Esophagectomy--it's not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer.

BACKGROUND: Esophageal resection (ER) remains the standard therapy for early esophageal cancer; however, because of concerns regarding high levels of morbidity and mortality reported in analyses of national databases, many patients are relegated to less effective endoscopic or chemotherapeutic approaches.
METHODS: All patients undergoing esophagectomy by a single surgeon for cancer or high-grade dysplasia between 05/91-05/06 were prospectively entered into an IRB-approved database. All aspects of work-up and treatment were guided by an evolving standardized perioperative clinical pathway.
RESULTS: Three hundred forty consecutive patients, mean age of 64 (33-90), underwent ER for Barrett's esophagus (17) or invasive cancer stages I-87, II-133, III-94, IV-9. One hundred thirty-nine (41%) had neoadjuvant therapy. Sixty-three percent were American Society of Anesthesiologists class III or IV, and five different operative approaches were used. Patient were managed intraoperatively with a "fluid restriction" protocol. Mean intraoperative blood loss was 230 cc. 99.5% of patients were extubated immediately, and mean ICU and hospital stays were 2.25 (1-30) and 11.5 (6-49) days, respectively. Postoperative analgesia was managed with patient-controlled epidural analgesia in 98.5%, and 86% were mobilized on day 1 after surgery. Complications occurred in 153 patients (45%), most commonly atrial dysrhythmia (13%), and postoperative delirium (11%). Anastomotic leaks occurred in 13 patients (3.8%). Mortality occurred in one patient (0.3%). No significant differences were seen in length of stay, operative time, blood loss, or complications in patients receiving neoadjuvant therapy. For stages I, II, and III, patients between 1998-2004 Kaplan-Meier 5-year cumulative survival was 92.4, 57.1, and 34.5%, respectively.
CONCLUSIONS: Surgical treatment of esophageal cancer can be done with moderate morbidity and very low mortality, and the expectation of improved levels of survival, especially in early-stage patients. Standardized perioperative clinical pathways can provide the infrastructure for the treatment of these patients and should include increased efforts to minimize blood loss and transfusions, improve postoperative pain control and extubation rates, and facilitate early mobilization and discharge. ER, as sole therapy or in combination with radiation/chemotherapy, should remain the standard of care in patients with early and locoregional esophageal cancer.