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Airway colonisation and postoperative pulmonary complications after neoadjuvant therapy for oesophageal cancer

^a Department of Thoracic Surgery and Diseases of the Oesophagus, Sainte Marguerite University Hospital, Marseille, France
^b Department of Anaesthesiology, Sainte Marguerite University Hospital, Marseille, France
^c Department of Intensive Care Medicine, Sainte Marguerite University Hospital, Marseille, France
^d Department of Respiratory Diseases, Sainte Marguerite University Hospital, Marseille, France
^e UMR 6020-IFR 48, Faculty of Medicine, University of the Mediterranean, Marseille, France

Received 12 June 2007; received in revised form 17 September 2007; accepted 27 September 2007.

^_* Corresponding author. Address: Department of Thoracic Surgery, Sainte Marguerite University Hospital-CHU Sud, 270 Bd Ste Marguerite, 13274 Marseille Cedex 9, France. (Email: pathomas{at}ap-hm.fr).

Objective: To evaluate the clinical relevance of preoperative airway colonisation in patients undergoing oesophagectomy for cancer after a neoadjuvant chemoradiotherapy. Methods: From 1998 to 2005, 117 patients received neoadjuvant chemoradiotherapy for advanced stage oesophageal cancer. Among them, 45 non-randomised patients underwent a bronchoscopic bronchoalveolar lavage (BAL group) prior to surgery to assess airways colonisation. The remaining patients (n = 72) constituted the control group. The two groups were similar with respect to various clinical or pathological characteristics. Results: Thirteen of the 45 BAL patients (28%) had a preoperative bronchial colonisation by either potentially pathogenic micro-organisms (PPMs) (n = 7, 16%) or non-potentially pathogenic micro-organisms (n = 6, 13%). Cytomegalovirus (CMV) was cultured from BAL in four patients. Pre-emptive therapy was administrated in seven patients: four antiviral and three antibiotic prophylaxes. Postoperatively, 14 patients (19%) developed acute respiratory distress syndrome (ARDS) in the control group and three (7%) in the BAL group (p = 0.064). The cause of ARDS was attributed to CMV pneumonia in six control group patients on the basis of the results of open lung biopsies (n = 3) or BAL cultures (n = 3) versus none of the BAL group patients (p = 0.08). Timing for extubation was shorter in the BAL group (mean 13 ± 3 h) as compared with the control group (mean 19.5 ± 14 h; p = 0.039). In-hospital mortality was not significantly lower in BAL group patients when compared to that of control group patients (8% vs 12.5%). Conclusions: Airway colonisation by PPMs after neoadjuvant therapy is suggested as a possible cause of postoperative ARDS after oesophagectomy. Pre-emptive treatment of bacterial and viral (CMV) colonisation seems an effective option to prevent postoperative pneumonia.

Abbreviations: ARDS = acute respiratory distress syndrome • BAL = bronchoalveolar lavage • CMV = cytomegalovirus • COPD = chronic obstructive pulmonary disease • FEV = forced expiratory volume in 1 s • PPMs = potentially pathogenic micro-organisms • Non-PPMs = non-potentially pathogenic micro-organisms

Key Words: Oesophageal cancer • Oesophagectomy • Neoadjuvant therapy • Cytomegalovirus • Bronchoalveolar lavage • Bronchoscopy • Airways colonisation