Protective Ventilation Influences Systemic Inflammation after Esophagectomy

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)-1beta, IL-6, IL-8, and tumor necrosis factor alpha were measured perioperatively and postoperatively. Pulmonary function and postoperative evolution were also evaluated. Patients who received protective strategy had lower blood levels of IL-1beta, 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.