Elsevier

Surgery

Volume 152, Issue 4, October 2012, Pages 606-616
Surgery

Central Surgical Association
An enhanced recovery pathway decreases duration of stay after esophagectomy

Presented at the Central Surgical Association, March 1–3, 2012, Madison, WI.
https://doi.org/10.1016/j.surg.2012.07.021Get rights and content

Purpose

Enhanced recovery pathways (ERP) decrease morbidity and duration of stay after colorectal surgery. There is little information about their role in complex procedures, such as esophagectomy. The purpose of this study was to determine the impact of an ERP on duration of stay, complications, and readmissions after esophagectomy.

Methods

Patients undergoing esophagectomy for cancer or high-grade dysplasia from June 2009 to December 2011 were identified from a prospectively maintained database. Beginning in June 2010, all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan, indications for intensive care admission, early structured mobilization, and diet and drain management. Short-term (30-day) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway. Data are expressed as median values [interquartile range].

Results

We identified 106 patients; 47 underwent esophagectomy before ERP implementation and 59 after. Patients were similar with respect to age, gender, diagnosis, and operative time. Hospital stay was shorter in the ERP group (8 [7–17] vs 10 [9–17] days; P = .01). There were no differences in rates of complications (59% vs 62%) or readmissions (6% vs 5%).

Conclusion

Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay, without an increase in complications or readmissions.

Section snippets

Methods

Patients undergoing esophagectomy for cancer or high-grade dysplasia at a single, high-volume, university-affiliated center from June 2009 to December 2011 were identified from a prospectively maintained database. Exclusion criteria included benign disease, emergency surgery, and pharyngolaryngoesophagectomies. Patients were categorized according to the date of their operation. An ERP was implemented on June 20, 2010. All patients undergoing preoperative evaluation after this date received

Results

A total of 113 esophagectomies were performed between June 2009 and December 2011, of which 106 met inclusion criteria for the study. Seven patients were excluded: 2 underwent pharygolaryngealesophagectomy, 2 were operated as emergencies, and 3 had benign disease. The 47 patients treated before June 10, 2010. received traditional care, and the next 59 patients were treated after initiation of the ERP. No patients were excluded from the pathway (Fig 2).

There were no differences identified

Discussion

The goal of an ERP is to identify and address factors that delay surgical recovery, principally represented by hospital discharge. Coordinated, multidisciplinary, evidence-based perioperative care plans require the active participation of all stakeholders. A recent Cochrane review concluded that clinical pathways are associated with a decrease in the rate of complications and improved documentation without negative impact on duration of stay and hospital costs.12 There is evidence for the

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    Funded by an investigator-initiated research grant from Ethicon Endosurgery Canada. Dr Li receives salary support from the Surgeon Scientist program, Department of Surgery, McGill University. The Steinberg-Bernstein Centre for Minimally Invasive Surgery and Innovation is supported by a centre of excellence grant from Covidien Canada.

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