Francesco Puccetti1, Fredrik Klevebro2, MadhanKumar Kuppusamy1, Shiwei Han1, Richard E Fagley3, Donald E Low1, Michal Hubka4. 1. Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA. 2. Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institute and Centre for Digestive Diseases, Karolinska University Hospital, Eugeniavägen 3, 171 76, Solna, Stockholm, Sweden. 3. Department of Anesthesiology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA. 4. Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, 1100 9th Avenue, Seattle, WA, 98101, USA. Michal.Hubka@virginiamason.org.
Abstract
BACKGROUND: ERAS guidelines have provided an effective recovery approach for esophagectomy. This study aimed to identify the relationship between the length of hospital stay (LOS) and compliance with clinical benchmarks of an established institutional ERAS program. METHODS: A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2016 and January 2020. All patients underwent surgery within a standardized ERAS pathway for esophagectomy. Compliance with individual ERAS benchmarks and postoperative outcomes were evaluated according to patient's LOS; accelerated (≤ 6 days, AR), targeted (7-8 days, TR), and delayed recovery (≥ 9 days, DR). RESULTS: The study included 100 consecutive patients undergoing esophagectomy with a median LOS of 7 (3.8-40.8) days, and a 30-day readmission rate of 12.6%. LOS was not affected by comorbidities, tumor type or stage, neoadjuvant therapy, operative approach or anastomotic leak. Postoperative complications were 49.5%, and 90-day mortality was 3.8%. AR, TR, and DL were achieved by 45%, 31%, and 24% of patients, respectively. Postoperative morbidity differed significantly among groups, impacting LOS (p < 0.001). Overall compliance with ERAS protocol was 82.7% and adherence to specific benchmarks was initially (< 48 h) high, but significantly affected by postoperative complications afterwards. CONCLUSIONS: Adherence to recovery benchmarks in patients undergoing esophagectomy is most commonly impacted by postoperative complications. In esophageal cancer surgery, the adherence to ERAS benchmarks after esophagectomy should be regularly audited. Modification to ERAS protocols to increase application in patients with complications should be considered.
BACKGROUND: ERAS guidelines have provided an effective recovery approach for esophagectomy. This study aimed to identify the relationship between the length of hospital stay (LOS) and compliance with clinical benchmarks of an established institutional ERAS program. METHODS: A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2016 and January 2020. All patients underwent surgery within a standardized ERAS pathway for esophagectomy. Compliance with individual ERAS benchmarks and postoperative outcomes were evaluated according to patient's LOS; accelerated (≤ 6 days, AR), targeted (7-8 days, TR), and delayed recovery (≥ 9 days, DR). RESULTS: The study included 100 consecutive patients undergoing esophagectomy with a median LOS of 7 (3.8-40.8) days, and a 30-day readmission rate of 12.6%. LOS was not affected by comorbidities, tumor type or stage, neoadjuvant therapy, operative approach or anastomotic leak. Postoperative complications were 49.5%, and 90-day mortality was 3.8%. AR, TR, and DL were achieved by 45%, 31%, and 24% of patients, respectively. Postoperative morbidity differed significantly among groups, impacting LOS (p < 0.001). Overall compliance with ERAS protocol was 82.7% and adherence to specific benchmarks was initially (< 48 h) high, but significantly affected by postoperative complications afterwards. CONCLUSIONS: Adherence to recovery benchmarks in patients undergoing esophagectomy is most commonly impacted by postoperative complications. In esophageal cancer surgery, the adherence to ERAS benchmarks after esophagectomy should be regularly audited. Modification to ERAS protocols to increase application in patients with complications should be considered.
Authors: B Feike Kingma; Peter P Grimminger; Pieter C van der Sluis; Marc J van Det; Ewout A Kouwenhoven; Yin-Kai Chao; Chun-Yi Tsai; Hans F Fuchs; Christiane J Bruns; Inderpal S Sarkaria; James D Luketich; Jan W Haveman; Boudewijn van Etten; Philip W Chiu; Shannon M Chan; Philippe Rouanet; Anne Mourregot; Jens-Peter Hölzen; Rubens A Sallum; Ivan Cecconello; Jan-Hendrik Egberts; Frank Benedix; Mark I van Berge Henegouwen; Suzanne S Gisbertz; Daniel Perez; Kristina Jansen; Michal Hubka; Donald E Low; Matthias Biebl; Johann Pratschke; Paul Turner; Kish Pursnani; Asif Chaudry; Myles Smith; Elena Mazza; Paolo Strignano; Jelle P Ruurda; Richard van Hillegersberg Journal: Ann Surg Date: 2020-11-09 Impact factor: 13.787