Esophagectomy is possible with TAP! Avoid the epidural: A retrospective cohort review

doi:10.21203/rs.3.rs-2064766/v1

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Esophagectomy is possible with TAP! Avoid the epidural: A retrospective cohort review

https://doi.org/10.21203/rs.3.rs-2064766/v1

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Background: Esophagectomy traditionally has high levels of perioperative morbidity and mortality due to the surgical techniques and case complexity. While thoracic epidural analgesia (TEA) is considered first-line for postoperative analgesia after esophagectomy, there can be complications related to its sympathectomy and mobility impairment. Additionally, it has been shown that postoperative outcomes are improved with early extubation following esophagectomy. Our aim is to describe the impact of transversus abdominus plane (TAP) blocks on extubation rates following esophagectomy when uncoupled from TEA.

Methods: This is a retrospective study of 42 patients who underwent trans-hiatal esophagectomy between 2019 and 2022 who received a TAP block in the absence of TEA. The primary outcomes of interest were the rates of extubation within the operating room (OR) and reintubation. Secondary outcomes included: intensive care unit (ICU) and hospital length of stay (LOS), opioid pain medication use, time to enteral diet, reported postoperative pain scores, development of anastomotic leak, and 30-day readmission.

Results: The mean age at operation was 63 years and 97.6% of patients were represented by American Society of Anesthesia (ASA) physical status class III or IV. 35 (83.3%) patients immediately extubated postoperatively. Nine patients (21.4%) underwent reintubation during their hospital course. Only six patients (14%) required vasopressors postoperatively. The median LOS was five days in the ICU and 10 days in the hospital. TAP block alone was found to be equivalent to TAP with additional regional blocks (TAP+) on the basis of immediate extubation, reintubation, ICU and hospital LOS, and reported postoperative pain.

Conclusion: The results of this study demonstrate TAP blocks do provide comparable rates of successful immediate extubation and reintubation to TEA with fewer hypotensive complications after trans-hiatal esophagectomy. This was shown despite the elevated comorbidity burden of this study’s population. Additionally, TAP blocks maintained similar reported pain control scores to TEA literature.Overall, this study supports the use of TAP blocks as the primary analgesia in patients undergoing trans-hiatal esophagectomy over TEA.

Trial Registration: This study includes participants who were retrospectively registered. IRB# 037.HPB.2018.R

Esophagectomy

Transversus Abdominis Plane (TAP)

Quadratus Lumborum (QL)

Block

Epidural

ERAS

Analgesia

Esophagectomy for both malignant and benign disease, are known to carry significant perioperative risk. In fact, several studies have shown the perioperative morbidity to be as high as 59% with a 90-day mortality risk of 4.5%¹. The elevated level of morbidity and mortality associated with esophagectomy is polyfactorial, but thought to be related to patient comorbidities, operative technique, and the devastating nature of the related postoperative complications. Opioid-based analgesia in tandem with thoracic epidural analgesia (TEA) is generally considered the first-line approach to postoperative analgesia for esophagectomy. As such, it has been incorporated into the enhanced recovery after surgery (ERAS) pathway in most hospitals². TEA is not without complications, including urinary retention, respiratory depression, hypotension, and impaired mobility which may slow postoperative recovery^3,4. Resulting hypotension is often treated with increased fluid administration in the perioperative setting and may lead to bowel edema, ileus, and ischemia related anastomotic breakdown. Hypotension occasionally necessitates early removal of TEA, resulting in insufficient postoperative analagesia². Moreover, many centers require intensive care unit (ICU) monitoring for the duration of TEA utilization and a dedicated pain management service for its proper titration^5,6. During a time with strained hospital resources and bed availability, these can be significant constraints, particularly in non-academic hospital settings. Finally, there are concerns regarding epidural hematoma development with TEA, often delaying prophylactic anticoagulation initiation². Alternatively, transversus abdominis plane (TAP) and quadratus lumborum (QL) blocks with local anesthetics may provide effective opioid-sparing relief of postoperative pain without exposing patients to TEA-related side effects^7,8.

Studies have confirmed that early postoperative clinical outcomes are improved with immediate extubation in the operating room (OR) following esophagectomy. However, most available literature cite TEA as the primary form of analgesia⁹. One retrospective review demonstrated that TAP blocks may decrease perioperative fluid requirements while still achieving adequate pain control but did not address ventilator liberation¹⁰. While it is known that early extubation in the OR is possible after esophagectomy with TEA and paravertebral blocks, there is no current literature on utilizing TAP blocks alone^2,5,10,11.

The aim of this study is to investigate the safety and effectiveness of immediate extubation after trans-hiatal esophagectomy utilizing TAP blocks, with and without QL and erector spinae blocks, in the absence of TEA.

This is a retrospective, IRB-approved, study of patients who underwent trans-hiatal esophagectomy at a single institution from January 2019 to January 2022. All patients 18 years or older who received a preoperative TAP block without use of TEA met inclusion criteria of the study. The use of additional block types was noted but did not result in study exclusion. Both surgeon and anesthesiologist were familiar with current ERAS guidelines specific to esophagectomy, and these standards were adhered to with appropriate variations based on clinical discretion and urgency of the procedure². 43 consecutive patients who underwent esophagectomy during the study period were identified via electronic medical record. One patient was excluded as a TAP block was not performed preoperatively.

Data Collection:

For all patients who met inclusion criteria, the following information was obtained from the electronic medical record:

Demographics: This includes sex, age at time of surgery, and the presence of pulmonary comorbidities such as asthma, chronic obstructive pulmonary disease (COPD), pulmonary hypertension, restrictive lung disease, and obstructive sleep apnea (OSA).
Preoperative measures: This includes American Society of Anesthesiologists physical status (ASA) classification and the timing of neoadjuvant radiation in relation to surgery.
Surgical intraoperative measures: This includes attending surgeon and anesthesiologist performing the case, type of conduit utilized, surgical access method, operative time, estimated blood loss (EBL), volume of transfused packed red blood cells (pRBC), urine output, and the volume of intravenous fluids (IVFs) administered.
Anesthesia intraoperative measures and medications: This includes duration of mean arterial pressure (MAP) less than 60 mmHg, duration of tidal volume (Vt) greater than 8 cc/kg ideal body weight, duration of time the fraction of inspired oxygen (FiO₂) was greater than 80%, duration of positive end expiratory pressure (PEEP) greater than 5 cm H₂O, mechanical ventilation time, types of regional blocks performed, and morphine milligram equivalents (MME) required. Medication information included vasopressor requirements at the conclusion of the case and the amount of norepinephrine, ketamine, magnesium, acetaminophen, and methocarbamol utilized.
Postoperative measures: This includes ability to extubate in OR, event of reintubation, reported postoperative pain scores as recorded by the anesthesiologists and nursing teams through postoperative day (POD) 3, presence of postoperative hypotension, fluid bolus volumes, anastomotic leak, vasopressor requirement, time to diet initiation, ICU length of stay (LOS), total hospital LOS, and hospital readmission.

Anesthetic Blocks:

All regional anesthetic blocks were performed in a bilateral fashion under ultrasound guidance using 0.25% bupivacaine, 0.5% bupivacaine, or 1.3% liposomal bupivacaine with appropriate dosing based on patient weight. Erector spinae plane (ESP) blocks were performed with the patient positioned upright and seated in the OR prior to induction. TAP and QL blocks were performed post induction, but prior to the initial surgical incision, with the patient in the supine position. ESP blocks were performed using a deep needle approach with injection of the local anesthetic deep to the erector spinae muscles¹². Performance of TAP blocks included both a lateral approach along with rectus sheath blocks, often referred to as a four-quadrant TAP block, placed according to the New York Society of Regional Anesthesia for TAP blocks^5,13,14. QL blocks, in this case a QL1 variation, were performed using a lateral approach, approximately 2 cm superior to the iliac crest¹⁵. TAP block with the addition of any other regional block combination are referred to as TAP+.

Data Analysis: 

Continuous parametric data were compared using Student’s t-test while a Mann-Whitney U test was used for non-parametric continuous data. Categorical variables were analyzed using Chi-square and Fischer’s exact tests where appropriate. Multiple linear regression analysis was performed to identify the correlation and impact of key variables in ICU LOS and hospital LOS. Proportions were reported as percentage, parametric continuous variables reported as the mean with interquartile range (IQR), and non-parametric continuous variables reported as the median with range. A p-value less than 0.05 was considered statistically significant. All multiple linear regression analysis and Mann-Whitney U tests were performed using IBM SPSS Version 28 (Predictive Analytics Software, Armonk, NY) while Student’s t-test, Fischer’s exact, and Chi-square tests were performed using Microsoft Excel Workbook Version 16.64 (Microsoft Corporation, Redmond, WA).

Table 1: Patient Demographics

Age at Surgery	Median	Range
Years	63	33-89
Sex	N	Percent %
Male	36	85.7
Female	6	14.3
ASA Classification	N	Percent %
ASA II	1	2.4
ASA III	30	71.4
ASA IV	11	26.2
Pulmonary Comorbidities	N	Percent %
Present	10	23.8
Not Present	32	76.2
Neoadjuvant Therapy	N	Percent %
Received Neoadjuvant Chemoradiation	24	57.1
Mean Time to Surgery Post Radiation	42.3 days

Abbreviations: ASA, American Society of Anesthesiology.

Table 1 shows the demographic data of the entire study population. The mean age at operation was 63 years and there was a male predominance (85.7%). 73.2% of the study population were ASA III and 23.9% were ASA IV.

Table 2: Intra-Operative Measures

Surgical Access	N	Percent %
Robotic-assisted	32	76.2
Open	10	23.8
Operative Time (minutes)	Median	Range
Robotic-assisted	146.5	103-264
Open	130.5	109-167
Volume Management (mL)	Robotic	Open
Median EBL	265	400
Median Transfused pRBC*	0	375
Median Perioperative IVFs	3875	4375
Hypotension and Treatment (minutes)	Median	Range
Duration of MAP <60 mmHg	4	0-20
Duration of Norepinephrine	0	0-180
Ventilatory Parameters (minutes)	Median	Range
Tidal Volume (Vt) >8cc/kg	101	0-246
FiO₂ >80%	43	0-297
PEEP >5 cm H2O	0	0-251
Mechanical Ventilation Time (hours)	3.5	2.5-94
Regional Block Types	N	Percent %
TAP	10	23.8
TAP+QL	31	73.8
TAP+QL+ESP	1	2.4
Perioperative Opiate Use (mg/kg)	Median	Range
Morphine Milligram Equivalent (MME)	0.88	0.25-2.63
Vasopressor Use	N	Percent %
Vasopressor ggt at End of Case	2	4.8
Intraoperative Norepinephrine Use	14	33.3
Adjunct Analgesics Used	N	Percent %
Ketamine	23	54.8
Magnesium	33	78.6
Acetaminophen	10	23.8
Methocarbamol	13	31

Legend: *indicates statistically significant difference between groups

Abbreviations: EBL, estimated blood loss; pRBC, packed red blood cells; IVFs, intravenous fluids; MAP, mean arterial pressure; FiO₂, fraction of inspired oxygen; PEEP, positive end expiratory pressure; TAP, transversus abdominis plane block; QL, quadratus lumborum block; ESP, erector spinae block; ggt, drip.

Table 2 displays the intraoperative surgical, anesthetic, and medication details of the study population. All patients underwent a trans-hiatal esophagectomy. 76.2% of cases were robotic-assisted. 14 patients (33%) required intraoperative norepinephrine use and two patients required a vasopressor infusion at the conclusion of the case.

Table 3: Post-Operative Measures

Extubation Circumstance	N	Percent %
Extubation in OR	35	83.3
Delayed Extubation	7	16.7
Reintubation	9	21.4
Pain control score (0-10)	Median	Range
PACU (n=42)	0	0-4
POD 1 (n=38)	4	0-8
POD 2 (n=17)	3.5*	0-7
POD 3 (n=10)	4*	0-6
Postoperative Hypotension (MAP<60 mmHg)	N	Percent %
POD 1	4	9.5
POD 2	5	11.9
POD 3	2	4.8
Postoperative Fluid Bolus Required	N	Percent %
POD 1	5	11.9
POD 2	5	11.9
POD 3	0	0
Postoperative Complications	N	Percent %
ICU Vasopressors Use	6	14.3
Anastomotic Leak	3	7.1
30-day Readmission	10	23.8
Care Timeline (days)	Median	Range
Time to Enteral Diet	7	5-12
ICU LOS	5	0-48
Total Hospital LOS	10	7-48

Legend: *POD 2 and 3 pain scores collected in less than 50% of patients recorded.

Abbreviations: OR, operating room; PACU, post anesthesia care unit; POD, postoperative day; LOS, length of stay; ICU, intensive care unit.

Table 3 includes the postoperative measures of interest. 35 patients (83.3%) were able to be immediately extubated in the OR. Nine (21.4%) patients had to be reintubated during their hospital stay, of which eight were due to acute hypoxic respiratory failure and one was related to hemodynamic instability. One patient was reintubated on POD 0. The average pain score was noted to be 0 on initial postoperative assessment in the post-anesthesia care unit (PACU) vs. an average of 4 on POD 1. Pain scores remained stable from POD 1 through POD 3, but scores were available for only 50% of the cohort on POD 2 and 3. Only six patients (14.3%) required the use of vasopressors postoperatively due to hypotension. Three patients (7%) were found to have an anastomotic leak. The average time to enteral diet was seven days. The median hospital LOS was 10 days (range: 7-48 days) and the median stay in the ICU was 5 days (range: 0-48 days). There was a 23.8% 30-day readmission rate while the 30-day mortality rate was found to be 2.4%.

Table 4: Statistically significant data from analysis using T-test tables and Chi-square Analysis

T-test Analysis	TAP	TAP+	p-value
FiO₂ >80% (time, min)	144	53	0.007
T-test Analysis	OR Extubation	Delayed Extubation	p-value
Acetaminophen (mg)	954	0	<0.001
Methocarbamol (mg)	646	0	<0.001
Mean Volume of Transfused pRBC (mL)	114	536	0.029

Abbreviations: FiO₂, fraction of inspired oxygen; ASA, American Society of Anesthesiology.

Table 4 compares the differences between TAP block alone vs TAP+ and immediate vs delayed extubation groups. No significance was identified when comparing TAP block alone vs TAP+ on the basis of early extubation rate (p=0.503), ICU (p=0.998) or total hospital LOS (p=0.941), or intraoperative opiate consumption (p=0.593). Differences were noted in FiO₂ requirements, with the TAP+ group requiring significantly less supplemental oxygen intraoperatively (p=0.007). There was no difference in median postoperative pain scores on any day between those who received TAP block alone v TAP+ (p= 0.058). When comparing immediate vs. delayed extubation, the immediate extubation group required statistically fewer intraoperative transfusions (p=0.029). Additionally, they received statistically more methocarbamol and acetaminophen intraoperatively (p<0.001). The extubation rate was not significantly affected by the presence of pulmonary comorbidities (p=0.403), or the requirement of norepinephrine intraoperatively (p=0.143).

Multiple linear regression to predict ICU LOS was calculated based on duration of intraoperative norepinephrine use, presence of ASA IV (p= 0.121), presence of reintubation, presence of POD 1 hypotension, and volume of perioperative IVFs (p= 0.023) (F(5,36)= 14.23, p<0.001) with an R² of 0.664. For 10 minutes of intraoperative norepinephrine use the average ICU length of stay increased by one day (b= 0.43, t(42)= 4.19, p< 0. 001). Reintubation was associated with in an average increase in ICU length of stay of 12.12 days (b= 0.50, t(42)= 4.59, p< 0. 001) while the presence of POD 1 hypotension corresponded to an increase in 12.94 days (b= 0.38, t(42)= 3.89, p< 0. 001). Prediction of total hospital length of stay was calculated based on ICU LOS, ASA IV status, and intraoperative EBL (p= 0.137) (F(3,38)= 59.04, p< 0.001). The R² was found to be 0.823. For every day spent in the ICU, the associated total hospital LOS increased by an average of 0.81 days (b= 0.94, t(42)= 13.2, p< 0. 001). The presence of ASA IV predicted an increased total hospital LOS of 4.27 days (b= 0.22, t(42)= 3.00, p= 0. 005).

This study is the first of its kind to specifically demonstrate that successful immediate extubation is possible after trans-hiatal esophagectomy using TAP blocks as the primary source of postoperative analgesia rather than TEA. The data set presented shows that 83.3% of trans-hiatal esophagectomy patients can be successfully extubated in the OR by means of TAP blocks with or without additional regional anesthetic blocks. This rate of extubation is similar to a rate of 90% using TEA by Lanuti et al¹⁶. There were substantially fewer postoperative hypotensive complications requiring vasopressor use among this study’s TAP block patients (14%) compared to the published literature of TEA patients (31%)⁹. The reintubation rate of this study was 21% which is nearly identical to the findings of 20% reported in a systematic review of 490 esophagectomy patients utilizing TEA¹⁷.

No statistically significant differences in any measured outcome were detected between patients who underwent TAP block alone vs TAP+ and as such, we treat the groups as equivocal. Due to the relatively limited number of patients who underwent TAP alone (n= 10), it is possible that with a larger sample size statistical significance would be achieved, particularly for reported pain scores in the PACU postoperatively (p=0.058). Grossly, this study resulted in a median difference of one on a 10-point scale for pain reported while in the PACU. While this study did not reflect a difference in intraoperative MME between groups or in immediate extubation rates it remains unclear if a one-point, or a similar value, difference would be clinically meaningful based on other real-life measures such as early postoperative MME requirements and insufficient pain control-associated complications. This potential difference warrants further investigation.

When looking at medication-related factors that might play a role in extubation, both acetaminophen and methocarbamol were used in statistically greater amounts among patients who underwent immediate extubation in the OR. In fact, no patient who underwent delayed extubation received a dose of either medication. Due to the retrospective nature of the study, the reason for this discrepancy is not clear. These findings serve to highlight the importance of multimodal pain control within the increasingly common ERAS pathways.

The total volume of IVF administration was fairly consistent among all patients, but there were significant differences in the volume of blood product administration between immediate and delayed extubation groups. Patients who were extubated in the OR immediately received on average 114 mL of pRBC whereas patients who were unable to be extubated received on average 536 mL of pRBC (p=0.029). This finding is likely reflective of a more “complicated” surgical course rather than reflective of anesthetic management as patients that received more blood were, unsurprisingly, found to have higher reported intraoperative EBL volumes. Significant differences identified in FiO₂ requirements between early and delayed extubation groups may represent issues in the oxygen diffusion capacity due to an underlying lung pathology, individual variation in practice among anesthesia providers, or it may be a spurious finding.

The median ICU stay after esophagectomy was 5 days (range: 0-48) and the median total hospital stay after esophagectomy was 10 days (range: 7-48). The mean ASA score of this study’s patients was 3.3. One study examining the rate of immediate extubation in the OR (n=42) following esophagectomy using TEA reported a median ICU stay of 3 days (IQR: 2.75-3) and median hospital stay of 22.5 days (IQR: 16.5-27.75)with an average ASA score of 1.5⁹. It is likely that the ICU LOS is similar between this study and the comparison study due to the similar rates of reintubation. Regression analysis of this study demonstrated that the primary driver for increased ICU LOS was reintubation. While our regression model did not identify ASA classification as a statistically significant factor in ICU LOS, ASA IV was correlated with an increased total hospital LOS. The results of this study demonstrated a shorter total hospital LOS despite the heavier comorbidity burden, although this is likely multifactorial and not a direct result of using TAP block as the primary source of analgesia instead of TEA.

This study has several limitations. First, this is a retrospective study from a single center and thus has an intrinsic risk of bias. Second, while this study was performed over a relatively short period of time, theoretically limiting the bias incurred due to unaccounted for changes over time, there were known significant changes in care due to the impact of covid-19 during the course of the study. Namely, these included the intermittent use of non-dedicated anesthesiologist, hospital bed availability, and delays in patient care due to covid infections. Third, when compared to other published studies, this study is small to moderate in size, but overall statistical inferences are limited by the number of available patients for analysis. Further publications of outcomes utilizing TAP block without TEA will be required to allow for future meta-analysis.

This study is the first of its kind to specifically demonstrate that regional TAP blocks can provide equivalent, if not superior, outcomes after esophagectomy as compared to TEA. This finding was born out despite the patient population of this study exhibiting severe comorbid health conditions and an elevated age at the time of surgery. This data should be used as a basis for further study and modification of existing ERAS pathways for esophagectomy patients.

TEA - thoracic epidural analgesia

ERAS - enhanced recovery after surgery

ICU - intensive care unit

TAP - transversus abdominis plane

ESP- erector spinae plane

QL - quadratus lumborum

OR - operating room

COPD - chronic obstructive lung disease

OSA - obstructive sleep apnea

ASA - American Society of Anesthesiologists physical status

EBL - estimated blood loss

pRBC - packed red blood cell products

IVF - intravenous fluids

MAP - mean arterial pressure

Vt - tidal volume

FiO₂ - fraction of inspired oxygen

PEEP - positive end-expiratory pressure

MME - morphine milligram equivalents

LOS - length of stay

IQR - interquartile

PACU - post anesthesia care unit

POD - postoperative day

TAP+ - combined TAP and all other regional blocks

MME- Morphine milligram equivalents

Ethics approval and consent to participate

This study has approval from the IRB protocol #037.HPB.2018.R at Methodist Richardson Medical Center. The Methodist Health System Independent Ethics Committee has waived the need for informed consent of the study participants on the basis of this being a retrospective chart review.

Guidelines

All surgical and procedural interventions on patients were performed in accordance with the most relevant and up to date guidelines for trans-hiatal esophagectomy and regional nerve blocks.

Consent for publication

Not applicable: retrospective chart review study

Availability of data and materials:

The datasets supporting the conclusions of this article are included within the article.

Competing interests:

The authors declare that they have no competing interests.

Funding:

Texas Christian University Open Access Fund.

Authors' contributions:

Acquisition, analysis, and interpretation of data:

Mr. William Mitchell, Mr. Thomas Roser, Dr. Shankar Logarajah, Dr. Jessica Heard

Drafting of the manuscript:

Mr. William Mitchell, Mr. Thomas Roser, Dr. Jessica Heard

Critical revision of the manuscript for important intellectual content:

Mr. William Mitchell, Mr. Thomas Roser, Dr. Jessica Heard, Dr. John Ok, Dr John Jay, Dr. Rohan Jeyarajah

Acknowledgements

Not applicable

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No competing interests reported.

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Esophagectomy is possible with TAP! Avoid the epidural: A retrospective cohort review

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