Hypotension Associated with MTS is Aggravated by Early Activation of TEA During Open Esophagectomy

Abstract

Objective

A mesenteric traction syndrome (MTS) is elicited by prostacyclin (PGI₂)-induced vasodilation and identified by facial flushing, tachycardia, and hypotension during abdominal surgery. We evaluated whether thoracic epidural anesthesia (TEA) influences the incidence of MTS.

Design

Randomized, blinded controlled trial.

Setting

Single-center university hospital.

Participants

Fifty patients undergoing open esophagectomy.

Interventions

Patients were randomized to either early (EA, after induction of general anesthesia) or late activation of TEA (LA, after re-established gastric continuity). Plasma 6-keto-PGF_1α, a stable metabolite of PGI₂ and interleukine-6 (IL6) were measured in plasma during surgery along with hemodynamic variables and MTS graded according to facial flushing together with plasma C-reactive protein on the third post-operative day.

Results

Forty-five patients met the inclusion criteria. Development of MTS tended to be more prevalent with EA (n=13/25 [52%]) than with LA TEA (n=5/20 [25%], p=0.08). For patients who developed MTS, there was a transient increase in plasma 6-keto-PGF_1α by 15 min of surgery and plasma IL6 (p<0.001) as C-reactive protein (P<0.009) increased. EA TEA influenced the amount of phenylephrine needed to maintain mean arterial pressure >60 mmHg in patients who developed MTS (0.16 [0.016–0.019] mg/min vs MTS and LA TEA 0.000 [0.000–0.005] mg/min, p<0.001).

Conclusion

The incidence of MTS is not prevented by TEA in patients undergoing open esophagectomy. On the contrary, the risk of hypotension is increased in patients exposed to TEA during surgery, and the results suggest that it is advantageous to delay activation of TEA. Also, MTS seems to be associated with a systemic inflammatory response, maybe explaining the aggravated post-operative outcome.

Keywords:

• mesenteric traction syndrome
• esophagectomy
• epidural anesthesia

Data Sharing Statement

The data are available from the corresponding author.

Ethics Approval and Informed Consent

The study was registered at the European Medicines Agency (EudraCT 2014-002036-14) as approved by the Scientific Ethical Committee, The Capital Region, Denmark (H-2-2013-101 approved by 14th July 2014) and the Danish Health and Medicines Authority (No. 2014060551 approved by 8th August 2014), and was monitored by the Good Clinical Practice unit at Copenhagen University Hospital (No. 2014-4661).

Acknowledgments

We thank the staff at the operating theatre for their support during the study.

Disclosure

The authors report no conflicts of interest in this work.

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.