Systematic review of enhanced recovery after gastro-oesophageal cancer surgery

Abstract

INTRODUCTION Fast track methodology or enhanced recovery schemes have gained increasing popularity in perioperative care. While evidence is strong for colorectal surgery, its importance in gastric and oesophageal surgery has yet to be established. This article reviews the evidence of enhanced recovery schemes on outcome for this type of surgery. METHODS A systematic literature search was conducted up to March 2014. Studies were retrieved and analysed using predetermined criteria. RESULTS From 34 articles reviewed, 18 eligible studies were identified: 7 on gastric and 11 on oesophageal resection. Three randomised controlled trials, five case-controlled studies and ten case series were identified. The reported protocols included changes to each stage of the patient journey from pre to postoperative care. The specific focus following oesophageal resections was on early mobilisation, a reduction in intensive care unit stay, early drain removal and early (or no) contrast swallow studies. Following gastric resections, the emphasis was on reducing epidural anaesthesia along with re-establishing oral intake in the first three postoperative days and early removal of nasogastric tubes. In the papers reviewed, mortality rates following fast track surgery were 0.8% (9/1,075) for oesophageal resection and 0% (0/329) for gastric resection. The reported morbidity rate was 16.5% (54/329) following gastric resection and 38.6% (396/1,075) following oesophageal resection. Length of stay was reduced in both groups compared with conventional recovery groups in comparative studies. CONCLUSIONS The evidence for enhanced recovery schemes following gastric and oesophageal resection is weak, with only three (low volume) published randomised controlled trials. However, the enhanced recovery approach appears safe and may be associated with a reduction in length of stay.

Postoperative fluid overload is a risk factor for adverse surgical outcome in patients undergoing esophagectomy for esophageal cancer: a retrospective study in 335 patients

“…However, these results are consistent with perioperative outcome described in the recent literature [13–15]. Our data suggest that intra- and postoperative fluid restriction is associated with an improved perioperative outcome, matching the results of several investigations from the field of pancreatic and colorectal surgery [3].…”

Enhanced recovery after surgery protocol in oesophageal cancer surgery: Systematic review and meta-analysis

“…The number of studies with control groups regarding the application of ERAS protocol in oesophageal surgery is limited. In our literature research we came upon only one systematic review by Gemmill et al, published in 2015 [28]. This review included 11 studies, none of which was a RCT, with no subsequent meta-analysis, thus the quality of evidence was rather limited.…”

Poorly Differentiated Medullary Phenotype Predicts Poor Survival in Early Lymph Node-Negative Gastro-Esophageal Adenocarcinomas

“…The large German gastric cancer trial showed in about 250 patients recruited from 1986–1989 a 5-year overall survival depending on the number of resected lymph nodes from 81%-85% in T1N0 stages to 67% in T2N0 stages [6]. These differences in survival are probably attributable to increased surgical quality in the last decades and the decreased postoperative 30 day mortality rate (mean 30 day mortality rate of 0.8% in 18 trials between 1998–2014 [45] compared to the German gastric cancer trial with 5.2% [3]).…”