Feasibility Of Early Ambulation For Enhanced Recovery After Surgery After Esophagectomy
Christopher Johnson, Marissa Mayor, Hiran Fernando, Sandeep Khandhar, Amit Mahajan, Devon Collins, Jennifer Tran
Inova Fairfax, Annandale, VA, USA
BACKGROUND: Recent prospective studies of minimally invasive esophagectomy (MIE) have demonstrated grade 3 or higher adverse event (AE) rates (G3+ AE) of 37-49% and pulmonary AE of 12-18%. This study investigated the feasibility of early ambulation and ERAS after esophagectomy, and whether this approach could impact AE, and, in particular, pulmonary AE rates.METHODS: This was a retrospective review using prospectively collected ambulation data. Patients were encouraged to ambulate 3 times daily for 20 minutes. On arrival to the preoperative area, patients were placed into a chair and ambulated to the operating room (OR). Extubation occurred in the OR with ambulation starting on post-operative day (POD)0, ideally in the recovery unit (PACU), based on staffing availability. The primary aim was the ability to achieve ambulation on POD0. Complications were graded using Common Terminology Criteria. RESULTS: Thirty patients (25 male;5 female) underwent esophagectomy. These included 28 MIE (1 elective conversion to thoracotomy) and 2 patients who underwent open transhiatal esophagectomy. Median age was 64 years (range 48-77), mean BMI was 27.7 (SD 5.1, range 16-40), and mean Charlson comorbidity index was 4.7 (SD 1.4, range 2-7). Mean FEV1 and DLCO were 90.9% and 67.0%, respectively. Twenty-one patients (70.0%) received neoadjuvant chemoradiation. Twenty-five patients (83.3%) achieved ambulation on POD0, including 11 patients (36.7%) who ambulated in the PACU. Twenty-seven patients (90.0%) ambulated on POD1, with 19 patients (63.3%) ambulating more than 1,250ft and seven patients (23.3%) ambulating more than 2,500ft. Median length of stay was 10 days. G3+ AE occurred in 6 (20.0%) patients. There were no 30-day or in-hospital mortalities. Anastomotic leaks occurred in 3 (10.0%) patients. Only 1 (3.3%) patient experienced a G3+ pulmonary AE.CONCLUSIONS: Early ambulation after esophagectomy is feasible, even starting in the recovery room, for select patients. Implementation of ambulation early in the post-operative period has the potential to improve outcomes after esophagectomy and should be considered a key component of ERAS after thoracic surgery.
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