Intraoperative Hemodynamic Management During Esophagectomy and Implications for Postoperative Care

BACKGROUND: Esophagectomy remains a high-morbidity operation despite advances in perioperative care. The relationship between intraoperative hemodynamic management and postoperative complications remains undefined. This study explores real-time hemodynamic management patterns and postoperative complications after esophagectomy. STUDY DESIGN: Using a paired anesthesia and surgical registry, patients undergoing elective esophagectomy at a single high-volume institution between 2015 and 2023 were analyzed. Patients were categorized by fluid-restrictive or fluid-liberal intraoperative volume strategies and vasopressor-low or vasopressor-high strategies based on cumulative dose required during the case. Additionally, anesthesiologists were characterized similarly according to their relative average fluid and vasopressor administrations. Adjusted rates of select and composite postoperative complications were compared by fluid and vasopressor strategies using multivariable logistic regression. RESULTS: Of 639 patients, 296 (46.3%) received a fluid-restrictive strategy and 343 (53.7%) received a fluid-liberal strategy. Three hundred nineteen patients (49.9%) occupied the vasopressor-low category, whereas 320 (50.1%) were in the vasopressor-high category. Across the cohort, the unadjusted leak rate was 23.2%, pneumonia 10.6%, and atrial fibrillation 32.3%. There were no significant differences in adjusted rates of complications between fluid and vasopressor groups. Patients managed by fluid-liberal anesthesiologists had higher adjusted rates of atrial fibrillation (19.6% vs 27.2%, odds ratio 1.60 [1.00 to 2.57], p = 0.049). CONCLUSIONS: Hemodynamic management during esophagectomy is variable. Intraoperative volume balance or vasopressor administration may not be associated with differential complication rates; however, further analysis is warranted. This may inform postoperative management by identifying at-risk patients for complications, thereby individualizing treatment decision-making.