Glycocalyx-Shedding and Inflammatory Reactions Occur Yet Do Not Predict Complications Resulting from an Esophagectomy in an Accelerated Recovery After Surgery Program

Abstract

Background/Objectives: "Accelerated Recovery after Surgery" (ARAS) programs for esophagectomy aim to shorten the perioperative course without increases in morbidity or mortality. In such programs, the prediction and early detection of perioperative complications is essential, as ICU observation times are limited. We evaluated two potential laboratory markers as predictors for postoperative complications: shedding of the endothelial glycocalyx and the veno-arterial CO₂-gap as indicators of microcirculatory disturbances. Methods: In total, 26 patients undergoing hybrid Ivor Lewis esophagectomy within an ARAS program were included. Macrocirculatory conditions were kept stable by enhanced hemodynamic monitoring (PiCCO). Glycocalyx shedding parameters (Syndecan-1, heparan sulfate, hyaluronic acid) and a panel of inflammatory mediators were measured preoperatively, upon ICU-admission, and on the first postoperative day. The veno-arterial CO₂-gap was calculated at induction of anesthesia, during laparoscopy, and upon admission to the ICU. Results: Complications (Dindo-Clavien ≥3) occurred in n = 16 (62%) patients. From preoperatively to admission to the ICU, Syndecan-1 (29 pre-op to 56 ng/mL at ICU-admission) and Interleukins 1b (1.2 to 1.4 pg/mL), 6 (1.3 to 19.9 pg/mL), 8 (5.2 to 19.9 pg/mL), and 10 (0.50 to 1.33 pg/mL) increased, indicating a temporary increase in inflammation and glycocalyx shedding during surgery. A difference between patients with or without complications could not be detected. There was also no difference in the veno-arterial CO₂-gap between the two groups (median of 6.8 mmHg in all patients, 6.7 in patients with complications, 7.8 in patients without complications). Conclusions: Signs of microcirculatory dysfunctions and inflammation occurred during esophagectomy within an ARAS protocol with tightly controlled hemodynamics. Increases in Syndecan-1 and the veno-arterial CO₂-gap could not predict perioperative complications.

Keywords: CO2-gap; Interleukins; endothelial glycocalyx; enhanced recovery after surgery; esophageal cancer; esophagectomy; perioperative complications.

Figure 1

Levels of the glycocalyx components heparan sulfate, syndecan-1, and hyaluronic acid in blood serum. (A): values of the entire study population. (B): values separated according to complication status. Box plot, Tukey method. Dots represent outliers above the 75th percentile plus 1.5 interquartile ranges in the Tukey method.

Figure 2

Veno-arterial CO2-gap in patients with or without complications. Box plot, Tukey method. Dots represent outliers above the 75th percentile plus 1.5 interquartile ranges in the Tukey method.