Effect of Volatile Anesthesia Versus Intravenous Anesthesia on Postoperative Pulmonary Complications in Patients Undergoing Minimally Invasive Esophagectomy: A Randomized Clinical Trial.

BACKGROUND: The effect of intraoperative anesthetic regimen on pulmonary outcome after minimally invasive esophagectomy for esophageal cancer is yet undetermined. The aim of this study was to determine the effect of volatile anesthesia (sevoflurane or desflurane) compared with propofol-based intravenous anesthesia on pulmonary complications after minimally invasive esophagectomy. METHODS: Patients scheduled for minimally invasive esophagectomy were randomly assigned to 1 of 3 general anesthetic regimens (sevoflurane, desflurane, or propofol). The primary outcome was the incidence of pulmonary complications within the 7 days postoperatively, which was a collapsed composite end point, including respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm, pulmonary embolism, and aspiration pneumonitis. The severity of pulmonary complications, surgery-related complications, and other secondary outcomes were also assessed. RESULTS: Of 647 patients assessed for eligibility, 558 were randomized, and 553 were analyzed. A total of 185 patients were assigned to the sevoflurane group, 185 in the desflurane, and 183 in the propofol group. Patients receiving a volatile anesthetic (sevoflurane or desflurane) had a significantly lower incidence (36.5% vs 47.5%; odds ratio, 0.63; 95% confidence interval, 0.44-0.91; P = .013) and lower severity grade of pulmonary complications ( P = .035) compared to the patients receiving propofol. There were no statistically significant differences in other secondary outcomes between the 2 groups. CONCLUSIONS: In patients undergoing minimally invasive esophagectomy, the use of volatile anesthesia (sevoflurane or desflurane) resulted in the reduced risk and severity of pulmonary complications within the first 7 postoperative days as compared to propofol-based intravenous anesthesia.

Positive end-expiratory pressure and risk of postoperative pulmonary complications in patients living at high altitudes and undergoing surgery at low altitudes: a single-centre, retrospective observational study in China.

OBJECTIVES: To examine whether a high positive end-expiratory pressure (PEEP ≥5 cmH2O) has a protective effect on the risk of postoperative pulmonary complications (PPCs) in a cohort of patients living at high altitudes and undergoing general anaesthesia. DESIGN: Retrospective, observational study. SETTING: A tertiary hospital in China. PARTICIPANTS: Adult Tibetan patients living at high altitudes (≥3000 m) and who went to the low-altitude plain to undergo non-cardiothoracic surgery under general anaesthesia, from January 2018 to April 2020. MEASUREMENTS: This study included 1905 patients who were divided according to the application of an intraoperative PEEP: low PEEP (<5 cmH2O, including 0 cmH2O) or high PEEP (≥5 cmH2O). The primary outcome was a composite of PPCs within the first 7 postoperative days. The secondary outcomes included reintubation and unplanned intensive care unit (ICU) admission within the first 7 postoperative days and total hospital stays (day). RESULTS: The study included 1032 patients in the low PEEP group and 873 in the high PEEP group. There were no differences in the incidence of PPCs between the high and low PEEP groups (relative risk (RR) 0.913; 95% CI 0.716 to 1.165; p=0.465). After propensity score matching, 643 patients remained in each group, and the incidence of PPCs in the low PEEP group (18.0%) was higher than in the high PEEP group (13.7%; RR 0.720; 95% CI 0.533 to 0.974; p=0.033). There were no differences in the incidence of reintubation, unplanned ICU admission or hospital stays. The risk factors of PPCs derived from multiple regression showed that the application of >5 cmH2O PEEP during intraoperative mechanical ventilation was associated with a significantly lower risk of PPCs in patients from a high altitude (OR=0.725, 95% CI 0.530 to 0.992; p=0.044). CONCLUSIONS: The application of PEEP ≥5 cmH2O during intraoperative mechanical ventilation in patients living at high altitudes and undergoing surgery at low altitudes may be associated with a lower risk of PPCs. Prospective longitudinal studies are needed to further investigate perioperative lung protection ventilation strategies for patients from high altitudes. TRIAL REGISTRATION NUMBER: Chinese Clinical Trial Registry (ChiCTR2100044260).