Durkin Chris, Schisler Travis, Lohser Jens
Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, V5Z-1M9, Canada.
Curr Opin Anaesthesiol. 2017 Feb;30(1):30-35. doi: 10.1097/ACO.0000000000000409.
Despite marked improvements in perioperative outcomes, esophagectomy continues to be a high-risk operation associated with significant morbidity and mortality. Progress has been achieved through evidence-based changes in preoperative optimization, intraoperative ventilation strategies, fluid therapy, and analgesia, as well as expedited postoperative recovery pathways. This review will summarize the recent literature on the anesthetic management of patients undergoing esophageal resection.
The current focus in publications on the perioperative management of esophagectomy patients can be summarized under the umbrella term of enhanced recovery pathways, focusing on ventilation, fluid therapy, analgesia and minimally invasive surgical approaches. Lung protective ventilation reduces pulmonary complications in cases requiring one-lung ventilation. Excess fluid administration contributes to morbidity while restrictive approaches have not resulted in an increased risk of acute kidney injury. Goal-directed fluid therapy remains intuitive yet unproven. Thoracic epidural analgesia reduces the systemic inflammatory response, pulmonary complications, and enhances postoperative pain control, yet if causing perioperative hypotension may be associated with anastomotic leaks. Enhanced recovery pathways have facilitated low morbidity and mortality rates in a high-risk population but are heterogeneous and limited by a weak evidence base. Minimally invasive surgical approaches are increasingly popular and appear to have at least equivalent outcomes to open procedures.
The morbidity and mortality after esophagectomy remains high despite significant improvements over the last decades. Enhanced recovery pathways appear promising in achieving further marginal gains but at present are lacking large scale, prospective, multicenter evidence.
尽管围手术期结局有了显著改善，但食管切除术仍然是一项高风险手术，伴有较高的发病率和死亡率。通过术前优化、术中通气策略、液体治疗和镇痛等基于证据的改变，以及加速术后恢复路径，已取得了进展。本综述将总结近期关于食管切除术患者麻醉管理的文献。
目前关于食管切除术患者围手术期管理的文献焦点可归纳在强化恢复路径这一总括术语下，重点在于通气、液体治疗、镇痛和微创外科手术方法。肺保护性通气可降低需要单肺通气的病例中的肺部并发症。过多的液体输注会增加发病率，而限制性方法并未导致急性肾损伤风险增加。目标导向液体治疗仍然直观但未经证实。胸段硬膜外镇痛可减轻全身炎症反应、肺部并发症，并增强术后疼痛控制，但如果导致围手术期低血压，可能与吻合口漏有关。强化恢复路径在高危人群中实现了低发病率和死亡率，但存在异质性且受证据基础薄弱的限制。微创外科手术方法越来越受欢迎，且似乎至少与开放手术有同等疗效。
尽管在过去几十年中有了显著改善，但食管切除术后的发病率和死亡率仍然很高。强化恢复路径在实现进一步的微小收益方面似乎很有前景，但目前缺乏大规模、前瞻性、多中心的证据。
