The effect of formalizing enhanced recovery after esophagectomy with a protocol

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

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.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

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

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.

Nasogastric tube utilization after esophagectomy: an unnecessary gesture?

INTRODUCTION

Nasogastric decompressive tube utilization has been accepted as one of the basic perioperative care measures after esophageal resection surgery. However, with the development of multimodal rehabilitation programs and without clear evidence to support their use, the systematic indication of this measure may be controversial.

MATERIAL AND METHODS

Retrospective, descriptive and comparative study of patients who had undergone Ivor-Lewis esophagectomy in our center -from January 2015 to December 2018- with placement (Group S), or without placement (Group N) of a decompressive tube in gastroplasty during postoperative period. Epidemiological variables and differences between groups in post-surgical morbidity and mortality, hospital stay, onset of oral tolerance and the need for nasogastric tube placement were evaluated.

RESULTS

A total of 43 patients were included in this study, with a median age of 61 years, being 86% male. 46.5% were hypertensive, 25.5% had lung disease and 16.3% had diabetes mellitus. The median length of hospital stay was 9 days in group S versus 11.5 days in group N, with no differences in the onset of oral tolerance. Anastomotic dehiscence rate was 5% and 0% respectively. The overall mortality was 2.3% in the first 90 days, without differences between the groups. Placement of nasogastric tube during postoperative period was required only in 1 patient (4.3%) of the group N.

CONCLUSIONS

Non-use of nasogastric tube during postoperative period of an Ivor-Lewis esophagectomy is a safe measure, as it is not associated with a higher rate of complications or hospital stay. This fact may be able to improve patients' comfort and postoperative recovery.

The Effect of Regional Anesthesia on Outcomes After Minimally Invasive Ivor Lewis Esophagectomy

OBJECTIVE

The objective of the present study was to determine whether regional anesthesia in addition to general anesthesia was associated with improved outcomes compared with general anesthesia alone in minimally invasive Ivor Lewis esophagectomy.

DESIGN

Retrospective cohort study.

DESIGN

This study examined patients across multiple hospital institutions using the American College of Surgeons National Surgical Quality Improvement Program dataset.

PARTICIPANTS

Patients who underwent minimally invasive Ivor Lewis esophagectomy were identified and grouped according to general plus regional anesthesia versus general anesthesia alone.

MEASUREMENTS AND MAIN RESULTS

Using multivariate logistic regression, outcomes, including 30-day mortality, respiratory complications, infection, blood clots, reintubation, return to the operating room, and length of hospital stay, were examined. Of the 463 patients who underwent minimally invasive Ivor Lewis esophagectomy, 398 met study inclusion criteria. General and regional anesthesia were administered to 108 patients in the study, with the remainder receiving only general anesthesia. Multivariate regression demonstrated no difference in the primary outcome of 30-day mortality (0.93% for regional and general anesthesia, 2.07% for general anesthesia alone [odds ratio 0.49; p = 0.534]). There was no significant difference for any secondary outcome including return to the operating room, failure to wean from the ventilator, reintubation, surgical site infection, pneumonia, renal insufficiency and failure, cardiac arrest, acute myocardial infarction, transfusion, venous thromboembolism, urinary tract infection, length of hospital stay, or total number of complications per patient.

CONCLUSIONS

Despite potential benefits of regional anesthesia for minimally invasive Ivor Lewis esophagectomy, the present study did not show significant differences in any outcomes between regional and general anesthesia versus general anesthesia alone.

Enhanced Recovery After Surgery (ERAS) Pathway in Esophagectomy: Is a Reasonable Prediction of Hospital Stay Possible?

OBJECTIVE

To assess whether perioperative variables or deviation from enhanced recovery after surgery (ERAS) items could be associated with delayed discharge after esophagectomy, and to convert them into a scoring system to predict it.

SUMMARY BACKGROUND DATA

ERAS perioperative pathways have been recently applied to esophageal resections. However, low adherence to ERAS items and high rates of protocol deviations are often reported.

METHODS

All patients who underwent esophagectomy between April 2012 and March 2017 were managed with a standardized perioperative pathway according to ERAS principles. The target length of stay was set at eighth postoperative day (POD). All significant variables at bivariate analysis were entered into a logistic regression to produce a predictive score. An initial validation of the score accuracy was carried out on a separate patient sample.

RESULTS

Two hundred eighty-six patients were included in the study. Multivariate regression analysis showed that American Society of Anesthesiology score ≥ 3, surgery duration > 255 min, "nonhybrid" esophagectomy, and failure to mobilize patients within 24 h from surgery were associated with delayed discharge. The logistic regression model was statistically significant (P < 0.001) and correctly classified 81.9% of cases. The sensitivity was 96.6%, and the specificity was 17.6%. The prediction score applied to 23 patients correctly identified 100% of those discharged after eighth POD.

CONCLUSIONS

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.

Hospital Teaching Status Impacts Surgical Discharge Efficiency

OBJECTIVE

There is a paucity of data regarding the efficiency of care provided by teaching hospitals. Yet, instruction on transitions in care and an understanding of systems-based practice are key components of modern graduate medical education. We aimed to determine the relationship between hospital teaching status and the discharge efficiency from a surgical service.

SETTING

Patients who were cared for at teaching and nonteaching hospitals captured in the Healthcare Cost and Utilization Project National Inpatient Sample from 2012.

PARTICIPANTS

A total of 272,090 patients who underwent one of 44 predefined general surgery procedure types.

DESIGN

Patients were stratified based on treating hospital teaching status (TH vs. NTH). Procedure-specific early discharge (PSED) was defined for each operation type as a discharge that occurred within the lowest 25th percentile for overall length of stay. PSED was used as the discharge efficiency metric. To adjust for cofounders and hospital level clustering, multivariable mixed-effects logistic regression was used to examine the association between teaching status and PSED. Subgroup analysis was performed by operation type. Models were constructed with and without adjustment for inpatient complications.

RESULTS

There were 140,878 (51.8%) patients who received care at a TH. TH status was significantly associated with lower PSED (TH: 10.7% vs. NTH: 11.4%; p < 0.001) and longer length of stay (TH: 5.5 days vs. NTH: 4.5 days; p < 0.001). In the adjusted model of the overall cohort, patients treated at a TH were 8% less likely to receive a PSED compared to those treated at NTH (odds ratio 0.92, 95% confidence interval (0.88, 0.97); p < 0.002). Differences in the rates and odds of PSED were noted across the subgroups.

CONCLUSIONS

Teaching hospital status is associated with a reduced likelihood of PSED. The effect of TH on PSED varied by procedure subgroup. Examining the recovery pathways and discharge practices at NTH may allow for the identification of more efficient methods of care that can be applied to the broader healthcare system.

A successful clinical pathway protocol for minimally invasive esophagectomy

BACKGROUND

Minimally invasive esophagectomy is associated with significant morbidity, which can substantially influence the hospital length of stay for patients. Anastomotic leak is the most devastating complication. Minimizing major postoperative complications can facilitate adherence to a clinical pathway protocol and can decrease hospital length of stay.

METHODS

This is a retrospective study of 130 patients who underwent an elective laparoscopic and thoracoscopic Ivor Lewis esophagectomy for esophageal carcinoma between August 2014 and June 2018. A total of 112 patients (86%) underwent neoadjuvant chemoradiation. All of the 130 patients underwent a laparoscopic gastric devascularization procedure a median of 15 days prior to the esophagectomy. The target discharge date was postoperative day number 8.

RESULTS

Thirty patients (23.08%) had postoperative complications. Atrial fibrillation (20 patients) [15.38%] was the most frequent complication. Four patients (3.1%) developed an anastomotic leak. There was one postoperative death (0.77%) in the cohort of patients. The median length of stay was 8 days. The mean length of stay for patients without complications was 8 days ± 1.2 days and 12.4 days ± 7.1 days for patients with one or more complications (p = 0.002).

CONCLUSION

The development of postoperative complications after minimally invasive Ivor Lewis esophagectomy significantly increases hospital length of stay. Performing the operation with a specialized tandem surgical team and including preoperative ischemic preconditioning of the stomach minimizes overall and anastomotic complications and facilitates on time hospital discharge as defined by a perioperative clinical pathway protocol.

Robot-assisted minimally invasive esophagectomy (RAMIE) improves perioperative outcomes: a review

Robotic assisted minimal invasive esophagectomy (RAMIE) is increasingly applied as a clinically and oncologically safe technique in the surgical treatment of esophageal cancer. This review focuses on the advantages and potential opportunities of RAMIE to improve the perioperative and oncological outcomes based on the evidence from current literature. In addition, critical notes on aspects such as procedure duration and costs are addressed in this paper.

The evolution of fast track protocols after oesophagectomy

Fast track is a standardised goal directed patient's care pathway that aims to facilitate recovery following surgery. Currently, there are large variations in the fast track protocols used in oesophagectomy due to the complexity of the procedure. The objective of this systematic review is to assess the evolution of fast track protocols following oesophagectomy since its implementation and the resulting effect on postoperative outcomes. Relevant electronic databases were searched for studies assessing the clinical outcome from fast track in oesophagectomy and also those assessing the effects of the individual key components in fast track protocols. The search yielded twenty-three publications regarding fast track implementation in oesophagectomy. A pattern of consistent evolution in fast-track protocols was clearly demonstrated and these have shown variations in the core-identified components across the studies. However, evolution in fast track protocols over time showed, an overall improvement in length of stay, anastomotic leak, pulmonary complications and mortality over time. Thirty publications were included that evaluated specific components of fast track protocols, with an increasing trend towards addressing the nutritional aspect in oesophagectomy care in more recent years. The variations in the key components of fast track protocol of care identify the need for continued assessment and identification for areas of improvement. In the future incremental gains through focused improvements in key components will lend itself to even better postoperative outcomes and patient experience during oesophageal cancer treatment.

Integrating perioperative medicine with anaesthesia in India: Can the best be achieved? A review

Integrating perioperative medicine with anaesthesia is the need of the hour. Evolution of a new superspeciality called perioperative anaesthesia can improve surgical outcomes by quality perioperative care and guarantee imminent escalation of influence and power for anaesthesiologists. All original peer-reviewed manuscripts pertaining to surgery-specific perioperative surgical home models involving preoperative, intraoperative and postoperative initiatives spanning the past 5 years have been reviewed using PubMed and Google Scholar. Whether the perioperative surgical home model is feasible or still a distant dream in the Indian perspective has been analysed.

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

BACKGROUND

Early 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.

METHODS

A 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.

RESULTS

Five 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).

CONCLUSION

After 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.

Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review

Surgery for esophageal cancer is a highly stressful and painful procedure, and a significant amount of analgesics may be required to eliminate perioperative pain and blunt the stress response to surgery. Proper management of postoperative pain has invariably been shown to reduce the incidence of postoperative complications and accelerate recovery. Neuraxial analgesic techniques after major thoracic and upper abdominal surgery have long been established to reduce respiratory, cardiovascular, metabolic, inflammatory, and neurohormonal complications.The aim of this review is to evaluate and discuss the relevant clinical benefits and outcome, as well as the possibilities and limits of thoracic epidural anesthesia/analgesia (TEA) in the setting of esophageal resections. A comprehensive search of original articles was conducted investigating relevant literature on MEDLINE, Cochrane reviews, Google Scholar, PubMed, and EMBASE from 1985 to July2017. The relationship between TEA and important endpoints such as the quality of postoperative pain control, postoperative respiratory complications, surgical stress-induced immunosuppression, the overall postoperative morbidity, length of hospital stay, and major outcomes has been explored and reported. TEA has proven to enable patients to mobilize faster, cooperate comfortably with respiratory physiotherapists and achieve satisfactory postoperative lung functions more rapidly. The superior analgesia provided by thoracic epidurals compared to that from parenteral opioids may decrease the incidence of ineffective cough, atelectasis and pulmonary infections, while the associated sympathetic block has been shown to enhance bowel blood flow, prevent reductions in gastric conduit perfusion, and reduce the duration of ileus. Epidural anesthesia/analgesia is still commonly used for major 'open' esophageal surgery, and the recognized advantages in this setting are soundly established, in particular as regards the early recovery from anesthesia, the quality of postoperative pain control, and the significantly shorter duration of postoperative mechanical ventilation. However, this technique requires specific technical skills for an optimal conduction and is not devoid of risks, complications, and failures.

Outcomes of Transhiatal and Intercostal Pleural Drain After Ivor Lewis Esophagectomy: Comparative Analysis of Two Consecutive Patient Cohorts

BACKGROUND

In a previous proof of concept study, transhiatal pleural drain has been shown to be safe and effective after hybrid Ivor Lewis esophagectomy. Aim of this study was to compare the short-term outcomes of transhiatal and intercostal pleural drainage.

PATIENTS AND METHODS

This is an observational retrospective cohort study. Two methods of pleural drainage were compared in patients undergoing hybrid Ivor Lewis esophagectomy. Patients treated with a transhiatal drain connected to a vacuum bag were compared to a historical cohort of patients treated with the conventional intercostal drain connected to underwater seal and suction. Postoperative morbidity, total and daily drainage output, serum albumin levels, and total dose of paracetamol and ketorolac administered on demand were recorded.

RESULTS

Between January 2014 and December 2016, 50 patients with transhiatal drain and 50 with intercostal drains met the criteria for inclusion in the study. Demographic and clinicopathological variables were similar in the two groups. There was no statistically significant difference in the rate of postoperative complications. The total volume of drain output and the serum albumin levels were similar in the two groups. The total dose of ketorolac was significantly reduced in patients with transhiatal drain (P < .001).

CONCLUSIONS

Transhiatal pleural drainage connected to a portable vacuum system could safely replace the intercostal drain after hybrid Ivor Lewis esophagectomy. It has the potential to reduce postoperative pain and use of nonsteroidal anti-inflammatory drugs, and to enhance recovery from surgery.

Enhanced recovery after surgery (ERAS) programs for esophagectomy protocol for a systematic review and meta-analysis

BACKGROUND

Esophageal cancer is one of the worst malignant digestive neoplasms with poor treatment outcomes. Esophagectomy plays an important role and offers a potential curable chance to these patients. However, esophagectomy with radical lymphadenectomy is known as one of the most invasive digestive surgeries which are associated with high morbidity and mortality. The enhanced recovery after surgery (ERAS) protocol is a patient-centered, surgeon-led system combining anesthesia, nursing, nutrition, and psychology, which is designed for reducing complications, promoting recovery, and improving treatment outcomes. This systematic review and meta-analysis is aiming at how beneficial, and to what extent ERAS really will be.

METHODS

A systematic literature search will be performed through January 2018 using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar for relevant articles published in any language. Randomized controlled trials, prospective cohort studies, and propensity-matched comparative studies will be included. All meta-analyses will be performed using Review Manager software. The quality of the studies will be evaluated using the guidelines listed in the Cochrane Handbook. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statements will be followed until the findings of the systematic review and meta-analysis are reported.

RESULTS

The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.

CONCLUSION

Our study will draw an objective conclusion of the comparisons between ERAS and conventional care in aspects of perioperative outcomes and provide level I evidences for clinical decision makings.

An investigation into the nutritional status of patients receiving an Enhanced Recovery After Surgery (ERAS) protocol versus standard care following Oesophagectomy

PURPOSE

Enhanced Recovery After Surgery (ERAS) protocols have been effectively expanded to various surgical specialities including oesophagectomy. Despite nutrition being a key component, actual nutrition outcomes and specific guidelines are lacking. This cohort comparison study aims to compare nutritional status and adherence during implementation of a standardised post-operative nutritional support protocol, as part of ERAS, compared to those who received usual care.

METHODS

Two groups of patients undergoing resection of oesophageal cancer were studied. Group 1 (n = 17) underwent oesophagectomy between Oct 2014 and Nov 2016 during implementation of an ERAS protocol. Patients in group 2 (n = 16) underwent oesophagectomy between Jan 2011 and Dec 2012 prior to the implementation of ERAS. Demographic, nutritional status, dietary intake and adherence data were collected. Ordinal data was analysed using independent t tests, and categorical data using chi-square tests.

RESULTS

There was no significant difference in nutrition status, dietary intake or length of stay following implementation of an ERAS protocol. Malnutrition remained prevalent in both groups at day 42 post surgery (n = 10, 83% usual care; and n = 9, 60% ERAS). A significant difference was demonstrated in adherence with earlier initiation of oral free fluids (p <0.008), transition to soft diet (p <0.004) and continuation of jejunostomy feeds on discharge (p <0.000) for the ERAS group.

CONCLUSION

A standardised post-operative nutrition protocol, within an ERAS framework, results in earlier transition to oral intake; however, malnutrition remains prevalent post surgery. Further large-scale studies are warranted to examine individualised decision-making regarding nutrition support within an ERAS protocol.

Transhiatal Chest Drainage After Hybrid Ivor Lewis Esophagectomy: Proof of Concept Study

BACKGROUND

Intercostal pleural drainage is standard practice after transthoracic esophagectomy but has some drawbacks. We hypothesized that a transhiatal pleural drain introduced through the subxyphoid port site incision at laparoscopy can be as effective as the intercostal drainage and may enhance patient recovery.

PATIENTS AND METHODS

A proof of concept study was designed to assess a new method of pleural drainage in patients undergoing hybrid Ivor Lewis esophagectomy (laparoscopy and right thoracotomy). The main study aims were safety and efficacy of transhiatal pleural drainage with a 15 Fr Blake tube connected to a portable vacuum system. Pre- and postoperative data, mean duration, and total and daily output of drainage were recorded in an electronic database. Postoperative complications were scored according to the Dindo-Clavien classification.

RESULTS

Between June 2015 and December 2016, 50 of 63 consecutive patients met the criteria for inclusion in the study. No conversions from the portable vacuum system to underwater seal and suction occurred. There was no mortality. The overall morbidity rate was 40%. Two patients (4%) required reoperation for hemothorax and chylothorax, respectively. Percutaneous catheter drainage for residual pneumothorax was necessary in 2 patients (4%) on postoperative day 2. The mean duration of drainage was 7 days (interquartile range [IQR] = 2), and the total volume of drain output was 1580 mL (IQR = 880). No pleural effusion on chest X-ray was detected at the 3-month follow-up visit.

CONCLUSIONS

Transhiatal pleural drainage is safe and effective after hybrid Ivor Lewis esophagectomy and could replace the intercostal drain in selected patients.

Cost-Benefit Analysis of the Implementation of an Enhanced Recovery Program in Liver Surgery

BACKGROUND

Enhanced recovery after surgery (ERAS) programs have been shown to ease the postoperative recovery and improve clinical outcomes for various surgery types. ERAS cost-effectiveness was demonstrated for colorectal surgery but not for liver surgery. The present study aim was to analyze the implementation costs and benefits of a specific ERAS program in liver surgery.

METHODS

A dedicated ERAS protocol for liver surgery was implemented in our department in July 2013. The subsequent year all consecutive patients undergoing liver surgery were treated according to this protocol (ERAS group). They were compared in terms of real in-hospital costs with a patient series before ERAS implementation (pre-ERAS group). Mean costs per patient were compared with a bootstrap T test. A cost-minimization analysis was performed.

RESULTS

Seventy-four ERAS patients were compared with 100 pre-ERAS patients. There were no significant pre- and intraoperative differences between the two groups, except for the laparoscopy number (n = 18 ERAS, n = 9 pre-ERAS, p = 0.010). Overall postoperative complications were observed in 36 (49 %) and 64 patients (64 %) in the ERAS and pre-ERAS groups, respectively (p = 0.046). The median length of stay was significantly shorter for the ERAS group (8 vs. 10 days, p = 0.006). The total mean costs per patient were €38,726 and €42,356 for ERAS and pre-ERAS (p = 0.467). The cost-minimization analysis showed a total mean cost reduction of €3080 per patient after ERAS implementation.

CONCLUSIONS

ERAS implementation for liver surgery induced a non-significant decrease in cost compared to standard care. Significant decreased complication rate and hospital stay were observed in the ERAS group.

Nutritional aspects of enhanced recovery after esophagectomy with gastric conduit reconstruction

Enhanced Recovery After Surgery (ERAS) aims to accelerate recovery by a set of multimodality management strategies. For esophagectomy, several nutritional elements of ERAS can be safely introduced and are advised in routine practice, including preadmission counseling to screen and treat for potential malnutrition, shortened preoperative fasting, and carbohydrate loading. However, the timing of oral intake and the use of routine nasogastric decompression remain matter of debate after esophagectomy. Furthermore, more research is needed on future developments such as perioperative immunonutrition.

Component analysis of enhanced recovery pathways for esophagectomy

The objective of this systematic review is to identify key components of enhanced recovery protocols (ERP) that lead to improved length of hospital stay (LOS) following esophagectomy. Relevant electronic databases were searched for studies comparing clinical outcome from esophagectomy followed by a conventional pathway versus ERP. Relevant outcome measures were compared and metaregression was performed to identify the key ERP components associated with reduced in LOS. Thirteen publications were included, ERP was associated with no changes in in-hospital mortality, total complications, anastomotic leak, or pulmonary complications compared with a conventional pathway, however LOS was reduced in the ERP group. Metaregression identified that immediate extubation was associated with reduced LOS (OR = -0.51, 95%CI -0.77 to -0.25; P < 0.01). Several postoperative factors were associated with a significant reduction in length of hospital stay, and in order of most important were (i) gastrograffin swallow ≤5 days (OR = -4.27, 95%CI -4.50 to -4.03); (ii) mobilization on postoperative day ≤1 (OR = -2.49, 95%CI -2.63 to -2.34); (iii) removal of urinary catheter ≤2 days (OR = -0.99, 95%CI -1.15 to -0.84); (iv) oral intake with at least sips of fluid ≤1 day (OR = -0.96, 95%CI -1.24 to -0.68); (v) enteral diet with feeding jejunostomy or gastrostomy ≤ 1 day (OR = -0.57, 95%CI -0.80 to -0.35) and (vi) epidural removal ≤ 4 days (OR = -0.17, 95%CI -0.27 to -0.07). Several core ERP components and principles appear to be associated with LOS reduction. These elements should form a part of the core ERP for the specialty, while surgical teams incorporate other elements through an iterative process.

Expedite recovery from esophagectomy and reconstruction for esophageal squamous cell carcinoma after perioperative management protocol reinvention

BACKGROUND

Surgery for esophageal cancer is invasive and challenging, and always to be followed with arduous post-operative care and recovery. This study, maybe one of the first in Asian populations, is to determine whether a reinvented protocol for perioperative management for esophageal cancer surgery which is being implemented in our department, will lead to a faster convalescence and also significantly decrease financial burdens garnered by patients during hospitalization.

METHODS

Operated on by the same surgeon and team in the same hospital, consecutive patients who had received esophagectomy and reconstruction for esophageal squamous cell carcinoma were retrospectively reviewed. On the basis of two different treatment periods, patients were divided into two groups: A and B. Group A was patients who had received the new reinvented protocol between 2012 and 2016, while group B patients were those having received the previous protocol between 2008 and 2011. Their demographics, post-operative outcome, and hospital charges were collected and compared.

RESULTS

There were 64 patients in group A, and 69 in group B. Ventilator days (P<0.001), ICU stay (P<0.001), and post-operative stay (P<0.001) were significantly shorter in group A patients. Complication rates were similar between the two groups. No hospital mortality was noted in either group. Hospital charges in group A were found to be perceptively lower, although not statistically significant (P value =0.078).

CONCLUSIONS

The current protocol of perioperative care effectively ameliorated convalescence after esophagectomy and reconstruction for esophageal squamous cell carcinoma without increasing complication rate or mortality. It is also potentially more practical in future health care policies during this era of financial shortage.

Enhanced recovery protocols after oesophagectomy

The feasibility and safety of enhanced recovery protocols (ERP) have been demonstrated in a large number of surgical specialties. Several studies have shown improved post-operative outcomes and economic benefit from the use of ERPs in oesophageal cancer surgery. However, these improvements are not always translated more widely into clinical practice due to variation in protocols, poor compliance and failure to implement a robust implementation strategy. ERP implementation strategies should reflect the fact that these are complex interventions that are influenced by a wide range of social, organizational and cultural factors.

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

Background

Enhanced Recovery After Surgery (ERAS) protocol are well established in many surgical disciplines, leading to decrease in morbidity and length of hospital stay. These multi-modal protocols have been also introduced to oesophageal cancer surgery. This review aimed to evaluate current literature on ERAS in oesophageal cancer surgery and conduct a meta-analysis on primary and secondary outcomes.

Methods

MEDLINE, Embase, Scopus and Cochrane Library were searched for eligible studies. We analyzed data up to May 2016. Eligible studies had to contain four described ERAS protocol elements. The primary outcome was overall morbidity. Secondary outcomes included length of hospital stay, specific complications, mortality and readmissions. Random effect meta-analyses were undertaken.

Results

Initial search yielded 1,064 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. A total of 2,042 patients were included in the analysis (1,058 ERAS group and 984 treated with traditional protocols). Analysis of overall morbidity as well as complication rate did not show any significant reduction. Non-surgical complications and pulmonary complications were significantly lower in the ERAS group, RR = 0.71 95% CI 0.62–0.80, p < 0.00001 and RR = 0.75, 95% CI 0.60–0.94, p = 0.01, respectively. Meta-analysis on length of stay presented significant reduction Mean difference = -3.55, 95% CI -4.41 to -2.69, p for effect<0.00001.

Conclusions

This systematic review with a meta-analysis on ERAS in oesophageal surgery indicates a reduction of non-surgical complications and no negative influence on overall morbidity. Moreover, a reduction in the length of hospital stay was presented.

Metabolic nodal response as a prognostic marker after neoadjuvant therapy for oesophageal cancer

BACKGROUND

The ability to predict recurrence and survival after neoadjuvant chemotherapy (NAC) and surgery for oesophageal cancer remains elusive. This study evaluated the role of [18 F]fluorodeoxyglucose (FDG) PET-CT in assessing tumour and nodal response as a prognostic marker.

METHODS

This was a single-centre UK cohort study. From 2006 to 2014, patients with oesophageal cancer staged with PET-CT before NAC, and restaged by CT or PET-CT before resection, were included. Pathological tumour response was evaluated using Mandard regression grades. Metabolic tumour and nodal responses (mTR and mNR respectively) were quantified using absolute and threshold reductions.

RESULTS

Among 294 included patients, mTR and mNR independently predicted prognosis before surgery. After surgery, mNR (but not mTR), pathological tumour response, resection margin status and pathological node category predicted prognosis. Patients with FDG-avid nodal disease after NAC were at high risk of recurrence/death at 1 and 2 years (43 and 71 per cent respectively; P = 0·030 and P = 0·025 versus patients without avid nodes), and had a worse prognosis than patients with non-avid nodal metastases: hazard ratio 4·19 (95 per cent c.i. 1·87 to 9·40) and 2·11 (1·12 to 3·97) respectively versus patients without nodal metastases. Considering mTR and mNR response separately improved prognostication.

CONCLUSION

mNR is a novel prognostic factor, independent of conventional N status. Primary and nodal tumours may respond discordantly and patients with FDG-avid nodes after NAC have a poor prognosis.

Standardized clinical pathways for esophagectomy are not a reality in Brazil, even with a high prevalence of esophageal cancer and achalasia

Background:

The adoption of standardized protocols and specialized multidisciplinary teams for esophagectomy involve changes in routines with the implantation of expensive clinical practices and deviations from ingrained treatment philosophies.

Aim:

To evaluate the prevalence of standardized protocols and specialized multidisciplinary teams in São Paulo state, Brazil.

Methods:

Institutions that routinely perform esophagectomies in São Paulo were contacted and questioned about the work team involved in the procedure and the presence of standardized routines in the preoperatory care.

Results:

Fifteen centers answered the questionnaire: 10 (67%) public institutions and five (33%) private. There were seven (47%) medical schools, six (40%) with a residency program and two (13%) nonacademic institutions. The mean number of esophagectomies per year was 23. There was a multidisciplinary pre-operative team in nine (60%). There was a multidisciplinary postoperative team in 11 (73%). Early mobilization protocol was adopted in 12 (80%) institutions, early feeding in 13 (87%), routinely epidural in seven (47%), analgesia protocol in seven (47%), hydric restriction in six (40%), early extubation in six (40%), standardized hospitalization time in four (27%) and standardized intensive care time in two (13%).

Conclusion:

The prevalence of standardized protocols and specialized teams is very low in Sao Paulo state, Brazil. The presence of specialized surgeons is a reality and standardized protocols related directly to surgeons have higher frequency than those related to other professionals in the multidisciplinary team.

Enhanced Recovery after Surgery in a Single High-Volume Surgical Oncology Unit: Details Matter

Benefits of ERAS protocol have been well documented; however, it is unclear whether the improvement stems from the protocol or shifts in expectations. Interdisciplinary educational seminars were conducted for all health professionals. However, one test surgeon adopted the protocol. 394 patients undergoing elective abdominal surgery from June 2013 to April 2015 with a median age of 63 years were included. The implementation of ERAS protocol resulted in a decrease in the length of stay (LOS) and mortality, whereas the difference in cost was found to be insignificant. For the test surgeon, ERAS was associated with decreased LOS, cost, and mortality. For the control providers, the LOS, cost, mortality, readmission rates, and complications remained similar both before and after the implementation of ERAS. An ERAS protocol on the single high-volume surgical unit decreased the cost, LOS, and mortality.

Anesthesia for esophagectomy

Esophagectomy is a high-risk operation with significant perioperative morbidity and mortality. Attention to detail in many areas of perioperative management should lead to an aggregation of marginal gains and improvement in postoperative outcome. This review addresses preoperative assessment and patient selection, perioperative care (focusing on pulmonary prehabilitation, ventilation strategies, goal-directed fluid therapy, analgesia, and cardiovascular complications), minimally invasive surgery, and current evidence for enhanced recovery in esophagectomy.

A systematic review and meta-analysis of somatic and germline DNA sequence biomarkers of esophageal cancer survival, therapy response and stage

Recent advances in next generation sequencing reinforce the potential for DNA sequence markers to guide esophageal cancer management. We report the first systematic review and meta-analysis, identifying 94 markers of outcome and 41 of stage. Overall, evidence was poor. Meta-analyses demonstrated outcome associations for 6 tumor and 9 germline variants: priorities for prospective evaluation.

Introduction

There is an urgent need for biomarkers to help predict prognosis and guide management of esophageal cancer. This review identifies, evaluates and meta-analyses the evidence for reported somatic and germline DNA sequence biomarkers of outcome and stage.

Methods

A systematic review was carried out of the PubMed, EMBASE and Cochrane databases (20 August 2014), in conjunction with the ASCO Level of Evidence scale for biomarker research. Meta-analyses were carried out for all reported markers associated with outcome measures by more than one study.

Results

Four thousand and four articles were identified, 762 retrieved and 182 studies included. There were 65 reported markers of survival or recurrence 12 (18.5%) were excluded due to multiple comparisons. Following meta-analysis, significant associations were seen for six tumor variants (mutant TP53 and PIK3CA, copy number gain of ERBB2/HER2, CCND1 and FGF3, and chromosomal instability/ploidy) and seven germline polymorphisms: ERCC1 rs3212986, ERCC2 rs1799793, TP53 rs1042522, MDM2 rs2279744, TYMS rs34743033, ABCB1 rs1045642 and MTHFR rs1801133. Twelve germline markers of treatment complications were reported; 10 were excluded. Two tumor and 15 germline markers (11 excluded) of chemo (radio)therapy response were reported. Following meta-analysis, associations were demonstrated for mutant TP53, ERCC1 rs11615 and XRCC1 rs25487. There were 41 tumor/germline reported markers of stage; 27 (65.9%) were excluded.

Conclusions

Numerous DNA markers of outcome and stage have been reported, yet few are backed by high-quality evidence. Despite this, a small number of variants appear reliable. These merit evaluation in prospective trials, within the context of high-throughput sequencing and gene expression.