Association between intraoperative hypotension and adverse clinical outcomes after esophagectomy for esophageal cancer: retrospective observational study

BACKGROUND: Esophagectomy for esophageal cancer is complex and frequently complicated by pulmonary issues, cardiac problems, and anastomotic leakage. While numerous factors contribute to these complications, the specific effects of intraoperative hypotension (IOH) on postoperative outcomes remain poorly understood. This study examined the relationship between IOH severity during esophagectomy and subsequent complications. METHODS: This retrospective observational study analyzed patients undergoing elective open transthoracic or thoraco-laparoscopic esophagectomy for esophageal cancer between May 2007 and February 2020. Multiple logistic regression assessed IOH's association with primary outcomes (composite of major complications including 30-day mortality, reoperation, anastomotic leakage, pneumonia, reintubation, and prolonged ventilation > 48 h) and secondary outcomes of anastomotic leakage. Additionally, Cox regression analyzed IOH's impact on long-term prognosis. RESULTS: The final cohort comprised 884 patients. The most prevalent postoperative complications were anastomotic leakage (25.2%) and pneumonia (23.4%). The 30-day mortality rate was 0.8%. No significant association existed between IOH and major composite outcomes across mean blood pressure (MBP) and systolic blood pressure thresholds. However, IOH was significantly associated with anastomotic leakage when MBP fell below 65 mmHg for extended periods (adjusted odds ratio: 1.02 per 10-min interval, 95% confidence interval: 1.01-1.04, P = 0.01). IOH did not significantly affect long-term survival. CONCLUSIONS: This study did not identify a significant association between intraoperative hypotension and composite major postoperative complications or long-term survival outcomes. However, intraoperative hypotension, specifically prolonged episodes with mean blood pressure below 65 mmHg, was significantly associated with the short-term complication of anastomotic leakage. TRIAL REGISTRATION: UMIN Clinical Trials Registry, UMIN000040455. Registered 28 May 2020, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000046165 .