Eur J Cardiothorac Surg 2005;28:19-21
© 2005 Elsevier Science NL
Thoracic epidural anesthesia does not improve the incidence of arrhythmias after transthoracic esophagectomy
Hyun Joo Ahn
a
,
Woo Seok Sim
a
,
Young Mog Shim
b
,
Jie Ae Kim
a
,*
a Department of Anesthesiology and Pain Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, 50, Ilwon-Dong, Kangnam-Gu, Seoul 135-710, South Korea
b Department of General Thoracic Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, South Korea
Received 25 November 2004;
received in revised form 10 January 2005;
accepted 12 January 2005.
* Corresponding author. Tel.: +82 2 3410 2470; fax: +82 2 3410 0361. (Email: jakim{at}smc.samsung.co.kr).
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Abstract
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Objective: The incidence of arrhythmias related to an esophagectomy is high, and its clinical significance has been well accepted. Thoracic epidural anesthesia (TEA) can modulate the sympathetic tone and neuroendocrine responses associated with major operation. This study was aimed to evaluate the effects of TEA on the incidence of arrhythmias in transthoracic esophagectomy patients. Methods: The records of 185 patients who underwent the Ivor-Lewis operation between 2001 and 2004 by the same operator were reviewed. The patients were divided into three groups. Group 1 (n=58) received post-operative intravenous patient-controlled analgesia without TEA. Group 2 (n=55) received postoperative epidural patient-controlled analgesia using local anesthetics. The patients of group 3 (n=72) were anesthetized intra-operatively by the combination technique of thoracic epidural bupivacaine and inhalation agents, and post-operative pain control was done in the same way with group 2. Results: Arrhythmias occurred 29.3, 50 and 29.2% in groups 1, 2 and 3, respectively. There were no statistical differences in the incidences of arrhythmias among the three groups. Conclusions: This result shows that TEA was not beneficial to reduce the incidence of arrhythmias in the transthoracic esophagectomy patients.
Key Words: Arrhythmia • Esophageal cancer • Thoracic epidural anesthesia
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1. Introduction
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Arrhythmia related to an esophagectomy is common and reported with the incidences of 20–50% [1–3]. The development of arrhythmias after an esophagectomy is associated with a worse outcome [4,5]. Murthy et al. reported that pulmonary complications, anastomic leakage, surgical sepsis, and morbidity are higher in the patients who developed arrhythmias after an esophagectomy [4]. Unfortunately, the causes of arrhythmias are unclear, although some have cited age, history of cardiac disease, amount of blood loss and limited intra-thoracic dissection as the predictors of arrhythmias [4]. Chen et al. reported that 87.0% of arrhythmias after an esophagectomy appeared within 24h after operation [1]. And Ritchie et al. found the incidences of arrhythmias as 52% of intra-operative and 24% of within the first 6h after operation [2]. Frequent developments of arrhythmias during the peri-operative period in which anesthetic agents are still present suggest that an interaction may also be important in the occurrence of arrhythmias. However, whether the anesthetic factors affect the incidence of arrhythmias has not been evaluated until now. Some reports indicated that a relatively high sympathotonic status caused by injury to the cardiac parasympathetic nerves by surgical manipulations could increase the incidence of post-operative cardiac arrhythmias [6–9]. Oka et al. reported that thoracic epidural bupivacaine attenuated supraventricular tachyarrhythmias after pulmonary resection [10]. And Groban also reported its role in the occurrence of post-thoracotomy atrial arrhythmias [11]. If the potential cause of arrhythmias is the sympathotonic status associated with injury to the cardiac parasympathetic nerves, sympathetic blockade by thoracic epidural anesthesia (TEA) can reduce the occurrence of arrhythmias after an esophagectomy. In our hospital, total 720 cases of esophageal cancer were radically operated between 1994 and 2004. However, we selected 287 patients who were operated by the Ivor-Lewis procedure by the same operator between 2001 and 2004 to eliminate the biases related to the surgical procedure and operator. In this study, we evaluated whether the use of TEA could affect the incidence of arrhythmias in the intra-operative period and within 3 days after the Ivor-Lewis operation by the review of charts.
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2. Materials and methods
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Between January 2001 and October 2004, 287 patients with esophageal cancer received Ivor-Lewis operations by the same surgeon at our hospital. After excluding the patients with suggested risk factors of peri-operative arrhythmias such as hypertension, arrhythmia, ischemic heart disease, congestive heart failure, or valvular disease, the remaining 185 patients were retrospectively reviewed.
The 185 patients were divided into three groups. In group 1 (n=58), the patients received post-operative pain control by intravenous rotes. In group 2 (n=55), the patients received post-operative pain control by epidural catheter with local anesthetics until the third post-operative day. In group 3 (n=72), the patients had combined regional and inhalational anesthesia intra-operatively and post-operative pain control was done in the same way with group 2. In groups 2 and 3, thoracic epidural catheter was inserted at T 5–6 or T 4–5 interspace before arriving at the operating theater. The epidural catheter was attached to the skin at a depth of 10–12cm, and test dose (2% lidocaine 3ml) was injected to confirm correct placement. Group 1 used an intravenous patient-controlled analgesia device with fentanyl and/or ketorolac as painkillers. Group 2 received single bolus epidural morphine 2mg mixed with 0.1% bupivacaine 10ml at the end of the operation and post-operative pain was controlled with 0.125% bupivacaine mixed with fentanyl through an epidural catheter. Patient controlled epidural analgesia was programmed with the rates of continuous infusion 4ml/h during postoperative first day, and then, bolus dose 3ml, lockout time 15min for 3 days after the operation. Group 3 received 0.25% bupivacaine 10ml via an epidural catheter before surgical incision and additional 10ml at 90-min intervals during an operation and had the same postoperative pain control as that of group 2.
The surgical approach of the operation is as follows. All patients underwent initial abdominal exploration through an upper abdominal laparotomy. The stomach was mobilized and all lymph nodes involved were resected. Pyloroplasty was done. After the abdominal stage, right posterolateral thoracotomy was performed. The esophagus was mobilized with all the paraesophageal and subcarinal lymph nodes. Upper mediastinal, right and left paratracheal lymphatic tissues including lymph nodes of recurrent laryngeal nerve were removed. Esophagogastrostomy was located in the level of the thoracic inlet.
The demographic data that we analyzed were age, sex, weight, American Society of Anesthesiologists status, medical and surgical histories, and forced expiratory volume in 1s (FEV1). For operational variables, we analyzed the one lung ventilation time, existence of adhesion, and hemoglobin concentration measured at the closure of operation (Table 1
). Continuous monitoring of EKG was done in the ICU and subICU for at least 3 days after the operation. The incidences of arrhythmias were divided into two periods: intra-operative and within post-operative 3 days.
Statistical analysis was performed with Sigmastat (version 2.0, SPSS Inc., USA). Demographic data were analyzed using Oneway analysis of variance or Kruskal-wallis test as appropriate. Chi-square test was used to evaluate the incidence of arrhythmias between groups. A P value of <0.05 was considered statistically significant.
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3. Results
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Average operation time was 280min (SD 30min). The most frequent postoperative morbidities were pulmonary complications including chylothorax, atelectasis, effusion, pneumothorax, pneumonia, and ARDS. Wound infection, vocal cord paresis, necrosis of gastric fat, and mediastinitis were followed in descending order. The incidences of pulmonary complications, wound infection, vocal cord paresis, necrosis of gastric fat, and mediastinitis were 57.0, 4.9, 2.5, 2.0, and 1.5%, respectively. There were no differences in the frequencies of post-operative complications among the three groups.
Arrhythmias occurred in 66 (35.7%) patients. The overall incidences of arrhythmias of intra-operative and within post-operative 3 days were 16.8 and 18.9%. The incidences of arrhythmias were not different among the three groups (Table 2
). To evaluate the effects of combined regional and inhalation anesthesia on the occurrence of arrhythmias during the intra-operative period, we compared the sum of groups 1 and 2 patients (n=113) with group 3 patients (n=72). There were no statistical differences in the incidences of intra-operative arrhythmias (19.5 and 12.5%). To evaluate the effects of the intravenous or epidural post-operative pain control method, we compared group 1 patients (n=58) and the sum of group 2 and group 3 patients (n=127), and found no difference in the incidences within post-operative 3 days (15.5 and 20.5%).
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4. Discussion
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Risk factors previously identified for the development of arrhythmias after an esophagectomy include male sex, increasing age, extent of resection, history of cardiac disease, hypertension and intraoperative blood loss [1,3,4,12]. Although the causes of arrhythmias are not clear, through the inspection of proposed risk factors, the imbalance of autonomic nervous system has been implicated as a causative factor [5,13,14]. The inflammatory responses to the sympathovagal nerve fibers of the heart following surgical trauma may alter the autonomic modulation of atrial myocardial cells to endogenous catecholamines. Increased sympathetic tone can shorten atrial refractory period and cause atrial re-entry or promote triggered automaticity to produce arrhythmias. In practice, drugs that attenuate the adrenergic response to surgery, such as beta-blockers have been frequently used to reduce arrhythmias after an esophagectomy.
TEA has the potential to attenuate these courses by direct blockade of cardiac accelerator fibers and by preventing the neuroendocrine stress responses. In previous reports, epidural anesthesia substantially altered stress responses induced by major operation but not general anesthesia [15]. And TEA reduced arrhythmias after myocardial infarction and thoracotomy [11]. We started from this base. However, our study has some limitations because we did not quantify the level of sympathetic blockade by epidural bupivacaine. But usually 10ml of bupivacaine in middle TEA produces sensory blockade of T3–T10 and higher sympathetic blockade [16]. We cannot guarantee the blockade of cardiac sympatheic fibers (T1–T4). In this situation, TEA may attenuate arrhythmias only through the secondary effect associated with the blockade of stress neuroendocrine responses. If we measured the serum catecholamine level, we could have shown the degree of blockade of stress responses. Another limitation of this study is that various combinations and rates of infusion of analgesic agents using TEA have been used in the practice, so this result cannot be of universal application.
We could not find any effects of TEA on the occurrences of arrhythmias after an esophagectomy. This result may indicate that TEA does not stabilize sympathovagal imbalance related to an esophagectomy, or sympathetic stimulation is not a major causative factor related to arrhythmia. We think that further studies will be needed to validate it.
We conclude that the application of TEA to the transthoracic esophagectomy operation does not affect the intra-operative and post-operative incidence of arrhythmias.
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References
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Abstract
1. Introduction
