1. Oesophagectomy Enhanced recovery Pathway
Alexander Phillips

2. 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.

3. 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.

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

5. 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

6. 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

7. 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

8. 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).

9. 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

10. 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.

11. 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