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Protective Ventilation Influences Systemic Inflammation after Esophagectomy: A Randomized Controlled Study

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Abstract

Background:

Esophagectomy induces a systemic inflammatory response whose extent has been recognized as a predictive factor of postoperative respiratory morbidity. The aim of this study was to determine the effectiveness of a protective ventilatory strategy to reduce systemic inflammation in patients undergoing esophagectomy.

Methods:

The authors prospectively investigated 52 patients undergoing planned esophagectomy for cancer. Patients were randomly assigned to a conventional ventilation strategy (n = 26; tidal volume of 9 ml/kg during two-lung and one-lung ventilation; no positive end-expiratory pressure) or a protective ventilation strategy (n = 26; tidal volume of 9 ml/kg during two-lung ventilation, reduced to 5 ml/kg during one-lung ventilation; positive end-expiratory pressure 5 cm H2O throughout the operative time).

Results:

Plasmatic levels of interleukin (IL)-1β, IL-6, IL-8, and tumor necrosis factor α were measured perioperatively and postoperatively. Pulmonary function and postoperative evolution were also evaluated. Patients who received protective strategy had lower blood levels of IL-1β, IL-6, and IL-8 at the end of one-lung ventilation (0.24 [0.15–0.40] vs. 0.56 [0.38–0.89] pg/ml, P < 0.001; 91 [61–117] vs. 189 [127–294] pg/ml, P < 0.001; and 30 [22–45] vs. 49 [29–69] pg/ml, P < 0.05, respectively) and 18 h postoperatively (0.18 [0.13–0.30] vs. 0.43 [0.34–0.54] pg/ml, P < 0.001; 54 [36–89] vs. 116 [78–208] pg/ml, P < 0.001; 16 [11–24] vs. 35 [28–53] pg/ml, P < 0.001, respectively). Protective strategy resulted in higher oxygen partial pressure to inspired oxygen fraction ratio during one-lung ventilation and 1 h postoperatively and in a reduction of postoperative mechanical ventilation duration (115 ± 38 vs. 171 ± 57 min, P < 0.001).

Conclusion:

A protective ventilatory strategy decreases the proinflammatory systemic response after esophagectomy, improves lung function, and results in earlier extubation.

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