The effect of formalizing perioperative enhanced recovery protocol in esophageal surgery.

Abstract

Introduction: The perioperative enhanced recovery protocol uses transdisciplinary approaches to reduce serious complications and accelerate recovery after a surgery. Esophagectomy is a high-risk operation (the mortality rate of 8-15%), carried out on patients with significant comorbidities. ERAS plays an important role in improving outcomes. The objective of the study is to prove the impact of the protocol on the outcomes of esophagectomy. Methods: Between December 2012 and December 2016 54 patients with esophageal cancer underwent esophagectomy with one-stage esophagoplasty at the Institute. The median age was 61,3 years (40;81), females were significantly less predisposed than males (1:2). Among the patients noted the prevalence of patients with stage III of esophageal cancer and ASA III-IV. The transthoracic esophagectomy (McKeown) and transhiatal esophagectomy were used for 47 and 7 patients with the reconstruction by a gastric tube. The perioperative enhanced recovery protocol included a consultation with an anesthesiologist, a resuscitator, a therapist (ERAS team), nutrition support, compensation comorbidities, maintenance of normothermia, rational use of vasopressors, immediate extubation, multimodal analgesia (using paravertebral, epidural or wound catheter), early mobilization and feeding (by sipping on the first day for 5 patients). Results: Intraoperative complications developed in 3 (5,5%) cases: damage spleen, lung, intercostal artery. 8 patients (14,8%) had postoperative complications. There was no anastomosis leakage, but thrombosis of transplant’s vascular was diagnosed twice and led to necrosis of the gastric tube (stage IIIb Clavien-Dindo). Eventration was observed in 2 cases, hematoma of the pleural cavity – in 1 case and it led to an emergency operation (stage IIIb). Pneumonia was diagnosed in 2 cases and TIA - in 1 case (stage I), pneumothorax – 1 patient (stage IIIa). 2 patients had a paresis of the vocal cords, aspiration and thereafter sepsis (stage IVa). There was no postoperative mortality rate. Median postoperative day (POD) and ICU were 8 and 0,8 days. Conclusion: Application of the perioperative enhanced recovery protocol personalization of treatment has allowed reducing the incidence of postoperative complications and mortality after esophagectomy, reducing the number of failures in the operation and minimizing the risks for patients with severe comorbidities (ASA III-IV).