Postoperative sublingual microvascular blood flow following esophagectomy and the effect of dobutamine

Typical complications of esophagectomy and gastric tube reconstruction
include leakage and stenosis from the anastomosis of the neck, which may be due
to the compromises microvascular blood flow (MBF). Recently Jhanji et al.
showed that MBF can be of predictive value for the postoperative course: those
with a disturbed postoperative microvascular perfusion have more postoperative
complications. In another study a similar predictive phenomenon was seen in
patients with septic shock. The patients who ultimately died from the shock,
had a worse microcirculation in the first 24 hours, than those who survived the
shock. Administration of dobutamine in these patients improved the
microvascular perfusion, independent of global hemodynamic parameters. It is
therefore important to investigate how the postoperative microcirculation
behaves in patients undergoing esophagectomy with gastric tube reconstruction,
and if this can positively be influenced by giving a low dose dobutamine.

- Primary Objective: to investigate whether the administration of a small
amount of dobutamine postoperatively is able to positively influence the
sublingual microcirculation in patients who are undergoing esophagectomy.

- Secondary Objective: to observe what effect postoperative administration of
dobutamine has on cardiac output, postoperative morbidity, IC- and hospital
stay

This study is designed as a prospective double blind randomized controlled
trial.

Patients who are undergoing an esophagectomy with gastric tube reconstrucion
are randomised in 2 groups; patients with and without intravenous
administration of low dose dobutamine during the first 2 postoperative days.

The microvascular perfusion is observed in all patients by placing a small
handheld camera, SDF-camera gently under the tongue. This Sidestream Dark Field
(SDF) imager is a new and more improved method to observe the subliungual
microcirculation at bedside, see page 12 of the protocol for more explanation.
The observation is not painful or invasive. By placing the camera at the mucosa
under the tongue a good image can be made of the microvascular perfusion. This
measurement takes place once a day for a total of 4 days. Each measurement
approximately takes 25-30 min. Patients who are classified in the intervention
group will immediately be connected to a postoperative intravenous dobutamine
pump. This will remain connected to 2 days postoperatively. This represents no
additional burden for the patient because the patient won*t notice anything due
to the anesthesia of the. No additional lines have to be punctured.

A side effect of dobutamine is that it can cause tachycardia. The chance of
this is however very small, because the dose used in this study is at most half
of the normally effective dose used in the IC. In addition, the administration
can immediately be stopped with a half life time of 2 min. In previous studies
with dobutamine good results are seen in the sublingual microvascular
perfusion. Therefore we expect a good improvement of the microvascular
perfusion.