Incidence and Types of Arrhythmias After Mediastinal Manipulation During Transhiatal Esophagectomy

doi:10.1016/j.athoracsur.2006.02.041

The Annals of Thoracic Surgery

Volume 82, Issue 1, July 2006, Pages 298-302

https://doi.org/10.1016/j.athoracsur.2006.02.041 Get rights and content

Background

Transhiatal esophagectomy (THE) is a common operative procedure for carcinoma esophagus. Complications of this procedure include arrhythmias and hypotension during blunt dissection of the esophagus from posterior mediastinum. In the literature, exact incidence and type of arrhythmias have not been reported. We employed Holter monitoring during mediastinal manipulation in patients undergoing THE, for this purpose.

Methods

This prospective study was carried out in 20 consecutive American Society of Anesthesiologists grade I-II patients undergoing THE. Anesthetic technique included induction with thiopentone and maintenance with morphine, vecuronium, and isoflurane. In addition to routine parameters, Holter monitoring was undertaken to record the exact incidence and types of arrhythmias. “Premanipulation” or control period included duration of 30 minutes preceding mediastinal manipulation, while “during manipulation” or study period included the duration of mediastinal manipulation. The incidence of arrhythmias was studied for 48 hours in the postoperative period. The Fisher exact test was applied to analyze incidence of arrhythmias and hypotension.

Results

Out of 20 patients, only 2 had arrhythmias in the premanipulation period, while 13 had arrhythmias during the manipulation period (p < 0.01). During the manipulation period, arrhythmias included supraventricular ectopics and ventricular ectopics in 2 patients each and a combination of both in 9 patients. Arrhythmias were transient and had no correlation with either duration or degree of hypotension in all the patients. However, there was a linear relationship between hypotension and duration of mediastinal manipulation. Two patients (10%) had atrial arrhythmias in the postoperative period.

Conclusions

In transhiatal esophagectomy, there is a significant incidence of both arrhythmias and hypotension during mediastinal manipulation. The incidence of arrhythmias can be minimized by limiting the duration of the manipulation. The incidence of postoperative arrhythmias was not significant.

Section snippets

Patient Population

This prospective study was carried out in 20 consecutive American Society of Anesthesiologists I-II patients, aged 40 to 60 years, of both sexes undergoing THE for carcinoma esophagus for midesophageal tumors. Institutional Review Board approved the study dated June 18, 2001 and individual informed consent from all the patients was duly obtained.

Patients excluded from the study were those with any cardiac dysfunctions, severe pulmonary obstruction or restriction, and patients with electrolyte

Patient Characteristics

The demographic data and various hemodynamic and electrolyte variables are given in Table 1. Total duration of the surgery ranged from 3 to 5 hours. The mean duration of mediastinal manipulation was 7.90 ± 3.49 minutes (range, 4 to 15 minutes).

Arrhythmias

In the premanipulation period, only 2 (10%) patients had arrhythmias while 13 (65%) had arrhythmias during the manipulation period (p < 0.01) as shown in Table 2. In almost all the patients, the arrhythmias were transient and occurred as singlet or

Comment

The transhiatal esophagectomy is based on an upper abdominal approach through a midline supraumbilical incision with blind manual manipulation of the esophagus in the mediastinum. During the manipulation, the surgeon’s hand, dissecting bluntly around the esophagus inevitably compresses the atria and distorts the heart, causing profound arterial hypotension and arrhythmias [2]. Also, the dissection can induce marked vagal stimulation resulting in bradyarrhythmia, ventricular escape beats and,

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Impaired cardiac filling has also been reported to be one of the causes. The need of beta-blockers has also been described for these arrhythmias [11–16]. The choice of route for gastric pull-up has to be based on the departmental and individual experience since there is no consensus yet among pediatric surgeons regarding the optimal route; whatever information is available in literature is based on small, mostly retrospective reports while well-designed comparative studies are lacking.
The authors herein report the results of esophageal replacement by gastric pull-up technique through the retrosternal route as an option for esophageal replacement in a resource-constrained setup.
Prospectively collected data upon twenty-two consecutive patients (male:female = 17:5) with mean age 24.9 months (7 months–12 years) and mean weight 7.9 kg (4.2–32 kg) who underwent retrosternal gastric pull-up for esophageal atresia (n = 18; 16 atresia with distal fistula & 2 pure atresia) and corrosive injuries to the esophagus (n = 4) over the past 8 years are presented.
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Retrosternal gastric pull-up could be performed in all cases with no mortality or graft loss. Of 22, 20 cases were extubated on-table and 2 cases were extubated within 48 hours of surgery.
Mean operative duration was 265 min (range: 175 min to 310 min) and blood loss was 115.3 ml (range: 80–400 ml). Dense vascular adhesions in the region of the esophageal hiatus were encountered in patients with abdominal esophagostomy (n = 4) which were probably related to the local dissection at the time of previous surgery.
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Of note and concern to the treating anesthesiologist, the blunt dissection of the middle third of the esophagus can induce both arrhythmias as well as impair ventricular filling causing transient hypotension. Malhotra et al found that more than half of patients suffered intraoperative arrhythmias during mediastinal manipulation, and that degree of hypotension was correlated linearly with duration of manipulation.18 Much controversy exists as to the overall reduction in patient morbidity and mortality using the transhiatal esophagectomy (THE) approach.
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We used our Esophagectomy Database to identify 133 profoundly obese patients (body mass index [BMI] ≥35 kg/m²) from among 2176 undergoing a THE from 1977 to 2006. This group was matched to a randomly selected, non-obese (BMI, 18.5 to 30 kg/m²) control population of 133 patients. Intraoperative, postoperative, and long-term follow-up results were compared retrospectively.
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Original articleGeneral thoracicIncidence and Types of Arrhythmias After Mediastinal Manipulation During Transhiatal Esophagectomy

Background

Methods

Results

Conclusions

Section snippets

Patient Population

Patient Characteristics

Arrhythmias

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Surg

J Cardiothorac Anesth

J Thorac Cardiovasc Surg

Ann Thorac Surg

The history of surgery for carcinoma of the esophagus

Chest Surg Clin N Am

Anaesthesia for gastrointestinal surgery

A preliminary report on anaesthesia for thoracoscopic oesophagectomy

Med J Malaysia

Esophageal surgery

Original article
General thoracic
Incidence and Types of Arrhythmias After Mediastinal Manipulation During Transhiatal Esophagectomy