Near-total esophagectomy: The influence of standardized multimodal management and intraoperative fluid restriction

Background and Objectives: Esophagectomy can be associated with high morbidity and mortality. We present our experience managing these patients using a standardized multimodal approach that emphasizes intraoperative fluid restriction and early extubation. Methods: This case series includes 56 consecutive patients over a 2-year period (1999-2000) that underwent near-total esophagectomy at a high-volume center. Surgical approach was determined by patient and tumor characteristics; intraoperative fluid replacement was conservative; and patient-controlled epidural anesthesia/ analgesia was used to promote early extubation, enteral feeding, and ambulation. Results: Overall morbidity was 18%; in-hospital and 30-day mortality was zero. Intraoperative urinary volume averaged 0.57 mL/kg/h. No patient developed postoperative renal dysfunction or pulmonary complications. All patients were extubated in the operating room. First ambulation averaged 1.6 days after surgery. Median intensive care unit and hospital stays were 1 and 10 days, respectively. Side effects from thoracic epidural analgesia were minimal. Conclusions: Significant reduction in esophagectomy- related morbidity is possible using a standardized multimodal approach in routine clinical practice. Intraoperative fluid restriction may facilitate early extubation and reduce pulmonary complications without compromising renal function. This preliminary observation warrants further study in a randomized clinical trial.