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

Figures & data

Table 1 Baseline and Intraoperative Characteristics for Patients with Thoracic Epidural Anesthesia (TEA) Activated Either Early or Late During Esophagectomy

	Early TEA	Late TEA
Sex, male/female, n	20/5	16/4
Age, years	64.1 ±7.8	65.1 ±7.8
BMI, kg/m^2	27.5 ±3.3	27.9 ±4.7
ASA score	2.2 ±0.5	2.2 ±0.4
Length of operation, min	262 ±46	253 ±44
Blood loss, mL	813 ±469	736 ±389
MTS, n (%)
None	4/25 (16%)	7/20 (35%)
Moderate	8/25 (32%)	8/20 (40%)
Severe	13/25 (52%)	5/20 (25%)

Note: Values are means ±SD.

Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; MTS, mesenteric traction syndrome.

Figure 1 Consort flow chart.

Table 2 Uni- and Multivariate Analysis

Univariate Analysis		Ordinal Regression
Variables	P-value	Odds ratio (95% CI)	P-value
Age ≥ 65 vs < 65 years	0.763
EA vs LA TEA	0.078	1.2 (−0.1–2.5)	0.071
ASA score >2 vs ≤ 2	0.445
BMI ≥ 27 vs < 27 kg/h^2	0.767
Vasopressor > 2 vs ≤ 2 boluses after induction of anesthesia	0.760

Notes: Dependent variable: non-MTS vs +MTS. Univariate analysis by X² or Fisher’s exact test. Results with a p-value ≤ 0.20 was included in the ordinal regression model.

Abbreviations: EA and LA, early and late activation of thoracic epidural anesthesia (TEA); ASA, American Society of Anaesthesiologists; BMI, body mass index.

Table 3 Prostacyclin and Hemodynamic Changes During Esophagectomy

	Baseline	After Laparotomy	15 Min of Surgery	After Mobilization of the Stomach
6-keto-PGF1α (pg/mL)
EA -MTS	166 (102–262)	408 (251–1081)	1965 (1601–2911)^b	1496 (963–2846)^b
LA -MTS	306 (128–474)	385 (156–805)	1352 (723–2010)^b	928 (516–1495)^b, *
EA +MTS		1574 (537–3230)^b	4378 (2529–9917)^b	1668 (999–2433)^b
LA +MTS		590 (460–1206)	5893 (5028–6806)^b	1531 (960–2878)^b
MAP (mmHg)
EA -MTS	73 ± 15	64 ± 14	63 ± 12^b	67 ± 12
LA -MTS		74 ± 11	75 ± 14	67 ± 10
EA +MTS	71 ± 15	63 ± 16	60 ± 9	65 ± 8
LA +MTS		87 ± 10*	84 ± 15*	68 ± 9
HR (beat/min)
EA -MTS	63 ± 14	69 ± 20	71 ± 10	68 ± 13
LA -MTS		59 ± 9	71 ± 12^a	70 ± 9
EA +MTS	70 ± 12	62 ± 10	70 ± 12^a	64 ± 9
LA +MTS		69 ± 9	89 ± 14^a, *	77 ± 12*
SVR (dyn·s/cm^5)
EA -MTS	1374 ± 479	1233 ± 242	943 ± 234^a, b	1136 ± 219^b
LA -MTS		1405 ± 589	1065 ± 393^a, b	1117 ± 497^b
EA +MTS	1324 ± 347	1110 ± 359^b	855 ± 173^b	1130 ± 198
LA +MTS		1437 ± 367	926 ± 278^a	1161 ± 269
CO (l/min)
EA -MTS	4.7 ± 1.1	4.5 ± 0.9	5.5 ± 1.0^a, b	4.9 ± 1.1
LA -MTS		4.5 ± 0.9	5.6 ± 0.9^a, b	4.9 ± 0.8
EA +MTS	4.9 ± 0.8	4.8 ± 1.	5.9 ± 1.2 ^a, b	4.8 ± 0.8
LA +MTS		5.1 ± 1.2	7.7 ± 1.4^b, *	5.0 ± 0.8

Notes: Values are means ± SD or median (IQR). *p<0.05, different compared to the between-group value. ^ap<0.05, different from “after laparotomy” within groups. ^bp<0.05, different from “baseline” within groups.

Abbreviations: EA and LA, early and late activated thoracic epidural anesthesia, respectively; +MTS, mesenteric traction syndrome; -MTS, non or moderate mesenteric traction syndrome; MAP, mean arterial pressure; HR, heart rate; SVR, systemic vascular resistance; CO, cardiac output.

Figure 2 Plasma 6-keto-PGF_1α and hemodynamic variables in patients developing MTS Values are mean ±SD (hemodynamic variables) or median (IQR; plasma 6-keto-PGF_1α). *Difference between groups, p<0.05. For within-group differences please see Table 3.

Abbreviations: EA/LA, early and late activation of thoracic epidural anesthesia (TEA); HR, heart rate; CO, cardiac output; MAP, mean arterial pressure; SVR, systemic vascular resistance.

Table 4 Fluid and Vasopressor Administration

	+MTS	Non or Moderate MTS	P-value
*Total fluid administration, mL	3101 ± 1180	2681 ± 686	0.142
**Total fluid loss, mL	1537 ± 1010	1102 ± 549	0.054
***Fluid balance, mL	1564 ± 537	1579 ± 596	0.093
Phenylephrine, mg/min	0.016 (0.003–0.018)	0.005 (0.000–0.013)	0.029
Phenylephrine, infusion min	190 (0–263)	155 (10–240)	0.808
Phenylephrine boli, mg	0.50 (0.30–0.60)	0.45 (0.20–0.88)	0.946
Ephedrine boli, mg	20 ± 16	18 ± 12	0.691
Number of boli administered after induction of anesthesia	2 (1–4)	2 (1–3)	0.254

Notes: Values are means ± SD. *Includes medicine, crystalloid, blood products, and human albumin. **Includes blood loss and urine output. ***Fluid administration – fluid output.

Abbreviations: EA and LA, early and late activated thoracic epidural anesthesia; +MTS, mesenteric traction syndrome.

Table 5 Perioperative Changes in Plasma Interleukin-6

	Baseline	End of Surgery	18 h Postoperatively
Non or moderate MTS	1 (1–3)	108 (46–204)	61 (33–83)
+MTS	1 (1–2)	175 (131–277)*	95 (34–113)

Notes: Values are medians (IQR). *p<0.05, different between groups.

Abbreviations: EA and LA, early and late activated thoracic epidural anesthesia, respectively; +MTS, mesenteric traction syndrome; -MTS, non or moderate mesenteric traction syndrome.