Enhanced recovery after surgery protocol in patients undergoing esophagectomy for cancer: a single center experience

Abstract

This article is about an emerging issue in esophageal surgery: enhanced recovery after surgery (ERAS) Few data are published in literature and its safety and feasibility is still debated. The focus of our paper is on the feasibility of an ERAS protocol for esophagectomy (including both the Ivor-Lewis and McKeown procedure) in a high volume center comparing to a standard perioperative protocol. We introduced a novelty item on this type of surgery: resume of oral feeding in the first postoperative day. We analyzed the dropout rate for each item and the postoperative morbidity. We studied 39 patients operated in the Upper GI division of Verona University Hospital between January 2013 and August 2014; 22 patients (ERAS group) were studied in a perspective way while 17 patients (standard group) were studied retrospectively. The enhanced recovery protocol included intraoperative fluid management, time of extubation after surgery, intensive care unit discharge, drains and nasogastric tube management, mobilization of the patient, oral food intake. We compared the results between the two groups in term of hospital stay, postoperative morbidity and mortality. We also calculated the percentage completion of the protocol, evaluating patient drop-out rates for each of the items. Patients showed an improvement in the ERAS group in terms of earlier extubation, earlier intensive care unit discharge (p < 0.01), earlier thoracic drain, urinary catheter (p < 0.01) and nasogastric tube removal (p = 0.02), earlier mobilization (p < 0.01), and resume of oral feeding (p < 0.01). Median length of hospital stays in the ERAS group was 9 days while in the standard group was 10 days (p = 0.23). Postoperative morbidity and mortality were comparable between the two groups. This study shows the feasibility and safety of an ERAS protocol for esophageal surgery in a high-volume center. These data strengthen the literature results on this argument calling for larger sample size studies.

Surgical treatment of esophageal cancer in the era of multimodality management

“…171 Previous studies suggested that it may be safe to allow clear liquids from postoperative day 1, 172 but feeding protocols vary widely. 173,174 Currently, a random-ized trial comparing early versus delayed start of oral intake after minimally invasive and hybrid esophagectomy is in its inclusion phase (i.e., the NUTRIENT II trial). 175 The results of this study are expected to provide more clarity regarding the role of early oral intake in the context of enhanced recovery after esophagectomy.…”

“…However, esophagectomy is somewhat unique owing to the construction of a gastric conduit and a necessary vagotomy, which leads to delayed gastric emptying in 10–15% of patients . Previous studies suggested that it may be safe to allow clear liquids from postoperative day 1, but feeding protocols vary widely . Currently, a randomized trial comparing early versus delayed start of oral intake after minimally invasive and hybrid esophagectomy is in its inclusion phase (i.e., the NUTRIENT II trial) .…”

Nutritional aspects of enhanced recovery after esophagectomy with gastric conduit reconstruction

“…To date, no clear evidence for superiority of either feeding route exists and, hence, both techniques are used . For patients that have resumed oral intake but cannot yet meet their caloric and protein demands, enteral feeding can be provided as a supplement to the patients oral diet . The most recent ESPEN “Clinical Nutrition in Surgery” guidelines recommend early initiation of enteral tube feeding in case patients cannot eat for at least 5 days or when oral intake is expected to be inadequate (ie, <50%) for more than 7 days .…”

“…66,69 For patients that have resumed oral intake but cannot yet meet their caloric and protein demands, enteral feeding can be provided as a supplement to the patients oral diet. 14,65,70,71 The most recent ESPEN "Clinical Nutrition in Surgery" guidelines recommend early initiation of enteral tube feeding in case patients cannot eat for at least 5 days or when oral intake is expected to be inadequate (ie, <50%) for more than 7 days. 36 However, even when the nutritional demands are met, tube feeding may not prevent weight loss after esophagectomy.…”

“…72 However, evidence for the optimal timing of oral intake is lacking and, consequently, widely varying feeding protocols are practiced after esophagectomy. In recent literature, some studies reported successful initiation of a clear liquid diet on postoperative day 1, 70,71 while others adhered to a nil by mouth regimen for up to 7 days after surgery. 65,73 A prospective multicenter trial suggested that the immediate start of oral liquid intake after esophagectomy is feasible and safe in terms of complications.…”