The impact of the American Society of Anesthesiology-Physical Status classification system on the treatment and prognosis of patients with esophageal cancer undergoing esophagectomy.

BACKGROUND: The American Society of Anesthesiologists-Physical Status (ASA-PS) classification system has been shown to predict morbidity and mortality after surgery. However, the impact of the ASA-PS on esophageal cancer treatment remains unclear. This study examined both the impact of the ASA-PS on treatment, including surgery and perioperative chemotherapy, and the prognostic effects of ASA-PS class in patients who had undergone esophagectomy for thoracic esophageal cancer or esophagogastric junction cancer. METHODS: ASA-PS status was collected for 301 patients who had undergone esophagectomy between January 2007 and June 2016 for thoracic esophageal cancer or esophagogastric junction cancer at a single institution. As the ASA-PS was updated in 2014, the previous classifications of all patients were reevaluated using the updated standard by a surgeon with the previous classifications masked. The dose intensity of preoperative chemotherapy was also compared across classes. Multivariate Cox regression analysis was used to analyze the association between ASA-PS class and overall survival. RESULTS: Patients whose reevaluations had placed them in a more severe ASA-PS class showed significantly poorer overall and cancer-specific survival rates. The dose intensities of cisplatin and 5-fluorouracil for preoperative chemotherapy were significantly lower in patients in the more severe ASA-PS classes. Multivariate analysis showed that ASA-PS class was an independent prognostic factor for overall survival. CONCLUSION: Preoperative ASA-PS classification may influence the intensity of perioperative treatment and may be a valuable long-term prognostic factor for patients with esophageal cancer undergoing esophagectomy.

Landiolol hydrochloride for prevention of atrial fibrillation during esophagectomy: a randomized controlled trial.

INTRODUCTION: Landiolol hydrochloride reduces the incidence of perioperative atrial fibrillation (AF) in cardiac surgery; however, little evidence is available regarding its effects in other types of surgery, including esophagectomy. We assessed the hypothesis that landiolol reduces perioperative AF and other complications associated with esophagectomy. METHODS: This single-center, randomized, double-blind, parallel-group study enrolled patients scheduled for esophagectomy. Patients were divided into those given landiolol at 3 µg/kg/min or placebo for 24 h. The primary outcome was the proportion of patients who developed AF within 96 h starting at 9:00 AM on the day of surgery. The secondary outcomes were the proportion of patients whose AF appeared within 24 h, other complications based on the Clavien-Dindo classification, and the intensive care unit and hospital stays. RESULTS: Despite early study termination, 80 patients were screened, and 56 were enrolled (28/group) from September 2016 to June 2018. AF occurred within 96 h of surgery in six (21.4%) patients in the landiolol group and five (17.9%) patients in the placebo group (odds ratio, 1.26; 95% confidence interval, 0.33-4.7) and within 24 h of surgery in three (10.7%) patients in the landiolol group and two (7.1%) patients in the placebo group. There were no significant differences in the incidence of complications or in the number of intensive care unit or hospital stays between the groups. CONCLUSION: Although our small sample size prevents definitive conclusions, landiolol might not reduce the occurrence of AF or other complications. TRIAL REGISTRATION: UMIN, UMIN000024040. Registered 13 September 2016, http://www.umin.ac.jp/ctr/index/htm.

Esophagectomy Surgical Apgar Score May Not Be Associated With Postoperative Morbidity.

This study was performed to investigate the association between the esophagectomy surgical Apgar score (eSAS) and 30-day morbidity after esophagectomy. We retrospectively identified patients who underwent esophagectomy in our facilities database from January 2011 through December 2015. We calculated the eSAS and modified eSAS, which was adjusted for the blood loss volume, according to our patients' data. After estimating the cut-off point of the eSAS using a receiver operating curve, the morbidity rates between the 2 groups were compared using Fisher's exact test. In addition, logistic regression analysis was performed to adjust the results by factors associated with morbidity. In total, 246 patients were included. Of these patients, 144 presented with major morbidity. The optimal cut-off value of the eSAS was 4 points. A total of 145 patients had an eSAS of <4 points, and 89 of them developed morbidity. A total of 101 patients had an eSAS of ≥4 points, and 55 of them developed morbidity. Fisher's exact test showed that an eSAS of <4 points was not significantly associated with morbidity after esophagectomy (P = 0.29). The association was improved after modification for the blood loss volume (P = 0.004). Multivariable analysis revealed that the modified eSAS and age were significantly associated with morbidity (odds ratio, 0.47 and 1.04, respectively). The validity of the eSAS to predict morbidity after esophagectomy could be low, and the modified blood loss volume may improve the predictive effect.

The effect of oral hydration on the risk or aspiration and hemodynamic stability before the induction of anesthesia: A systematic review and meta-analysis.

OBJECTIVE: Preoperative oral rehydration solutions (ORS) are frequently used in clinical practice in Japan, although their effect remains to be explained. The purpose of this study was to investigate the clinical outcomes associated with ORS usage. DESIGN: Systematic review and meta-analysis. SETTING: Surgical departments at each hospital. PARTICIPANTS: A total of 546 patients with American Society of Anesthesiologists physical status classification I or II (non-pregnant adults only) reported in six articles. INTERVENTIONS: Patients in the included studies had originally been randomly allocated to the ORS or control group. MEASUREMENTS: Incidence of aspiration and vomiting during induction of anesthesia, gastric fluid volume (absolute volume), gastric pH, stroke volume variation (SVV) during induction of anesthesia. Risk difference (RD) or mean difference (MD) with 95% confidence interval (CI) were calculated using a random effects model. MAIN RESULTS: There was no aspiration or vomiting in either group [3 studies, 428 patients, RD 0 (95% CI -0.01 to 0.01), I2 = 0%]. ORS administration caused no significant difference in gastric volume [4 studies, 486 participants, MD -1.12 ml (95% CI -5.61 to 3.36), I2 = 62%] or gastric pH [4 studies, 486 participants, MD -0.03. (95% CI -0.37 to 0.31), I2 = 0%] compared with the control group. In contrast, ORS resulted in a significant reduction in SVV during the anesthesia induction period [3 studies, 118 participants, MD -3.02 (95% CI -5.44 to -0.59), I2 = 65%]. CONCLUSIONS: Our systematic review indicates that oral rehydration therapy does not increase the risk of aspiration or vomiting. In contrast, it may help stabilize circulatory dynamics during anesthesia induction.

Sugammadex and amino acid infusion can contribute to safe anesthetic management of variegate porphyria.

BACKGROUND: Variegate porphyria (VP) is an inherited type of porphyria characterized by cutaneous manifestations and/or acute neurovisceral attacks. We report successful anesthetic management of VP. CASE PRESENTATION: A 66-year-old woman with VP was scheduled to undergo distal pancreatectomy for pancreatic cancer. Medical history was unremarkable except for sudden onset of abdominal pain that occurred every few months, possibly due to VP. There was no abnormality in laboratory data except for a mild increase in creatinine levels. General anesthesia was induced and maintained with total intravenous anesthesia using propofol, remifentanil, and rocuronium. Blood glucose levels were measured every hour and glucose administered to prevent hypoglycemia. Amino acids were also infused to treat hypothermia. Upon completion of distal pancreatectomy, sugammadex was administered to reverse neuromuscular blockade. She was neurologically intact and discharged on postoperative day 15 with no acute attack. CONCLUSIONS: Sugammadex and amino acids can be used safely in patients with VP.

Perioperative Amino Acid Infusion for Preventing Hypothermia and Improving Clinical Outcomes During Surgery Under General Anesthesia: A Systematic Review and Meta-analysis.

Amino acid (AA) infusion is sometimes selected to avoid hypothermia during general anesthesia. However, the widespread clinical use of AA infusion therapy has not been established. This study aimed to clarify the evidence that AA infusion can increase patient body temperature and improve clinical outcomes using the Grading of Recommendations Assessment, Development, and Evaluation system. We searched MEDLINE (PubMed), Cochrane Central Register of Controlled Trials, and Igaku Chuo Zasshi (Japana Centra Revuo Medicina) in November 2015. Studies were reviewed by 2 independent assessors to identify randomized controlled trials (RCTs) involving AA infusion compared with placebos during surgery under general or combined general/epidural anesthesia. Study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation system and the Cochrane methodology. The primary outcome was difference in body temperature before and after perioperative AA infusion. Shivering frequency, blood loss volume, postoperative intubation time, and hospitalization period were also assessed as clinical outcomes. We analyzed the outcome data using a random effect model. From 298 screened titles, 14 RCTs met our inclusion criteria, including 626 patients (327 in AA and 299 in placebo groups). In 626 participants from 14 RCTs, AA infusion increased body temperature by a mean difference (MD) of 0.46°C (95% confidence interval [CI], 0.31-0.62, low-quality evidence). Regarding other outcomes, AA infusion decreased shivering frequency by a risk ratio of 0.34 (95% CI, 0.12-0.94; 7 RCTs, 248 participants, very low-quality evidence), shortened postoperative intubation time by MD of -125 minutes (95% CI, -210 to -38.8; 2 RCTs, 158 participants, moderate-quality evidence), and shortened the hospitalization period by MD of -1.81 days (95% CI, -2.07 to -1.55; 3 RCTs, 230 participants, low-quality evidence) compared with placebo. There was no significant difference in the volume of blood loss between the 2 groups (standardized MD, -0.20, 95% CI, -0.44 to 0.04; low-quality evidence). There was no publication bias. AA infusion in the perioperative period increased patient body temperature and improved clinical outcomes compared with placebo. However, the evidence to support the use of AA infusion is limited, and further large-scale RCTs are required.