Guide to Enhanced Recovery for Cancer Patients Undergoing Surgery: ERAS and Oesophagectomy

An audit of perioperative speech pathology intervention on improving enhanced recovery after surgery in oesophagectomy patients

PURPOSE

To evaluate the impact of a speech-language pathology (SLP) pathway on recovery following oesophagectomy.

METHOD

An audit was conducted at a single metropolitan public hospital in Sydney, Australia. Patients between 2014-2021 undergoing a three-stage oesophagectomy (n = 41) were included in the study. The sample was divided into two groups, those who received usual care (2014-2019) and those who received perioperative SLP assessment and intervention (2020-2021), with data collected across swallowing and health outcomes. Patient demographics and outcomes between the two groups were compared.

RESULT

Patients who received perioperative SLP intervention commenced oral intake faster postoperatively (SLP intervention group Mdn = 6.50 days, IQR = 6.00-7.00; usual care group Mdn = 9.00 days, IQR = 7.00-13.25; p = 0.001). There was no statistically significant difference between groups in rates of aspiration on the postoperative leak test (p = 0.32). No statistically significant differences were found between the two groups in length of hospital stay or number of swallowing-related medical images completed during their admission.

CONCLUSION

Perioperative SLP intervention has a positive impact on commencing oral intake following a three-stage oesophagectomy, however, it does not have a significant impact on rates of aspiration postoperatively. This pathway may contribute to enhanced recovery after oesophagectomy.

State of the art of enhanced recovery after surgery (ERAS) protocols in esophagogastric cancer surgery: the Western experience

Enhanced recovery after surgery (ERAS) programs provide a framework to standardize care processes and improve outcomes. The results of this multimodal and multidisciplinary approach based on actions focused on reducing physiological surgical stress in the preoperative, intraoperative, and postoperative periods are beneficial in reducing morbidity and hospital stay, without increasing readmissions across different surgical settings. The implementation of ERAS in resection procedures of esophageal and gastric cancer has been challenging due to the complexity of these surgical techniques and the high risk of complications. Despite the limited evidence of ERAS in esophagectomy operations, systematic reviews and meta-analysis have confirmed a reduction of pulmonary complications and hospital stay without increasing readmissions. In gastrectomy operations, the implementation of ERAS reduces the use of nasogastric tubes and intraabdominal drains, facilitates early diet, and reduces the length of hospital stay, without increasing complications. There is, however, wide heterogeneity and absence of standardization in the number and definition of the ERAS components. The development of ERAS consensus guidelines including procedure-specific components may reduce this variability. Regardless growing evidence of the effectiveness of ERAS, the adherence rate is still low. The commitment of the multidisciplinary team and leadership is critical in the application and refinement of ERAS protocols in parallel with periodic audits. Pre- and post-habilitation methods are emerging concepts to be incorporated in ERAS protocols.

Incidence of postoperative hypothermia and shivering and risk factors in patients undergoing malignant tumor surgery: a retrospective study

BACKGROUND

Perioperative hypothermia and shivering are common and can cause adverse outcomes. The aim of this study was to investigate the incidence of postoperative hypothermia and shivering and their risk factors in patients undergoing malignant tumor surgery.

METHODS

This retrospective study collected data from patients with American Society of Anesthesiologists physical status (ASA) I or II who underwent scheduled surgery from November 2020 to March 2021 at Fudan University Shanghai Cancer Center. Each patient's core body temperature was measured at three time points: time point 1 (arrival at the postanesthesia care unit (PACU)), time point 2 (after 30-min care in the PACU), and time point 3 (at discharge from the PACU). At time point 1, if the patient's body temperature was below 36 ℃, we provided an active forced-air warmer. At time point 2, if it was still below 36 ℃, the forced-air warmer was still applied until the patient was discharged from the PACU. If it reached 36 ℃, the forced-air warmer would be switched off. Univariate and multivariate logistic regression combined with stepwise methods and linear regression were used to explore risk factors for postoperative hypothermia and shivering.

RESULTS

The numbers (percentage) of 202 patients who developed postoperative hypothermia at the different time points were 52 (25.7%), 37 (18.3%) and 28 (13.9%). Eight patients (4.0%) experienced shivering. Multivariate logistic regression showed that high weight (OR = 0.923, 95% CI: 0.884 to 0.964, P = 0.0003) and low estimated blood loss (OR = 0.252, 95% CI: 0.115 to 0.550, P = 0.0005) were protective factors against hypothermia, while long surgical duration (OR = 3.339, 95% CI: 1.675 to 6.655, P = 0.0006) was an independent risk factor for hypothermia at time point 1. There was no risk factor associated with the occurrence of shivering (P > 0.05). There was a significant difference between the hypothermia and normothermia groups in the median length of stay in the PACU (59.0 vs. 49.0 min, P = 0.0123).

CONCLUSIONS

Postoperative hypothermia occurred frequently. Weight, estimated blood loss and surgical duration were significantly associated with hypothermia on arrival at the PACU.

Analysis of Compliance with Enhanced Recovery After Surgery (ERAS) Protocol for Esophagectomy

BACKGROUND

ERAS guidelines have provided an effective recovery approach for esophagectomy. This study aimed to identify the relationship between the length of hospital stay (LOS) and compliance with clinical benchmarks of an established institutional ERAS program.

METHODS

A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2016 and January 2020. All patients underwent surgery within a standardized ERAS pathway for esophagectomy. Compliance with individual ERAS benchmarks and postoperative outcomes were evaluated according to patient's LOS; accelerated (≤ 6 days, AR), targeted (7-8 days, TR), and delayed recovery (≥ 9 days, DR).

RESULTS

The study included 100 consecutive patients undergoing esophagectomy with a median LOS of 7 (3.8-40.8) days, and a 30-day readmission rate of 12.6%. LOS was not affected by comorbidities, tumor type or stage, neoadjuvant therapy, operative approach or anastomotic leak. Postoperative complications were 49.5%, and 90-day mortality was 3.8%. AR, TR, and DL were achieved by 45%, 31%, and 24% of patients, respectively. Postoperative morbidity differed significantly among groups, impacting LOS (p < 0.001). Overall compliance with ERAS protocol was 82.7% and adherence to specific benchmarks was initially (< 48 h) high, but significantly affected by postoperative complications afterwards.

CONCLUSIONS

Adherence to recovery benchmarks in patients undergoing esophagectomy is most commonly impacted by postoperative complications. In esophageal cancer surgery, the adherence to ERAS benchmarks after esophagectomy should be regularly audited. Modification to ERAS protocols to increase application in patients with complications should be considered.

Perioperative statin medication impairs pulmonary outcome after abdomino-thoracic esophagectomy

Background

Although surgery is the curative option of choice for patients with locally advanced esophageal cancer, morbidity, especially the rate of pulmonary complications, and consequently mortality of patients undergoing abdomino-thoracic esophagectomy remain unacceptably high. Causes for developing post-esophagectomy pulmonary complications are trauma to the lung and thoracic cavity as well as systemic inflammatory response. Statins are known to influence inflammatory pathways, but whether perioperative statin medication impacts on inflammatory response and pulmonary complication development after esophagectomy had not been investigated, yet.

Methods

Retrospective analysis and propensity score matching of patients, who either received perioperative statin medication [statin( +)] or not [statin( −)], with regard to respiratory impairment (PaO₂/FiO₂ < 300 mmHg), pneumonia development, and inflammatory serum markers after abdomino-thoracic esophagectomy.

Results

Seventy-eight patients who underwent abdomino-thoracic esophagectomy for cancer were included into propensity score pair-matched analysis [statin( +): n = 26 and statin( −): n = 52]. Although no differences were seen in postoperative inflammatory serum markers, C-reactive protein values correlated significantly with the development of pneumonia beyond postoperative day 3 in statin( −) patients. This effect was attenuated under statin medication. No difference was seen in cumulative incidences of respiratory impairment; however, significantly higher rate (65.4% versus 38.5%, p = 0.0317, OR 3.022, 95% CI 1.165–7.892) and higher cumulative incidence (p = 0.0468) of postoperative pneumonia were seen in statin( +) patients, resulting in slightly longer postoperative stay on intensive care unit (p = 0.0612) as well as significantly prolonged postoperative in-hospital stay (p = 0.0185).

Conclusions

Development of pulmonary complications after abdomino-thoracic esophagectomy is multifactorial but frequent. The establishment of preventive measures into the perioperative clinical routine is mandatory for an improved patient outcome. Perioperative medication with statins might influence pneumonia development in the highly vulnerable lung after abdomino-thoracic esophagectomy. Perioperative interruption of statin medication might be beneficial in appropriate patients; however, further clinical trials and translational studies are needed to prove this hypothesis.