Crystalloid volume versus catecholamines for management of hemorrhagic shock during esophagectomy - assessment of microcirculatory tissue oxygenation of the gastric conduit in a porcine model using hyperspectral imaging - an experimental study

A Studier-Fischer; B Özdemir; M Rees; L Ayala; S Seidlitz; J Sellner; K F Kowalewski; C M Haney; J Odenthal; S Knödler; M Dietrich; D Gruneberg; T Brenner; K Schmidt; F C F Schmitt; M A Weigand; G A Salg; A Dupree; H Nienhüser; A Mehrabi; T Hackert; B P Müller; L Maier-Hein; F Nickel

doi:10.1097/JS9.0000000000001849

Crystalloid volume versus catecholamines for management of hemorrhagic shock during esophagectomy - assessment of microcirculatory tissue oxygenation of the gastric conduit in a porcine model using hyperspectral imaging - an experimental study

Int J Surg. 2024 Jul 8;110(10):6558-6572. doi: 10.1097/JS9.0000000000001849. Online ahead of print.

Authors

A Studier-Fischer^{1

2

3

4}, B Özdemir^{1

3

4}, M Rees^{5

6}, L Ayala⁵, S Seidlitz^{5

6

7}, J Sellner^{5

7}, K F Kowalewski^{2

3

4}, C M Haney^{2

3

4}, J Odenthal¹, S Knödler¹, M Dietrich⁸, D Gruneberg⁸, T Brenner⁹, K Schmidt⁹, F C F Schmitt⁸, M A Weigand⁸, G A Salg¹, A Dupree¹⁰, H Nienhüser¹, A Mehrabi¹, T Hackert¹⁰, B P Müller¹¹, L Maier-Hein^{5

6

7

12}, F Nickel^{1

7

10}

Affiliations

¹ Department of General, Visceral, and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
² Department of Urology and Urosurgery, University Medical Center Mannheim, Medical Faculty of the University of Heidelberg, Mannheim, Germany.
³ German Cancer Research Center (DKFZ) Heidelberg, Division of Intelligent Systems and Robotics in Urology (ISRU), Heidelberg, Germany.
⁴ DKFZ Hector Cancer Institute at the University Medical Center Mannheim, Mannheim, Germany.
⁵ German Cancer Research Center (DKFZ) Heidelberg, Division of Intelligent Medical Systems, Heidelberg, Germany.
⁶ Faculty of Mathematics and Computer Science, Heidelberg University, Heidelberg, Germany.
⁷ HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany.
⁸ Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany.
⁹ Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany.
¹⁰ Department of General, Visceral and Thoracic Surgery, University Medical Center, Hamburg-Eppendorf, Hamburg, Germany.
¹¹ Department of Digestive Surgery, University Digestive Healthcare Center Basel, Switzerland.
¹² National Center for Tumor Diseases (NCT), NCT Heidelberg, a partnership between DKFZ and University Hospital Heidelberg, Heidelberg, Germany.

Abstract

Introduction: Oncologic esophagectomy is a two-cavity procedure with considerable morbidity and mortality. Complex anatomy and the proximity to major vessels constitute a risk for massive intraoperative hemorrhage. Currently, there is no conclusive consensus on the ideal anesthesiologic countermeasure in case of such immense blood loss. The objective of this work was to identify the most promising anesthesiologic management in case of intraoperative hemorrhage with regards to tissue perfusion of the gastric conduit during esophagectomy using hyperspectral imaging (HSI).

Material and methods: An established live porcine model (n=32) for esophagectomy was used with gastric conduit formation and simulation of a linear stapled side-to-side esophagogastrostomy. After a standardized procedure of controlled blood loss of about 1 L per pig, the four experimental groups (n=8 each) differed in anesthesiologic intervention i.e. (I) permissive hypotension, (II) catecholamine therapy using noradrenaline, (III) crystalloid volume supplementation and (IV) combined crystalloid volume supplementation with noradrenaline therapy. HSI tissue oxygenation (StO2) of the gastric conduit was evaluated and correlated with systemic perfusion parameters. Measurements were conducted before (T0) and after (T1) laparotomy, after hemorrhage (T2) and 60 minutes (T3) and 120 minutes (T4) after anesthesiologic intervention.

Results: StO2 values of the gastric conduit showed significantly different results between the four experimental groups with 63.3% (±7.6%) after permissive hypotension (I), 45.9% (±6.4%) after catecholamine therapy (II), 70.5% (±6.1%) after crystalloid volume supplementation (III) and 69.0% (±3.7%) after combined therapy (IV). StO2 values correlated strongly with systemic lactate values (r=-0.67; CI -0.77 to -0.54), which is an established prognostic factor.

Conclusion: Crystalloid volume supplementation (III) yields the highest StO2 values and lowest systemic lactate values and therefore appears to be the superior primary treatment strategy after hemorrhage during esophagectomy with regards to microcirculatory tissue oxygenation of the gastric conduit.