-13.4% vs 1.8%-5.6%; P < .001). CONCLUSIONS AND RELEVANCE Among cardiothoracic surgery patients with or at risk for respiratory failure, the use of high-flow nasal oxygen therapy compared with intermittent BiPAP did not result in a worse rate of treatment failure. The findings support the use of high-flow nasal oxygen therapy in similar patients.

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High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial.

Objective:To investigate whether the number of lymph nodes metastasis (LNMs) and the ratio between metastatic and examined lymph nodes (LNs) are better prognostic factors when compared with traditional staging systems in patients with esophageal carcinoma.Summary Background Data:The accuracy of the

The number of metastatic lymph nodes and the ratio between metastatic and examined lymph nodes are independent prognostic factors in esophageal cancer regardless of neoadjuvant chemoradiation or lymphadenectomy extent.

assigned to receive, during the postoperative period, either i.v. morphine 1 mg ml 21 or morphine with ketamine 1 mg ml 21 for each. Morphine consumption was evaluated by cumulative doses every 12 h for the three postoperative days. Postoperative respiratory disorders were assessed by spirometric evaluation and recording of nocturnal desaturation. Results. The adjunction of ketamine resulted in a significant reduction in cumulative morphine consumption as early as the 36th postoperative hour [43 (SD 18) vs 32 (14) mg, P¼0.03] with a similar visual analogue scale. In the morphine group, the percentage of time with desaturation ,90% was higher during the three nights [1.80 (0.21‐6.37) vs 0.02 (0‐0.13), P,0.001; 2.15 (0.35‐8.65) vs 0.50 (0.01‐1.30), P¼0.02; 2.46 (0.57‐5.51) vs 0.55 (0.21‐1.00), P¼0.02]. The decrease in forced expiratory volume in 1 s was less marked in the ketamine group at the first postoperative day [1.04 (0.68‐1.22) litre vs 1.21 (1.10‐0.70) litre, P¼0.039]. Conclusions. Adding small doses of ketamine to morphine in PCA devices decreases the morphine consumption and may improve respiratory disorders after thoracic surgery.

Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

Background. One-lung ventilation-related hypoxaemia (OLV-RH) can occur in patients with healthy lungs. In this case, PEEP frequently improves oxygenation. The aim of this study was to determine, in a healthy lung model of OLV, whether the increase in PEEP improved oxygenation and whether the mechanisms involved include both inspiratory lung recruitment and an end-expiratory lung volume increase. Since inhaled nitric oxide (iNO) may have a synergistic effect on oxygenation in the case of PEEP-induced recruitment, their association was also tested. Methods. Twenty pigs were studied during open-chest, left OLV. Arterial blood gases and haemodynamic variables were measured at different levels of PEEP (0, 5, 10 and 15 cm H2O) applied in random order with or without iNO 4 p.p.m. Pressure–volume curves were measured at each level of PEEP. Results. PEEP5 and PEEP10 improved PaO2 /FIO2 ratio (P<0.005) and shunt (P<0.005) regardless of the presence of iNO. PEEP15 improved oxygenation and shunt only when it was associated with iNO (P<0.001). Whereas PEEP5, PEEP10 and PEEP15 were associated with a significant increase in end-expiratory volume (P<0.001), only PEEP5 and PEEP10 were associated with continuous lung volume recruitment (P<0.01). Moreover, PEEP15 induced a significant decrease in linear compliance (P<0.001). Conclusions. In a healthy porcine lung model of OLV-RH, moderate PEEP can improve oxygenation. This effect implies both expiratory and inspiratory pulmonary recruitment. Co-administration of 4 p.p.m. iNO was ineffective. Br J Anaesth 2005; 95: 267–73

Effects of PEEP on oxygenation and respiratory mechanics during one-lung ventilation

Background:

The aim of this case–control study was to compare the efficacy of non-invasive positive pressure ventilation (NPPV) with that of conventional treatment in patients who develop postoperative acute respiratory failure (ARF) after oesophagectomy.



Methods:

Thirty-six consecutive patients with ARF treated by NPPV were matched for diagnosis, age within 5 years, sex, preoperative radiochemotherapy and Charlson co-morbidity index with 36 patients who received conventional treatment (control group).



Results:

NPPV was associated with a lower reintubation rate (nine versus 23 patients; P = 0·008), lower frequency of acute respiratory distress syndrome (eight versus 19 patients; P = 0·015), and a reduction in intensive care stay (mean(s.d.) 14(13) versus 22(18) days; P = 0·034). Anastomotic leakage was less common in patients receiving NPPV (two versus ten; P = 0·027). These patients also showed a greater improvement in gas exchange in the first 3 days after onset of ARF (P = 0·013).



Conclusion:

The use of NPPV for the treatment of postoperative ARF may decrease the incidence of endotracheal intubation and related complications, without increasing the risk of anastomotic leakage after oesophagectomy. Copyright © 2008 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy

Laboratoire d’Epide´miologie et de Statistiques, Faculte´deMe´decine de Marseille, Marseille, FranceBackground: The oesophagectomy procedure includes the for-mation of a gastric tube to re-establish the continuity of thegastrointestinal tract. The effect of thoracic epidural analgesia(TEA) on gastric mucosal blood flow (GMBF) remains unknownin clinical practice. The aim of this prospective observationalstudywastoassess themicrocirculatorychanges inducedbyTEAin the early post-operative course.Methods: Eighteen consecutive patients who underwent radicaloesophagectomy with en-bloc resection and two-field lymphade-nectomy for oesophageal cancer, and benefited from TEA duringthe post-operative course, were studied prospectively, and com-paredwith nine patients who declined theuse of TEAin thesameperiod (control group). GMBF was measured using a laserDoppler flowmeter in three consecutive time periods (beforeand after 1 and 18 h of TEA infusion). Post-operative monitoringalso included the measurement of arterial pressure, cardiac out-put, gas exchange and intrathoracic blood volume index.Results: Afterthefirstand18thhourofinfusion,TEAinducedanincrease in GMBF compared with baseline and the control group.The mean arterial pressure and intrathoracic blood volume indexdecreasedafterthefirsthourofTEAinfusionwithnoinfluenceonthe cardiac index.Conclusions: This clinical study demonstrates that TEA im-proves the microcirculation of the gastric tube in the early post-oesophagectomy period. The clinical relevance of TEA in thissetting should be validated in larger studies focusing on theclinical outcome following oesophagectomy.

Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy

Objective: Controversy continues over the optimal extent of lymphadenectomy for the surgical treatment of Adenocarcinoma of the oesophagus. Methods: From 1996 to 2003, 102 transthoracic en-bloc esophagectomy were performed for adenocarcinoma. Based on the 1994 consensus conference of the International Society of Disease of Esophagus, 35 patients underwent standard lymphadenectomy whereas 67 underwent extended lymphadenectomy. Mortality, morbidity and long-term survival were reviewed in each group. Results: Extended lymphadenectomy increased the number of resected lymph nodes and improved the healthy/invaded lymph node ratio. It allowed to detect skip nodal metastasis in 36.4% of the NC patients. Morbidity was higher following extended lymphadenectomy, with respect to pulmonary complications, and blood transfusions requirement (PZ0.04). However, operative mortality was similar in both groups (9 vs. 11%). Overall disease-free survival was 28% at 5 years. Median of survival was higher in N0 than in NC patients (55 months vs. 20 months; PZ0.02). Extended lymphadenectomy was associated with an improving of disease-free survival when compared to standard lymphadenectomy (41 vs. 10% at 5 years; P!0.05), especially in the subgroup of patients with a N0 disease (median of survival 44 months vs. 17 months; PZ0.001). Based on multivariable analyses, predictive factors of recurrence affecting disease free-survival were the pT status (PZ0.02), standard lymphadenectomy (PZ0.05) and extracapsular lymph node involvement (0.04). Conclusions: These results indicate that extended 2-field lymphadenectomy is an important component of the surgical treatment of patients with adenocarcinoma of the oesophagus. It increases the likelihood of proper staging and affects patient outcome, while it does not enhance the operative mortality. However, extended lymphadenectomy increases non-fatal morbidity, especially the incidence of pulmonary complications and the need for blood transfusion. q 2005 Elsevier B.V. All rights reserved.

/pdf/transthoracic-esophagectomy-for-adenocarcinoma-of-the-276h98rluz.pdf

P. Michelet

Papers

Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

Effects of PEEP on oxygenation and respiratory mechanics during one-lung ventilation

Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy

Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy

Transthoracic esophagectomy for adenocarcinoma of the oesophagus: standard versus extended two-field mediastinal lymphadenectomy?