Impact of standardized clinical pathways on esophagectomy: a systematic review and meta-analysis

Abstract

Summary Esophageal surgery is historically associated with adverse postoperative outcomes. Selected high-volume centers have previously reported the effect on clinical outcomes following the adoption of a standardized clinical pathway (SCP). This meta-analysis aims to evaluate the current literature to document the effect of SCP and enhanced recovery after surgery (ERAS) on esophagectomy outcomes. A literature search was conducted through the main search engines (PubMed, Embase, Medline, and Cochrane database) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All eligible comparative studies (randomized control trial, prospective, retrospective, and combined) were identified and assessed based on Methodological Index for Non-Randomized Studies and Jadad quality criteria. Data concerning overall morbidity, early mortality, and length of stay (LOS) were primarily collected and compared. Secondary outcomes included anastomotic leaks, pulmonary complications, and readmission rate. Twenty-six articles (including five randomized controlled trials and six prospective trials) were included in the analysis. Overall study quality was moderate and the included studies utilized a variable approach to SCP. No statistically significant differences were found between groups in terms of overall morbidity, postoperative mortality, anastomotic leak, and readmission rates. Significant improvements included pulmonary complications (odds ratios [OR] 0.66, 95% confidence interval [CI] 0.49–0.94) and hospital LOS (OR −3.68, 95% CI −4.49 to −2.87). Previous reports of SCP within esophagectomy programs have demonstrated clinical improvements in postoperative pulmonary complications and LOS. Given the high heterogeneity historically demonstrated within SCPs, further improvement in outcomes should be expected following the adoption of standardized ERAS guidelines.

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

“…Firstly, due to the study design, the hospital length of stay could be subjective and influenced by an individual surgeon’s perspective. Secondly, we did not examine how each pathway contributed to acceleration of recovery; therefore, a standardized ERAS pathway in esophagectomy would be required in future studies [ 43 ]. Thirdly, this study did not evaluate the long-term effect of ERAS on esophageal cancer patients.…”

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

“…A recent systematic review and meta-analysis (26 articles; 5 RCT and 6 prospective trials) has assessed the collective reported experience with standardized clinical pathways before the introduction of the esophagectomy-specific ERAS consensus guidelines [11]. This meta-analysis confirmed significant improvements in pulmonary complication (34% reduction) and hospital LOSalthough no difference in overall morbidity, post-operative mortality or readmission rates was identified (Table 1).…”

“…This meta-analysis confirmed significant improvements in pulmonary complication (34% reduction) and hospital LOSalthough no difference in overall morbidity, post-operative mortality or readmission rates was identified (Table 1). However, from the analysis of the studies included in this publication, it is clear that there is a great variability of protocols and only few ERAS elements such as the use of epidural analgesia, jejunostomy placement, start enteral feeds and mobilization ≤ 1 day, start soft solid diet ≤ 4 day and chest tube removal ≤ 5 day were widely utilized (> 50% of the studies) [11].…”

“…Although some authors have shown the importance of the adherence of specific factors of the ERAS protocol toachievegood results, there is increasing evidence that the greatest benefits are obtained by the aggregation of marginal gains due to the adherence of the entire pathways [24]. In this setting, it is important that all team participants should be convinced that ERAS goals are a critical component of patient-centered care to improve outcomes and reduce costs [11,12].…”

“…Over the last decade, systematic reviews and meta-analysis have confirmed that ERAS programs reduce consistently pulmonary complications and hospital stay after esophagectomy without increasing readmissions [9,10,11]. However, it has become clear over the years that there has been absence of standardization and wide heterogeneity in the number and definition of the ERAS components.…”