Rohin, Mittal (2008) Evaluation of the Effect of Elective Tracheostomy on Morbidity and Mortality following Oesophageal Surgery with Neck Anastomosis. Masters thesis, Christian Medical College, Vellore.
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Abstract
INTRODUCTION: Oesophageal surgery involves a major surgical and physiological insult to the body with associated significant morbidity and mortality. Oesophageal surgery remains a demanding surgical procedure for surgeons who deal with benign and malignant disease of oesophagus. Significant advances in perioperative and postoperative care have occurred in the past decade. However mortality and morbidity rates associated with oesophagectomy worldwide remain high. Major contributors to the mortality and morbidity are post operative pulmonary complications. Pulmonary complications remain the most common complications that develop after oesophageal surgery. The incidence of pulmonary complications has been reported to vary from 17% to 45% in published literature. These account for up to 50% of the hospital deaths in patients undergoing oesophagectomy. 20% of patients who undergo oesophageal surgery require prolonged ventilatory support and undergo tracheostomy in the intensive care setting. The role of early tracheostomy in critically ill patients has been extensively studied6. Recent literature has shown that an early tracheostomy in the intensive care setting, for patients requiring prolonged ventilation, reduces the duration of ventilation, duration of ICU stay and mortality. The timing of tracheostomy is still a matter of debate, but clearly there is a definite trend that the earlier tracheostomy is associated with better outcome in terms of morbidity and mortality. Elective tracheostomy for patients undergoing major oesophageal surgery has not been studied so far, though some centers have been using the same in a few patients. This study aims at evaluating the effect of tracheostomy performed at the time of primary operation, in reducing pulmonary complications and improving outcomes after major oesophageal surgery. AIMS AND OBJECTIVES: To evaluate the effect of elective tracheostomy on morbidity and mortality following oesophageal surgery with neck anastomosis. METHODOLOGY: This study aimed at assessing the role of an elective tracheostomy in reduction of mortality and morbidity due to pulmonary complications in patients undergoing oesophageal surgery with neck anastomosis. Design of Study: Case control study with a prospective cohort of cases and a retrospective cohort of controls. Selection Criteria: Patients for the study were selected according to a set of inclusion and exclusion criteria. They were as follows: Inclusion criteria: All patients undergoing oesophageal resection or bypass with a cervical oesophageal anastomosis.i.e. 1. Substernal Colon Bypass for corrosive stricture oesophagus. 2. Mc Keowns oesophagectomy for benign or malignant oesophageal lesions. 3. Transhiatal oesophagectomy for oesophageal malignancies or benign oesophageal disease. Exclusion criteria: 1. Patients undergoing laryngectomy. 2. Non consenting patients. 3. Patients found inoperable at surgery. Duration of the Study: The study extended from May 2005 to April 2007 (2 years) A retrospective cohort of controls was used. Controls were chosen using the same inclusion criteria over a period of May 2002 to April 2005 (3 years). METHODOLOGY: A review of all patients who confirmed to the inclusion criteria was done for the year 2004. The incidence of pulmonary complications among these patients was found to be 65%. 30% of these patients required prolonged ventilation and hence a tracheostomy. Aspiration pneumonia was the most common pulmonary complication (73 %) and was responsible for 50 % of the hospital deaths. Based on this data, the sample size was calculated to be 22. Sample size = 4pq/d^2. Where, p = incidence of pulmonary complications (65%), q = 1-p (35%), d = expected difference in outcome (=20%). After the detailed research plan was laid down, approval was obtained from the Department of Upper Gastrointestinal Surgery unit and the fluid research committee. All patients fitting into the inclusion criteria were included in the study. Informed consent was taken prior to inclusion in the study. (Appendix 2). All the include patients underwent an elective open surgical tracheostomy at the end of surgery. They were then transferred to the surgical intensive care unit for further monitoring and ventilation if required. No changes were made in the surgical intensive care protocols for monitoring these patients. Number of cases enrolled: There were a total of 56 patients enrolled for the study. These included 14 cases and 42 controls. This included patients undergoing transhiatal or transthoracic oesphagectomy and substernal colon pullthrough. Patients who had undergone similar operations during the last 3 years were included in the control group. CONCLUSION: Prevention of pulmonary complications is the cornerstone to reduction of morbidity and mortality in oesophageal surgery. This study reveals that if tracheostomy is done at the time of primary operation, there is a trend that the patients are weaned off the ventilator earlier and a shorter ICU stay. Also there is a trend that these patients are discharged earlier from hospital. Although these differences did not reach stastical significance, there was a definite trend in the reduction of morbidity and mortality. This has clinical implications, especially with regard to ARDS and aspiration pneumonia. The small sample size and the absence of randomization in this study need to be kept in mind. It has also been shown that a tracheostomy by itself is associated with minimal morbidity and is tolerated well by the patient. With the above findings in mind, there is a strong case for a prospective randomized case control trial for evaluating elective tracheostomy as a strategy to reduce morbidity and mortality in patients undergoing oesophageal surgery.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Elective Tracheostomy ; Morbidity and Mortality ; Oesophageal Surgery ; Neck Anastomosis. |
| Subjects: | MEDICAL > General Surgery |
| Depositing User: | Devi S |
| Date Deposited: | 04 May 2018 03:09 |
| Last Modified: | 04 May 2018 03:09 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/7424 |
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