Abstract
Esophageal cancer surgery, comprising esophagectomy with radical lymphadenectomy, is a complex procedure associated with considerable morbidity andmortality. The enhanced recovery after surgery (ERAS) protocol which aims to improve perioperative care, minimize complications, and accelerate recovery is showing promise for achieving better perioperative outcomes. ERAS is a multimodal approach that has been reported to shorten the length of hospital stay, reduce surgical stress response, decrease morbidity, and expedite recovery. While ERAS components straddle preoperative, intraoperative, and postoperative periods, they need to be seen in continuum and not as isolated elements. In this review, we elaborate on the components of an ERAS protocol after esophagectomy including preoperative nutrition, prehabilitation, counselling, smoking and alcohol cessation, cardiopulmonary evaluation, surgical technique, anaesthetic management, intra- and postoperative fluid management and pain relief, mobilization and physiotherapy, enteral and oral feeding, removal of drains, and several other components. We also share our own institutional protocol for ERAS following esophageal resections.
Highlights
Esophageal cancer surgery is a major and complex surgery comprised of esophagectomy with radical lymphadenectomy
We must endeavour to reduce complications and promote early recovery. One such strategy showing promise is the enhanced recovery after surgery (ERAS) protocol, which aims to improve perioperative care, minimize complications, and accelerate recovery
It has evolved over the years into a multidisciplinary team approach involving surgeons, anaesthesiologists, critical care physicians, physiotherapists, nutritionists and nurses in the perioperative care of the patient and integrating evidencebased protocols into clinical practice
Summary
Esophageal cancer surgery is a major and complex surgery comprised of esophagectomy with radical lymphadenectomy. Cardiac and pulmonary status is assessed routinely before major surgery such as esophagectomy, to identify patients requiring preoperative optimization and those at higher risk of postoperative complications. The perfusion of the gastric conduit depends on the right gastro-epiploic artery and there may be concerns that vasoconstriction can adversely affect flow to the gastric conduit These fears seem unfounded and two small studies have shown that the use of vasopressors to counter the hypotension caused by TEA improves blood flow in the gastric conduit [87, 88]. Prolonged bed rest after surgery leads to muscle loss, increased pulmonary complications, insulin resistance, and increased risk of venous thromboembolism [92] To circumvent these problems, patients should be encouraged to ambulate early in the postoperative period, preferably on the day of surgery. In patients undergoing esophagectomy, the use of TEA results in decreased pulmonary infections, chronic post-thoracotomy pain and postoperative mortality [94–97]. On analyzing our perioperative outcomes in two time periods: pre-ERAS(2001–2010) and post-ERAS (2011–2019), we found that there was a substantial reduction in overall morbidity and mortality rates (6.6% before 2010 vs 4.9% after 2011) with the introduction of ERAS (64% and 6.6% before 2010 vs. 43% and 4.9% after 2011, respectively)
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