Application Of Enhanced Recovery Program In Esophagectomy

BackgroundThe distribution of esophageal cancer has regional characteristics.China is among the countries which has the highest morbidity of esophageal cancer in the world.Surgical resection is still the mainstay of the treatment of esophageal and esophagogastric junction carcinoma.It’s a complex resection and reconstruction operation which requires cooperation of the whole operation team.Although great progress has been made in perioperative management of esophageal cancer,esophagectomy is associated with high rates of mortality and complications.ERAS has been most widely developed in the past ten years.And good results have been achieved in the treatment of general surgery,especially colorectal surgery.ERAS concept has been used in thoracic surgery for a long time.Most of the literature reports mainly focus on lung surgery.At present,the experience of ERAS application in esophageal surgery is still limited,.Preemptive analgesia is an effective part of multimodal analgesia.Epidural anesthesia is regarded as the golden standard of perioperative analgesia in esophagectomy.With the promotion of minimally invasive esophagectomy,the application of epidural anesthesia is limited.Further searching for effective,safe and simple regional block method is an important part of ERAS scheme for esophageal cancer surgery.This study was designed to observe the effectiveness of perioperative multi-modal enhanced rehabilitation program on postoperative rehabilitation of patients with esophageal cancer,and attempting to take new measures to explore a reasonable ERAS program which is suitable for esophagectomy.PART I The Implementation and Effectiveness of an EnhancedRecovery Programme for Patients with Esophageal Cancer Objective:To describe the implementation of an ERAS programme for esophagectomy and evaluate the effectiveness of the ERAS programme after surgery.Methods:A retrospective cohort study was conducted among patients who underwent elective radical esophagectomy in the thoracic surgery department of the Affiliated Hospital of Taishan Medical College.For patients from June 2016 to September 2017,a multimodal rapid rehabilitation measures was implemented(ERAS group).Patients from June 2014 to September 2015 were treated with traditional management(T group).We retrospectively collected the basic information of the patients and perioperative datas of two groups.Postoperative complications and post-operative rehabilitation information were also recorded.And we made a comparative analysis of the two groups.Univariable logistic regression was used to assess the association between various prognostic predictors and pulmonary complications or length of hospital stay.Factors in univariable analysis with a P-value<0.05 were entered into a multivariable regression model.Results:155 cases in ERAS group and 163 cases in T group were included in the statistical analysis.1.There were no differences in age,height,weight,body mass index,sex ratio,smoking history,preoperative complications,Hgb,albumin and ASA grade between the two groups(P>0.05).2.Compared with the traditional management group(group T),there were more thoracoscopic surgery in ERAS group(0 vs 34cases,21.9%).3.The extubation time of ERAS group was significantly shorter than that of the T group(45.0+4.9)(P<0.001).The resuscitation time of PACU in T group was longer than that in ERAS group(99.85+12.4 vs 87.14+11.26),the difference was significant(P<0.001).In ERAS group,16 cases had restlessness during recovery,the incidence was 10.3%,which was significantly lower than that of T group(28.2%)(P<0.001).The incidence of shivering in ERAS group(9.7%)was significantly lower than T group(39.9%)and the difference was statistically significant(P<0.001).4.The incidence of pneumonia(18.1%vs.23.9%,P＝0.200)was the highest among the postoperative complications.The incidence of atelectasis(7.7%vs.14.7%,P=0.170),respiratory distress(2.6%vs.1.8%,P＝0.946)and pneumothorax(1.3%vs.1.8%,P=0.692)were similar,but the total incidence of pulmonary complications in ERAS group(29.7%,46/155)was significantly lower than that in T group(42.3%,69/163).(P=0.019),the difference was significant.There was no significant difference between ERAS group and T group(14.2%and 12.3%,P=0.613)in incidence of cardiac complications.The incidence of myocardial ischemia was 9(5.8%)and 4(2.5%)respectively,P=0.131,and the incidence of arrhythmia was.13(8.4%)and 16(9.8%)respectively,P=0.658,there was no significant difference between the two groups.We did not find significant difference in incidence of delirium、anastomotic fistula and incision infection between the two groups.In T group,one patient had pulmonary embolism,one case had right cephalic vein thrombosis,and there was no venous thrombosis in ERAS group.5.The median length of postoperative stay(13 days)in the traditional management group was significantly longer than that in the ERAS group(12 days),P<0.05.6.Univariable analysis regression analysis showed that group,age,smoking history,history of lung disease,diabetes mellitus and preoperative albumin were related with postoperative pulmonary complications.Multivariable regression analysisshowed that smoking history and history of lung diseases were independent predictors of postoperative pulmonary complications.7.Univariable analysis analysis showed that group,age,history of lung disease,coronary heart disease and surgical methods were the influencing factors of the length of postoperative stay;Multivariable analysis showed that group,history of lung disease,coronary heart disease,surgical methods were independent predictors.Conclusions:The application of an ERAS programme in esophagectomy for esophageal cancer can improve anesthesia recovery outcomes,reduce the incidence of postoperative complications,shorten length of postoperative stay and promote rapid recovery of patients.Smoking history and preoperative pulmonary diseases are independent risk factors for pulmonary complications.Preoperative pulmonary diseases,coronary heart disease,and surgical methods were associated with long length of postoperative stay.PART II The Effect of Erector Spinae Plane Block on Postoperative Analgesia and Rehabilitation in EsophagectomyObjective:To evaluate the analgesic effect and short-term rehabilitation effect of erector spinae plane block before single-incision esophagectomy.Methods:Ninety patients with American Society of Anesthesiologists(ASA)Ⅰ-Ⅲwho were scheduled to undergo single-incision esophagectomy were randomly assigned to an ESPB group(ESPB)and a control group(CON)according to whether an erector spinae plane block was performed.For the ESPB group,before general anaesthesia,an erector spinae plane block was performed at the level of the T5 transverse process.The control group received general anaesthesia only.NRS scores of resting pain and cough pain were recorded at 0 h,1 h,4 h,8 h,12 h,24 h,36 h and 48 h after extubation.The dosage of sufentanil and remifentanil during the operation and the cumulative dosage of sufentanil at 1 h,24 h and 48 h after the operation were recorded.The time of extubation,the recovery time in the PACU and the incidence of restlessness after the operation were recorded.The serum levels of IL-6 and TNF-alpha at the time point before anaesthesia(TO),6 h after the operation(T1),24 h after the operation(T2)and 72 h after the operation(T3)were evaluated by ELISA(enzyme-linked immunosorbent assay).We recorded the incidence of complications after the operation and the duration of the hospitalization stay after the operation.Results:1.There were no significant differences in age,sex,BMI,education level or preoperative complications between the two groups(P>0.05).The operation time,one-lung ventilation time and anaesthesia time of the ERAS group and T group were similar,and there were no significant differences between the two groups(P>0.05).2.Compared with the control group,the extubation time and PACU resuscitation time of the ESPB group were significantly shortened(P<0.01).The dosages of sufentanil and remifentanil in the ESPB group were significantly lower than in the T group(P<0.001).The incidence of postoperative agitation was not significantly different.3.The NRS scores for resting pain and cough pain in the ESPB group were significantly lower than those in the CON group from 0 h to 24 h after the operation,and there was a significant difference between the two groups(P<0.05).There was no significant difference in the NRS scores for resting pain and cough pain between the two groups at 24-48 hours after the operation(P>0.05).4.The cumulative dosage in 1 h and 1-24 h and the cumulative total dosage of sufentanil after the operation were significantly lower than those in the CON group(P<0.001).There was no significant difference in the cumulative dosage of sufentanil between the two groups 24-48 hours after the operation(P=0.260).5.Compared with preoperative(TO)levels,the concentrations of IL-6 and TNF-a in T1 and T2 of the two groups increased significantly(P<0.05).The serum IL-6 and TNF-a concentrations at the T1 and T2 time points in the ESP group were significantly lower than in the CON group(P<0.05).6.There was no difference in postoperative complications between the two groups.The median length of postoperative postoperative stay was 12 days(p=0.098),and there was no difference between the two groups.Conclusion:Preoperative erector spinae plane block can reduce the pain score after single-incision oesophagectomy,reduce the dosage of opioids used during the perioperative period,reduce the intraoperative stress response,and help patients recover after the operation.It can enhance the recovery of patients and reduce the pain score after the operation and reduce the dosage of narcotic analgesics used during the perioperative period.The ESPB inhibits the inflammatory response and helps patients recover after the operation.The ESPB is a safe and effective option for oesophagectomy.