ERATS for Esophagectomy

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Best Practice Recommendations on Enhanced Recovery after Thoracic Surgery (ERATS) for Esophagectomy

N Seyednejad, B. Johnson, G. Darling, A. Seely

Background

Enhanced Recovery After Surgery aims to approach the care of surgical patients in a multimodal, multidisciplinary manner to in order to improve surgical outcomes and quality of care. Enhanced Recovery After Surgery (ERAS) programs are becoming the standard of practice in many surgical specialties throughout the world. Data on implementation of ERAS pathways at many centres have demonstrated improvements in clinical outcomes, patient satisfaction, and results in significant cost savings to the health care system. While ERAS has been widely implemented across the country in various oncological specialties, its uptake for ERATS procedures have been slower and extensively documented. Here, we outline the recommendations for ERATS in patients undergoing an esophagectomy.

Recommendations

Preoperative
  1. Nutritional assessment and optimization:
    • Early involvement / consultation of dietician
    • Use of pharmaco-nutrition when necessary: e.g. Ensure, Boost, or Resource TID
  1. Pre-rehabilitation and exercise regimen:
    • Recommendations for daily exercise: i.e. 45 minute walk daily
  1. Complete smoking cessation:
    • Any duration of time prior to surgery; at least 4 weeks prior to surgery highly advised
    • Nicotine replacement as necessary
  1. Discharge planning:
    • Managing postoperative expectations
    • Patient education i.e. information booklets, outlining what patients should expect in the immediate post operative settings (i.e. drains/chest tubes, analgesic management) and upon discharge
    • Early involvement of allied team members i.e. social worker, nurse educator
  1. Timing of Surgery:
    • 3-6 weeks following completion of chemotherapy
    • 6-10 weeks following the completion of radiation after chemoradiation
  1. Bowel Preparation:
    • Routine use of bowel prep not currently recommended
Intraoperative
  1. Standardized best practice anesthesia:
    • Maintain euvolemia
    • Low tidal volumes / lung protective ventilation
  1. Minimally invasive techniques:
    • Laparoscopic abdominal approach preferred when possible; currently controversial, no conclusive evidence available
    • Thoracoscopic chest approach if possible
  1. Minimized use of chest tubes, drains:
    • Eg. 1 chest tube in right pleural cavity
  1. Use of enteric feeding tubes (i.e. nasoduodenal or jejunostomy) is generally recommended, especially if pre-operative malnutrition present:
    • Selective avoidance of feeding tubes reasonable (e.g. no pre-operative malnutrition, no anastomotic concerns)
  1. Optimal multimodal analgesia
    • Use of paravertebral analgesia over a thoracic epidural
    • Regular acetaminophen dosing
    • Limited opioid use
    • NSAID use controversial due to concern for increased risk for anastomotic leak (see references 4 & 6)
Postoperative
  1. Optimal Multimodal analgesia:
    • Early transition to oral/enteral analgesics
    • Minimal use of intravenous opioids
  1. Early oral nutrition:
    • Initiate early oral fluids (e.g. 2 days of sips of water, followed by 2 days of clear fluids, followed by 2 days of full fluids based on recent randomized controlled trial demonstrating no increased risk of adverse events) – see reference 1
    • Patients to stay on full fluids on discharge, until POD7, then transition to post esophagectomy diet
  1. Early Mobilization:
    1. Assisted mobilization (i.e. first steps) POD0
    2. Independent mobilization POD1
  1. Early removal of tubes and drains if no clinical contraindications:
    1. Eg. Removal of Foley catheter POD1 if no epidural (D/C foley on day of epidural discontinuation otherwise)
    2. Eg. Chest tube removal POD3 if no evidence of air leak, chyle leak
    3. Eg. JP Drain removal POD6
    4. Eg. Remove NG POD3 ager clamping evening of POD2 and if no evidence of gastric conduit distention
  2. Optimized glycemic control to normalized levels to promote healing (goal <10mmol/L):
  3. Target timeline to discharge (without any):
    • POD6

 

References

  1. Berkelmans GH, Fransen LF, Dolmans-Zwartjes AC, Kouwenhoven EA, van Det MJ, Nilsson M, Nieuwenhuijzen GA, Luyer MD. Direct oral feeding following minimally invasive esophagectomy. Annals of Surgery
  2. Chao L, Ferri L, Mulder S, Ncuti A, Neville A, Lee L, Kaneva P, Watson D, Vassiliou M, Carli F, Feldman L. An enhanced recovery pathways decreases duration of stay after esophagectomy. Surgery 2012: 606-616.
  3. Findlay J, Gillies R, Millo J, Sgromo B, Marshall R, Maynard N. Enhanced recovery for esophagectomy: A systematic review and evidence based guidelines. Ann of Surgery 2014; 259:413-431.
  4. Fjederholt KT,Okholm C,  Svendsen LB, Achiam MP, Kirkegård J, Mortensen FV. Ketorolac and Other NSAIDs Increase the Risk of Anastomotic Leakage After Surgery for GEJ Cancers: a Cohort Study of 557 Patients. J Gastrointestinal Surg 2018: 587-594.
  5. Giménez-Milà M, Klein AA, Martinez G. Design and implementation of an enhanced recovery program in thoracic surgery. Journal of thoracic disease 2016 Feb;8(Suppl 1):S37.
  6. Hakkarainen TW, Steele SR, Bastaworous A, Dellinger EP, Farrokhi E, Farjah F, Florence M, Helton S, Horton M,, Pietro M, Varghese TK, Flum DR. Nonsteroidal anti-inflammatory drugs and the risk for anastomotic failure: a report from Washington State’s Surgical Care and Outcomes Assessment Program (SCOAP). JAMA Surg 2018; 223-228.
  7. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A review. JAMA Surg 2017; 152:292-298.
  8. Low DE, Allum W, De Mazoni G, Ferri L, Immanuel A, Kuppusamy M, Law S, Lindblad M, Maynard N, Neal J, Pramesh C, Scott M, Smithers B, Addor V, Ljungqvist O. Guidelines for perioparative care in esophagectomy : enhanced recovery after surgery (ERAS) society recommendations. World J of Surgery 2018; 43:299-330.
  9. Markar S, Karthikesaligam A, Low D. Enhanced recovery pathways lead to an improvement in postoperative outcomes following esophagectomy: systematic review and pooled analysis. Disease of the esophagus 2015; 28: 468-475.
  10. Martin LW, Sarosiek BM, Harrison MA, Hedrick T, Isbell JM, Krupnick AS, Lau CL, Mehaffey JH, Thiele RH, Walters DM, Blank RS. Implementing a thoracic enhanced recovery program: lessons learned in the first year. The Annals of thoracic surgery 2018; 105(6):1597-604.
  11. Thiele RH, Rea KM, Turrentine FE, Friel CM, Hassinger TE, Goudreau BJ, et al. Standardization of Care: Impact of an Enhanced Recovery Protocol on Length of Stay, Complications, and Direct Costs after Colorectal Surgery. Journal of the American College of Surgeons 2015; 220:430–43.