Volatile versus intravenous anaesthesia for oesophagectomy: addressing confounding factors and temporal trends in clinical practice

Correspondence to: Shuting Yin (e-mail: yin13938214200@163.com)

Department of Education and Sports

Zhengdong New District

Zhengzhou

China

BJS, https://doi.org/10.1093/bjs/znaf052, published 01 April 2025

The recent study by Hirano et al.1 comparing desflurane, sevoflurane, and propofol anaesthesia for respiratory outcomes after oesophagectomy provides valuable clinical insights, but several methodological limitations warrant discussion.

The significant temporal trends in anaesthetic practice during the study (2012-2022) are a critical confounding factor. Desflurane usage increased remarkably from 11.1% to 52.5%, while sevoflurane and propofol use declined from 64.7% to 35.3% and 24.2% to 12.2%, respectively. This evolution coincided with the adoption of minimally invasive surgical techniques, optimized perioperative management, and implementation of early extubation strategies, making it difficult to attribute the observed benefits entirely to the pharmacological properties of desflurane.

Although the authors employed propensity score-matching and instrumental variable analysis to adjust for potential confounders, unmeasured clinical parameters (such as detailed pulmonary function indices, cardiac status, and tumour burden) may still have influenced outcomes. Furthermore, the absence of data regarding anaesthetic monitoring, drug dosages, and specific ventilation parameters limits the understanding of dose-response relationships. The study also lacks subgroup analyses for high-risk populations (such as elderly patients or those with chronic pulmonary disease), restricting the individualized application of findings.

We suggest that future research employs RCT design to minimize these limitations, ideally with standard perioperative protocols and detailed risk-stratified analyses. Until then, clinicians should fully consider these methodological constraints when interpreting the reported advantages of desflurane for oesophagectomy.