Oesophagectomy Enhanced recovery Pathway Alexander Phillips

Background ERP increasingly adopted in surgical pathways Original concept for colorectal surgery by Kehlet. Multimodal evidence based interventions Original aim to provide “pain and risk free procedure for patients” Found to hasten recovery, and reduce morbidity and mortality.

ERP and oesophagectomy ERP pathways increasingly designed for patients having an oesophagectomy Follow the original principles advocated by Kehlet. Most have demonstrated significant shortening in length of stay, no deterioration or improvement in complication rates.

Components of the pathway Pain Control Nutrition Mobilisation / physiotherapy Daily goals Radiology

Study undertaken Standardised ERP introduced in 2009 Comparison of patients 18 months either side who underwent two-stage subtotal oesophagectomy Outcome measures Mortality rates Length of stay Morbidity

Results 1 50 patients pre pathway, 75 post pathway. No significant difference in base line demographics: (gender, ASA, neoadjuvant chemo, BMI, disease stage.) Except age (Median 61 Vs 66 ERP group p=0.035) Preoperative co-morbidities similar

Pre-Pathway ERP p No of Patients 50 75 Male:Female 40:10 59:16 0.86 Median Age (range) 61 (38-77) 66 (43-82) 0.035 ASA 1 11 7 0.11 2 28 46 3 10 22 4 1 Neoadjuvant Chemo 29 49 0.41 Median BMI (range) 27 (18-54) 26 (18-47) 0.83 Tumour Stage 1 28% 33% 0.43 26% 35% 44% 30% 2% Type of surgery -open 48 64 0.07 - Laparoscopic assisted Median length of Stay 17 days 14 days 0.013 Readmissions 5

Results 2 1 Mortality in each cohort Median Length of Stay 17 days Vs 14 days (p=0.013) Readmissions 3 Vs 5 (p=1) Complications between groups similar However chest complications 28% Vs 21% not reached statistical significance).

Complication Prepathway ERP p Wound Infection 4 3 0.44 Pneumonia 9 10 0.61 Other pulmonary* 5 6 0.75 Anastomotic Leak 1 Dysrhythmia DVT 0.41 PE CVA C difficile Post op bleed MI Reoperation In hospital mortality No Complication 25 37

Limitations Effect of laparoscopic surgery and its increasing use. Complication differences may not have reached statistical levels. Use of gastrografin swallow and implications of positive findings. Day of discharge does not necessarily equate to date medically fit for discharge.

Conclusion Formalised pathway has led to a small but significant reduction in length of stay No difference in mortality, and morbidity. Chest complications remain the most significant factor in prolonging length of stay- improved with the pathway but not to statistical significance No change in readmission rates