Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS^®) Society Recommendations

Abstract

Introduction Enhanced recovery after surgery (ERAS) programs provide a format for multidisciplinary care and has been shown to predictably improve short term outcomes associated with surgical procedures. Esophagectomy has historically been associated with significant levels of morbidity and mortality and as a result routine application and audit of ERAS guidelines specifically designed for esophageal resection has significant potential to improve outcomes associated with this complex procedure. Methods A team of international experts in the surgical management of esophageal cancer was assembled and the existing literature was identified and reviewed prior to the production of the guidelines. Well established procedure specific components of ERAS were reviewed and updated with changes relevant to esophagectomy. Procedure specific, operative and technical sections were produced utilizing the best current level of evidence. All sections were rated regarding the level of evidence and overall recommendation according to the evaluation (GRADE) system. Results Thirty-nine sections were ultimately produced and assessed for quality of evidence and recommendations. Some sections were completely new to ERAS programs due to the fact that esophagectomy is the first guideline with a thoracic component to the procedure. Conclusions The current ERAS society guidelines should be reviewed and applied in all centers looking to improve outcomes and quality associated with esophageal resection.

Impact of postoperative complications on survival after oesophagectomy for oesophageal cancer

“…As complications were independently predictive of survival, regardless of tumour stage or grade, it follows that reducing the likelihood of complications may improve survival. Recent studies have focused on prehabilitation, enhanced recovery after surgery, intensive postoperative physiotherapy and incentive spirometry, with mixed findings. Additionally, minimally invasive and hybrid oesophagectomy techniques appear to reduce pulmonary complications.…”

The application of enhanced recovery after surgery for upper gastrointestinal surgery: Meta-analysis

“…Intake of carbohydrates up to 2 h before anaesthesia does not increase rates of delayed gastric emptying and is recommended prior to surgery [44]. Other practices [6,34] in ERAS protocols include the use of preoperative carbohydrates, procedures to avoid hypothermia, complete avoidance of the use of nasogastric tubes, and early oral feeding and mobilization.…”

“…Studies were included in the meta-analysis when they adhered to consensus guidelines for ERAS protocols [6,34]. The basic characteristics of the included studies are shown in Table 1.…”

Paravertebral catheter versus EPidural analgesia in Minimally invasive Esophageal resectioN: a randomized controlled multicenter trial (PEPMEN trial)

“…QoL; quality of life as measured by the EORTC C30 and OG-25 questionnaires QoR; quality of recovery as measured by the QoR-40 questionnaire. which state that regional analgesia should be the backbone of pain management in enhanced recovery after esophagectomy protocols [25]. In absence of trials in patients undergoing MIE, both epidural and paravertebral analgesia were considered to be suitable options based on extrapolated evidence, although no recommendations in favour of either modality could be made [25].…”

“…which state that regional analgesia should be the backbone of pain management in enhanced recovery after esophagectomy protocols [25]. In absence of trials in patients undergoing MIE, both epidural and paravertebral analgesia were considered to be suitable options based on extrapolated evidence, although no recommendations in favour of either modality could be made [25]. Retrospective cases series suggest that paravertebral analgesia is associated with less technical failure and reduces the incidence of hypotensive events, which may promote postoperative recovery [26,27].…”