Enhanced Recovery After Surgery (ERAS) Pathway in Esophagectomy

Parise, Paolo; Ferrari, C.; Cossu, Andrea; Puccetti, Francesco; Elmore, Ugo; Pascale, Stefano De; Garutti, Leonardo; Fumagalli, Uberto; Serio, Mariaclelia Stefania Di; Rosati, Riccardo

doi:10.1097/sla.0000000000002775

Cited by 29 publications

(10 citation statements)

References 32 publications

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“…There are many reasons for a delayed recovery after surgical resection of esophageal cancer. In a recent study, Parise et al [25] reported that prolonged stay after esophagectomy was associated with both the patient clinical characteristics (ASA score > 3, failure of postoperative mobilization) and factors related to the operation (surgery duration > 255 min and "non-hybrid esophagectomy"). Therefore, an optimal ERAS protocol should include a wide spectrum of perioperative elements.…”

Section: Discussionmentioning

confidence: 99%

The effect of enhanced recovery after minimally invasive esophagectomy: a randomized controlled trial

et al. 2022

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Background The purpose of this randomized controlled trial was to determine if enhanced recovery after surgery (ERAS) would improve outcomes for three-stage minimally invasive esophagectomy (MIE). Methods Patients with esophageal cancer undergoing MIE between March 2016 and August 2018 were consecutively enrolled, and were randomly divided into 2 groups: ERAS+group that received a guideline-based ERAS protocol, and ERAS- group that received standard care. The primary endpoint was morbidity after MIE. The secondary endpoints were the length of stay (LOS) and time to ambulation after the surgery. The perioperative results including the Surgical Apgar Score (SAS) and Visualized Analgesia Score (VAS) were also collected and compared. Results A total of 60 patients in the ERAS+ group and 58 patients in the ERAS- group were included. Postoperatively, lower morbidity and pulmonary complication rate were recorded in the ERAS+ group (33.3% vs. 51.7%; p = 0.04, 16.7% vs. 32.8%; p = 0.04), while the incidence of anastomotic leakage remained comparable (11.7% vs. 15.5%; p = 0.54). There was an earlier ambulation (3 [2–3] days vs. 3 [3–4] days, p = 0.001), but comparable LOS (10 [9–11.25] days vs. 10 [9–13] days; p = 0.165) recorded in ERAS+ group. The ERAS protocol led to close scores in both SAS (7.80 ± 1.03 vs. 8.07 ± 0.89, p = 0.21) and VAS (1.74 ± 0.85 vs. 1.78 ± 1.06, p = 0.84). Conclusions Implementation of an ERAS protocol for patients undergoing MIE resulted in earlier ambulation and lower pulmonary complications, without a change in anastomotic leakage or length of hospital stay. Further studies on minimizing leakage should be addressed in ERAS for MIE.

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Section: Discussionmentioning

confidence: 99%

The effect of enhanced recovery after minimally invasive esophagectomy: a randomized controlled trial

et al. 2022

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“…It has been shown that the application of Enhanced Recovery after Surgery (ERAS) programs for esophagectomy is associated with favorable overall morbidity and mortality, and reduced hospital length of stay [35–40]. However, the methodological quality of these studies is limited [41–42]. Identifying a clinically relevant CRP cut-off may be a helpful adjunct to the fast-track pathways by providing an early alert for leakage, selecting patients for diagnostic studies, and tailoring the therapeutic interventions.…”

Section: Discussionmentioning

confidence: 99%

Use of C-reactive protein for the early prediction of anastomotic leak after esophagectomy: Systematic review and Bayesian meta-analysis

et al. 2018

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BackgroundEarly suspicion, diagnosis, and timely treatment of anastomotic leak after esophagectomy is essential. Retrospective studies have investigated the role of C-reactive protein (CRP) as early marker of anastomotic leakage. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP after esophageal resection.MethodsA literature search was conducted to identify all reports including serial postoperative CRP measurements to predict anastomotic leakage after elective open or minimally invasive esophagectomy. Fully Bayesian meta-analysis was carried out using random-effects model for pooling diagnostic accuracy measures along with CRP cut-off values at different postoperative day.ResultsFive studies published between 2012 and 2018 met the inclusion criteria. Overall, 850 patients were included. Ivor-Lewis esophagectomy was the most common surgical procedure (72.3%) and half of the patients had squamous-cell carcinoma (50.4%). The estimated pooled prevalence of anastomotic leak was 11% (95% CI = 8–14%). The serum CRP level on POD3 and POD5 had comparable diagnostic accuracy with a pooled area under the curve of 0.80 (95% CIs 0.77–0.92) and 0.83 (95% CIs 0.61–0.96), respectively. The derived pooled CRP cut-off values were 17.6 mg/dl on POD 3 and 13.2 mg/dl on POD 5; the negative likelihood ratio were 0.35 (95% CIs 0.096–0.62) and 0.195 (95% CIs 0.04–0.52).ConclusionAfter esophagectomy, a CRP value lower than 17.6 mg/dl on POD3 and 13.2 mg/dl on POD5 combined with reassuring clinical and radiological signs may be useful to rule-out leakage. In the context of ERAS protocols, this may help to avoid contrast radiological studies, anticipate oral feeding, accelerate hospital discharge, and reduce costs.

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“…However, as this was the first time that LGE was implemented occurred at the beginning of the learning, the operation duration was still close to that of existing esophagectomy approaches 4 . In a recent study by Parise et al, 9 a surgical duration of over 255 minutes predicted operative morbidity and prolonged postoperative length of stay. Hence, LGE may result in better surgical outcomes as the operation time shortens as more experience with the procedure is gained.…”

Section: Commentsmentioning

confidence: 72%

“…Transmediastinal esophagectomy obviates the need for entry into the pleural cavity 8 but only provides a narrow working space for multiple surgical instruments 4 . Expansion of the surgical field, which aims to reduce instrumental collision and improve visualization within the mediastinum, can be realized by the introduction of an artificial pneumomediastinum 9 . However, CO 2 insufflation into the mediastinum may also lead to hemodynamic instability and therefore add potential risks to cardiopulmonary complications 5 …”

Section: Commentsmentioning

confidence: 99%

Advancing Gastroscope From Intraluminal to Extraluminal Dissection: Primary Experience of Laparo-gastroscopic Esophagectomy

Shen

Zhang

et al. 2021

Annals of Surgery

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Transhiatal esophagectomy facilitates esophageal resection without the need for thoracotomy. However, this procedure carries the risks of blind and blunt dissection within the mediastinum. More recently, video-assisted or mediastinoscopic transhiatal esophagectomy was introduced to mobilize the esophagus under direct visualization. Even though, the procedure is technically demanding and animal studies have shown that the CO 2 pneumomediastinum may be associated with hemodynamic instability. By further developing already established techniques, we pioneered the transhiatal esophageal mobilization by using hybrid gastroscope (Fig. 1 ). Laparo-gastroscopic esophagectomy, which integrates gastroscope and laparoscope for esophageal mobilization, was successfully implemented on an esophageal cancer patient with a history of lung cancer surgery. The operative duration was 240 minutes with an estimated blood loss of 110 mL. The patient experienced an uneventful recovery and was discharged on postoperative day 9. Further studies will be required to confirm the surgical and oncological efficacy of this innovation.

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Enhanced Recovery After Surgery (ERAS) Pathway in Esophagectomy

Abstract: The results of this study seem to be clinically meaningful and in line with those from other studies. The initial validation revealed good predictive properties.

Cited by 29 publications

References 32 publications

The effect of enhanced recovery after minimally invasive esophagectomy: a randomized controlled trial

The effect of enhanced recovery after minimally invasive esophagectomy: a randomized controlled trial

Use of C-reactive protein for the early prediction of anastomotic leak after esophagectomy: Systematic review and Bayesian meta-analysis

Advancing Gastroscope From Intraluminal to Extraluminal Dissection: Primary Experience of Laparo-gastroscopic Esophagectomy

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