Original Article| Volume 35, ISSUE 10, P2952-2960, October 2021

Download started.


Pulmonary Complications in Esophagectomy Based on Intraoperative Fluid Rate: A Single-Center Study

Published:January 12, 2021DOI:


      Esophagectomy is associated with significant morbidity and mortality. The authors assessed the relationship between intraoperative fluid (IOF) administration and postoperative pulmonary outcomes in patients undergoing a transthoracic, transhiatal, or tri-incisional esophagectomy.


      Retrospective cohort study (level 3 evidence).


      Tertiary care referral center.


      Patients who underwent esophagectomy from 2007 to 2017.


      The IOF rate (mL/kg/h) was the predictor variable analyzed both as a continuous and binary categorical variable based on median IOF rate for this cohort (11.90 mL/kg/h).


      Primary outcomes included rates of acute respiratory distress syndrome (ARDS) within ten days after esophagectomy. Secondary outcomes included rates of reintubation, pneumonia, cardiac or renal morbidity, intensive care unit admission, length of stay, procedure-related complications, and mortality. Multivariate regression analysis determined associations between IOF rate and postoperative outcomes. Analysis was adjusted for age, sex, body mass index, procedure type, year, and thoracic epidural use.

      Main Results

      A total of 1,040 patients comprised this cohort. Tri-incisional esophagectomy was associated with a higher hospital mortality rate (7.8%) compared with transthoracic esophagectomy (2.6%, p = 0.03) or transhiatal esophagectomy (0.7%, p = 0.01). Regression analysis revealed a higher IOF rate was associated with greater ARDS within ten days (adjusted odds ratio [OR] = 1.03, p = 0.01). For secondary outcomes, a higher IOF rate was associated with greater hospital mortality (adjusted OR = 1.05, p = 0.002), although no significant association with 30-day hospital mortality was identified.


      Increased IOF administration during esophagectomy may be associated with worse postoperative pulmonary complications, specifically ARDS. Future well-powered studies are warranted, including randomized, controlled trials comparing liberal versus restrictive fluid administration in this surgical population.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Raymond DP
        • Seder CW
        • Wright CD
        • et al.
        Predictors of major morbidity or mortality after resection for esophageal cancer: A Society of Thoracic Surgeons General Thoracic Suergery Database Risk Adjustment Model.
        Ann Thorac Surg. 2016; 102: 207-214
        • Dhungel B
        • Diggs BS
        • Hunter JG
        • et al.
        Patient and peri-operative predictors of morbidity and mortality after esophagectomy: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), 2005-2008.
        J Gastrointest Surg. 2010; 14: 1492-1501
        • Ferguson MK
        • Celauro AD
        • Prachand V.
        Prediction of major pulmonary complications after esophagectomy.
        Ann Thorac Surg. 2011; 91 (discussion 500-1): 1494-1501
        • Kinugasa S
        • Tachibana M
        • Yoshimura H
        • et al.
        Postoperative pulmonary complications are associated with worse short- and long-term outcomes after extended esophagectomy.
        J Surg Oncol. 2004; 88: 71-77
        • Chau EH
        • Slinger P.
        Perioperative fluid management for pulmonary resection surgery and esophagectomy.
        Semin Cardiothorac Vasc Anesth. 2014; 18: 36-44
        • Ashes C
        • Slinger P.
        Volume management and resuscitation in thoracic surgery.
        Curr Anesthesiol Rep. 2014; 4: 386-396
        • Avendano CE
        • Flume PA
        • Silvestri GA
        • et al.
        Pulmonary complications after esophagectomy.
        Ann Thorac Surg. 2002; 73: 922-926
        • Xu JX
        • Wang HZ
        • Dong J
        • et al.
        Analysis of risk factors for acute lung injury/acute respiratory distress syndrome after esophagectomy [article in Chinese].
        Beijing Da Xue Xue Bao Yi Xue Ban. 2018; 50: 1057-1062
        • Yoshida N
        • Watanabe M
        • Baba Y
        • et al.
        Risk factors for pulmonary complications after esophagectomy for esophageal cancer.
        Surg Today. 2014; 44: 526-532
        • Law S
        • Wong KH
        • Kwok KF
        • et al.
        Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer.
        Ann Surg. 2004; 240: 791-800
        • Reinersman JM
        • Allen MS
        • Deschamps C
        • et al.
        External validation of the Ferguson pulmonary risk score for predicting major pulmonary complications after oesophagectomy.
        Eur J Cardiothorac Surg. 2016; 49: 333-338
        • Xing X-Z
        • Gao Y
        • Wang H-J
        • et al.
        Assessment of a predictive score for pulmonary complications in cancer patients after esophagectomy.
        World J Emerg Med. 2016; 7: 44-49
        • Wei S
        • Tian J
        • Song X
        • et al.
        Association of perioperative fluid balance and adverse surgical outcomes in esophageal cancer and esophagogastric junction cancer.
        Ann Thorac Surg. 2008; 86: 266-272
        • Joshi GP.
        Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery.
        Anesth Analg. 2005; 101: 601-605
        • Kita T
        • Mammoto T
        • Kishi Y.
        Fluid management and postoperative respiratory disturbances in patients with transthoracic esophagectomy for carcinoma.
        J Clin Anesth. 2002; 14: 252-256
        • Karaman Ilic M
        • Madzarac G
        • Kogler J
        • et al.
        Intraoperative volume restriction in esophageal cancer surgery: An exploratory randomized clinical trial.
        Croatian Med J. 2015; 56: 290-296
        • Xing X
        • Gao Y
        • Wang H
        • et al.
        Correlation of fluid balance and postoperative pulmonary complications in patients after esophagectomy for cancer.
        J Thorac Dis. 2015; 7: 1986-1993
        • Haase O
        • Raue W
        • Neuss H
        • et al.
        Influence of postoperative fluid management on pulmonary function after esophagectomy.
        Acta Chirurgica Belgica. 2013; 113: 415-422
        • Casado D
        • Lopez F
        • Marti R.
        Perioperative fluid management and major respiratory complications in patients undergoing esophagectomy.
        Dis Esophagus. 2010; 23: 523-528
        • Glatz T
        • Kulemann B
        • Marjanovic G
        • et al.
        Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: A retrospective study in 335 patients.
        BMC Surg. 2017; 17: 6
        • Eng OS
        • Arlow RL
        • Moore D
        • et al.
        Fluid administration and morbidity in transhiatal esophagectomy.
        J Surg Res. 2016; 200: 91-97
        • Hung Leong Chau E
        • Slinger P
        Perioperative fluid management for pulmonary resection surgery and esophagectomy.
        Semin Cardiothorac Vasc Anesth. 2013; 18: 36-44
        • Gisbertz S
        • Veelo D
        • Van Berge Henegouwen M
        • et al.
        The effect of intra-operative goal directed fluid therapy on outcome after esophageal surgery-A quality improvement study.
        Dis Esophagus. 2016; 29: 107A
        • Masi A
        • Desiato V
        • Melis M
        • et al.
        Increased intraoperative fluid volume administration is associated with worse outcomes after gastro-esophageal resection for cancer.
        J Am Coll Surg. 2015; 2: e129-e130
        • Ramaiah RS
        • Roman M
        • Carvalho P
        • et al.
        Fluid balance as a predictor of mortality in elective esophagectomy.
        Intensive Care Med. 2011; 1: S161
        • Ljungqvist O
        • Scott M
        • Fearon KC.
        Enhanced recovery after surgery: A review.
        JAMA Surg. 2017; 152: 292-298
        • Ban KA
        • Berian JR
        • Ko CY.
        Does implementation of enhanced recovery after surgery (ERAS) protocols in colorectal surgery improve patient outcomes?.
        Clin Colon Rectal Surg. 2019; 32: 109-113
        • Collazo S
        • Graf NL.
        A system-based nursing approach to improve outcomes in the postoperative esophagectomy patient.
        Semin Oncol Nurs. 2017; 33: 37-51
        • Ng JM.
        Perioperative anesthetic management for esophagectomy.
        Anesthesiol Clin. 2008; 26: 293-304
        • Pirchi D
        • Cerutti R
        • Mihura M
        • et al.
        Initial experiences of an enhanced recovery protocol for minimally invasive esophagectomy.
        Dis Esophagus. 2014; 1: 117A-118A
        • Markar SR
        • Karthikesalingam A
        • Low DE.
        Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: Systematic review and pooled analysis.
        Dis Esophagus. 2015; 28: 468-475
        • Taniguchi H
        • Sasaki T
        • Fujita H
        • et al.
        Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program.
        Clin Nutr ESPEN. 2018; 23: 184-193
        • Taniguchi H
        • Ushigome K
        • Sasaki T
        • et al.
        Study of the effects of target-oriented fluid therapy is given to promoting recovery after surgery-intervention comparative observation research in the patients applied to enhanced recovery of after surgery protocol.
        Clin Nutr. 2016; 35: S239
        • ARDS Definition Task Force
        • Ranieri VM
        • Rubenfeld GD
        • et al.
        Acute respiratory distress syndrome: The Berlin definition.
        JAMA. 2012; 307: 2526-2533
        • Linden PA
        • Towe CW
        • Watson TJ
        • et al.
        Mortality after esophagectomy: Analysis of individual complications and their association with mortality.
        J Gastrointest Surg. 2020; 24: 1948-1954
        • Blank RS
        • Colquhoun DA
        • Durieux ME
        • et al.
        Management of one-lung ventilation: Impact of tidal volume on complications after thoracic surgery.
        Anesthesiology. 2016; 124: 1286-1295
        • Brower RG
        • Matthay MA
        • Morris A
        • et al.
        Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
        N Engl J Med. 2000; 342: 1301-1308
        • Fan E
        • Del Sorbo L
        • Goligher EC
        • et al.
        An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical ventilation in adult patients with acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2017; 195: 1253-1263
        • Levit D
        • Levit A.
        Restrictive fluid therapy in major abdominal surgery: Selection of fluid combination.
        Intensive Care Med. 2011; 1: S255
        • Levit D
        • Levit A.
        Different combinations of colloids and crystalloids in major abdominal surgery: Hemodynamics effects.
        Intensive Care Med. 2012; 1: S152
        • Choi H
        • Cho JH
        • Kim HK
        • et al.
        Prevalence and clinical course of postoperative acute lung injury after esophagectomy for esophageal cancer.
        J Thorac Dis. 2019; 11: 200-205
        • Kaufmann KB
        • Baar W
        • Glatz T
        • et al.
        Epidural analgesia and avoidance of blood transfusion are associated with reduced mortality in patients with postoperative pulmonary complications following thoracotomic esophagectomy: A retrospective cohort study of 335 patients.
        BMC Anesthesiol. 2019; 19: 162
        • Tandon S
        • Batchelor A
        • Bullock R
        • et al.
        Peri-operative risk factors for acute lung injury after elective oesophagectomy.
        Br J Anaesth. 2001; 86: 633-638
        • Schieman C
        • Wigle DA
        • Deschamps C
        • et al.
        Patterns of operative mortality following esophagectomy.
        Dis Esophagus. 2012; 25: 645-651
      1. The Society of Thoracic Surgeons Composite Score for Evaluating Esophagectomy for Esophageal Cancer.
        Ann Thorac Surg. 2017; 103: 1661-1667
        • Abdelsattar ZM
        • Habermann E
        • Borah BJ
        • et al.
        Understanding failure to rescue after esophagectomy in the United States.
        Ann Thorac Surg. 2020; 109: 865-871
        • Liou DZ
        • Serna-Gallegos D
        • Mirocha J
        • et al.
        Predictors of failure to rescue after esophagectomy.
        Ann Thorac Surg. 2018; 105: 871-878
        • Busweiler LA
        • Henneman D
        • Dikken JL
        • et al.
        Failure-to-rescue in patients undergoing surgery for esophageal or gastric cancer.
        Eur J Surg Oncol. 2017; 43: 1962-1969
        • Fumagalli U
        • Melis A
        • Balazova J
        • et al.
        Intra-operative hypotensive episodes may be associated with post-operative esophageal anastomotic leak.
        Updates Surg. 2016; 68: 185-190
        • Low DE
        • Allum W
        • De Manzoni G
        • et al.
        Guidelines for perioperative care in esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations.
        World J Surg. 2019; 43: 299-330
        • Findlay JM
        • Gillies RS
        • Millo J
        • et al.
        Enhanced recovery for esophagectomy: A systematic review and evidence-based guidelines.
        Ann Surg. 2014; 259: 413-431
        • Schmidt HM
        • El Lakis MA
        • Markar SR
        • et al.
        Accelerated recovery within standardized recovery pathways after esophagectomy: A prospective cohort study assessing the effects of early discharge on outcomes, readmissions, patient satisfaction, and costs.
        Ann Thorac Surg. 2016; 102: 931-939
        • Deng HY
        • Zha P
        • Peng L
        • et al.
        Preoperative sarcopenia is a predictor of poor prognosis of esophageal cancer after esophagectomy: A comprehensive systematic review and meta-analysis.
        Dis Esophagus. 2018; 32
        • Mantziari S
        • Hübner M
        • Demartines N
        • et al.
        Impact of preoperative risk factors on morbidity after esophagectomy: Is there room for improvement?.
        World J Surg. 2014; 38: 2882-2890
        • Nakashima Y
        • Saeki H
        • Nakanishi R
        • et al.
        Assessment of sarcopenia as a predictor of poor outcomes after esophagectomy in elderly patients with esophageal cancer.
        Ann Surg. 2018; 267: 1100-1104
        • Sheetz KH
        • Zhao L
        • Holcombe SA
        • et al.
        Decreased core muscle size is associated with worse patient survival following esophagectomy for cancer.
        Dis Esophagus. 2013; 26: 716-722
        • Soma D
        • Kawamura YI
        • Yamashita S
        • et al.
        Sarcopenia, the depletion of muscle mass, an independent predictor of respiratory complications after oncological esophagectomy.
        Dis Esophagus. 2019; 32: doy092
        • Wang PY
        • Xu LD
        • Chen XK
        • et al.
        Sarcopenia and short-term outcomes after esophagectomy: A meta-analysis.
        Ann Surg Oncol. 2020; 27: 3041-3051
        • Pathak D
        • Pennefather SH
        • Russell GN
        • et al.
        Phenylephrine infusion improves blood flow to the stomach during oesophagectomy in the presence of a thoracic epidural analgesia.
        Eur J Cardiothoracic Surg. 2013; 44: 130-133
        • Al-Rawi OY
        • Pennefather SH
        • Page RD
        • et al.
        The effect of thoracic epidural bupivacaine and an intravenous adrenaline infusion on gastric tube blood flow during esophagectomy.
        Anesth Analg. 2008; 106: 884-887
        • Jagannathan R
        • Niesen AD
        • D'Souza RS
        • et al.
        Intermittent bolus versus continuous infusion techniques for local anesthetic delivery in peripheral and truncal nerve analgesia: The current state of evidence.
        Reg Anesth Pain Med. 2019; 44: 447-451
        • Michelet P
        • Roch A
        • D'Journo X-B
        • et al.
        Effect of thoracic epidural analgesia on gastric blood flow after oesophagectomy.
        Acta Anaesthesiol Scand. 2007; 51: 587-594
        • Quinn TD
        • Brovman EY
        • Urman RD.
        Analysis of variability in intraoperative fluid administration for colorectal surgery: An argument for goal-directed fluid therapy.
        J Laparoendosc Adv Surg Tech A. 2017; 27: 892-897
        • Zhu AC-C
        • Agarwala A
        • Bao X.
        Enhanced recovery after aurgery (ERAS) for colorectal surgery: Perioperative fluid management in the enhanced recovery after surgery (ERAS) pathway.
        Clin Colon Rectal Surg. 2019; 32: 114
        • Elias KM
        • Stone AB
        • McGinigle K
        • et al.
        The reporting on ERAS Compliance, Outcomes, and Elements Research (RECOvER) checklist: A joint statement by the ERAS and ERAS USA societies.
        World J Surg. 2019; 43: 1-8
        • Joshi GP
        • Kehlet H.
        CON: Perioperative goal-directed fluid therapy is an essential element of an enhanced recovery protocol?.
        Anesth Analg. 2016; 122: 1261-1263