BACKGROUND: Esophagectomy is a complex surgical procedure. Enhanced recovery (ERAS) protocols may offer faster recovery and minimized complications.
METHODS: This is a retrospective review from Jan 2020 - Mar 2023 for all patients who underwent esophagectomy for cancer at a single institution. All operations were done trans-thoracic with a laparoscopic or robotic abdominal approach and a robotic thoracic approach with anastomosis in the chest or neck. A formalized ERAS protocol was implemented in the second half of the cohort in Jan 2022. Enteral jejunostomy was used rarely. Nasogastric tubes were placed routinely across the anastomosis and removed on POD 3. Early mobilization protocols and aggressive chest physiotherapy were universal. NGT was routinely removed on POD3 with subsequent contrast swallow and initial oral intake. Patients were routinely discharged on POD4-5 after all chest drains are removed. Neck drains are removed on follow-up appointment. RESULTS: ): A total of 32 patients underwent esophagogastrectomy during the study period. There were 16 patients operated on prior to a formal ERAS protocol and 16 after. Overall comorbidity burden was low. All underwent minimally invasive abdominal portions and robotic thoracic dissections. There were no conversions from robotic approach. Average operating time was 6 hours (5-11). Jejunostomy was largely performed in patients in the early cohort. 3 patients had J-tubes placed postoperatively without significant difference between cohorts.. Ivor-Lewis approach was used in 78% of operations with three field operations accounting for the rest. Median length of stay was overall 7.2 days and significantly shorter in the later cohort (9.75±1.2 vs 5.68±0.6, p=0.024). Major morbidity occurred in 25% patients. Two patients required tracheostomy for recurrent laryngeal nerve paresis, both of whom were eventually decannulated with functional vocal chords. One patient had a small leak at the anastomosis in the neck, which healed with conservative treatment. There was no difference in complication incidence between the groups. There were no 30 day mortalities or readmissions.
CONCLUSIONS: Our experience demonstrates shorter hospital stays and similarly low non-surgical and pulmonary complications in patients undergoing minimally invasive esophagectomy with enhanced recovery. Our ERAS protocol maintained high quality outcomes with regard to overall morbidity, mortality, or readmission rates.
