Enhanced Recovery Pathways for Minimally Invasive Esophageal Surgery

Implementation of ERAS

Although ERAS recommendations consist of the most current medical data available, implementation requires time for best evidence-based practices to take effect.^1,10 A major obstacle to ERAS implementation is the multidisciplinary nature of the pathway with the perioperative, operative, and postoperative care process requiring the coordinated contribution from multiple provider teams. ¹¹ After implementation, ERAS protocols may be able to achieve sustainable success by providing feedback of positive results through regular team updates. ¹² Porteous et al. described the installation of a standardized anesthetic and surgical pathway for esophageal resection that was continuously adjusted over two decades. ¹¹ Many elements of this pathway, including regional analgesia, avoidance of excessive intravenous fluid administration, and early mobilization of postoperative patients, are similar to the recommendations in colorectal ERAS pathways. As this pathway evolved to adopt interventions similar to the current definition of ERAS, the authors reported significant decreases in median hospital stay (8 days versus 10 days, P < .001) and ICU length of stay (LOS; 1 day versus 2 days, P < .001) with stable complication rates despite treating esophageal cancer patients with more advanced tumor stages over time. ¹¹ Although this hospital's circumstances differ from many hospitals that aim to implement ERAS pathways, this clinical pathway demonstrates the positive outcomes that can be sustainably attained once the pathway becomes established.

Outcomes with ERAS

There are currently two published RCTs that studied the impacts of ERAS in esophageal surgery compared with conventional care pathways.^13,14 The first trial by Wang et al. found patients in the ERAS pathway after minimally invasive esophagectomy experienced earlier return of bowel function (3.28 days versus 4.68 days, P = .007), shorter time to chest tube removal (2.70 days versus 4.30 days, P < .0001), decreased length of postoperative hospital stay (9.0 days versus 11.7 days, P < .0001), and reduced incidence of complications (6.67% versus 18.9%, P = .018) (Tables 1 and 2). ¹³ In the second trial by Zhao et al., the approach to esophageal resection is not described. ¹⁴ However, patients in the ERAS group experienced earlier return of bowel function (3.75 days versus 4.84 days, P = .007), decreased postoperative hospital stay (7.15 days versus 12.52 days, P < .0001), and amassed fewer hospitalization expenditures ($4666.34 USD versus $5808.73 USD, P < .0001). ¹⁴

A 2016 Cochrane Review studying ERAS protocols versus conventional perioperative care pathways in major upper gastrointestinal, liver, and pancreatic surgery found that ERAS patients experienced fewer minor complications (rate ratio 0.52, 95% confidence interval [CI] 0.39–0.70), spent less days in the hospital (mean difference −2.19 days, 95% CI −2.53 to −1.85 days), and reduced hospital costs (mean difference −$6300 USD, 95% CI −$8400 to −$4200 USD). ¹⁵ However, of the 10 studies included in the review, only 2 studies included data on esophagectomy.^14,16 One of the trials employed open surgical technique, whereas the techniques in the second trial were not defined.^14,16 Although the Cochrane Review reported statistically significant findings, the authors remarked that the overall quality of evidence was low and questioned the certainty of their results. ¹⁵

Although there remains a scarcity of RCT data examining ERAS in minimally invasive esophageal surgery, compelling evidence exists in other non-RCT studies. Specifically, ERAS patients in a retrospective case-control cohort study by Pan et al. experienced quicker return of intestinal activity (3 days versus 6 days, P < .0001), shorter postoperative hospital stay (7 days versus 12 days, P < .0001), and received less intravenous fluids (2.10 L versus 2.80 L, P < .0001) when compared with the traditional perioperative care cohort. ¹⁷ Moreover, in a prospective cohort study by Ford et al. in which 77% of the patients in the ERAS cohort underwent laparoscopic esophagogastrectomy, the ERAS cohort experienced a lower anastomotic leakage rate (4% versus 14%, P = .05) and shorter postoperative LOS (10 days versus 12 days, P < .001) when measured against the conventional “Pre-ERAS” cohort. ¹⁸ The LOS finding is consistent with two additional prospective cohort studies that reported significantly decreased postoperative LOS in ERAS patients compared with conventional recovery pathways.^19,20 Furthermore, a retrospective cohort analysis by Molina et al. compared a cohort of planned postoperative admissions with a cohort of planned day surgery discharges for patients undergoing laparoscopic hiatal procedures. ²¹ Patients in the planned day surgery cohort were required to achieve many of the same postoperative ERAS milestones—adequate pain control, tolerance of oral fluids, and ability to mobilize safely—before discharge. Although the planned day surgery discharges serve as a proxy for an ERAS pathway, the planned day surgery cohort experienced shorter LOS (0.3 days versus 2.3 days, P = .001) and significantly lower postoperative complication rate (9.2% versus 19%, P = .033). ²¹

Two meta-analyses and multiple systematic reviews have examined the effects of ERAS in esophageal surgery.^4,5,22–24 Pooled data in meta-analyses by Pisarska et al. and Markar et al. found significant decreases in hospital LOS and pulmonary complications in patients participating in an ERAS pathway versus a conventional pathway after esophagectomy (Table 3).^22,23 These findings are similar to the conclusions expressed in multiple systematic reviews.^4,5 Despite these conclusions, most of the studies used in the meta-analysis data are retrospective case cohorts due to the lack of RCT data regarding ERAS in esophageal surgery. In addition, the meta-analyses contain mostly data from open procedures, as several studies noted that less than half of procedures included were performed laparoscopically.^25,26 The combination of weak data and lack of laparoscopic technique highlights the need for further study of ERAS outcomes in minimally invasive esophageal surgery.

Safety of ERAS

A consecutive series of 80 patients by Jianjun et al. studied the outcomes of enhanced recovery in patients undergoing minimally invasive esophagectomy. ²⁷ Although no direct comparison was made with a control group, 97.5% of the patients completed the ERAS pathway and were discharged home on postoperative day 7. Discharge on postoperative day 7 matched similar postoperative LOSs measured in ERAS cohorts of the Zhao et al. RCT and Pan et al. retrospective case–cohort study.^14,17,27 Perhaps most importantly, the Jianjun series found that no patients were readmitted within 30 days of discharge and no patients experienced anastomotic leakage. ²⁷ Thus, the authors concluded that ERAS in minimally invasive esophagectomy is both feasible and safe. ²⁷

Similarly, the prospective cohort study by Ford et al. found no significant difference in mild-to-moderate (49% versus 29%, P = .07) and severe (15% versus 22%, P = .42) complication rates between the ERAS and conventional cohorts. ¹⁸ This suggests that esophageal surgery patients can undergo ERAS without jeopardizing the safety quality of their recovery.

Finally, an examination of the data available in meta-analyses agrees that ERAS in esophageal surgery does not compromise patient safety. Both Pisarska et al. and Markar et al. reported no significant change in hospital readmission and mortality for ERAS patients.^22,23 Although Pisarska et al. also reported no significant change in morbidity and surgical complications in ERAS cohorts, Markar et al. concluded that anastomotic leakage rates were significantly reduced in ERAS patients.^22,23

Financial impacts of ERAS

A retrospective cost analysis by Lee et al. of an ERAS pathway compared with a traditional pathway in minimally invasive esophagectomy found an overall cost savings of $2607 USD. ²⁸ The study also reported that the use of minimally invasive surgical technique as part of the ERAS pathway did not significantly affect surgical costs. Prior studies, such as the RCT by Zhao et al. and 2016 Cochrane Review demonstrated similar reductions in cost in ERAS cohorts.^14,15 The cost savings shown in the existing ERAS data suggest that the pathway is cost effective in minimally invasive esophageal surgery. ²⁹