title: Initial Experiences of an Enhanced Recovery Protocol in Esophageal Surgery Short and Long-Term Outcomes of Epidural or Intravenous Analgesia after Esophagectomy: A Propensity-Matched Cohort Study Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy versus open transthoracic esophagectomy for resectable esophageal cancer, a randomized controlled trial (ROBOT trial) Effects of goal-directed fluid therapy on enhanced postoperative recovery: An interventional comparative observational study with a historical control group on oesophagectomy combined with ERAS program. Observation of clinical efficacy of application of enhanced recovery after surgery in perioperative period on esophageal carcinoma patients. A Propensity Score Matched Analysis of Open Versus Minimally Invasive Transthoracic Esophagectomy in the Netherlands Fast-track surgery improves postoperative clinical recovery and cellular and humoral immunity after esophagectomy for esophageal cancer The effect of formalizing enhanced recovery after esophagectomy with a protocol. Omission of Nasogastric Tube Application in Postoperative Care of Esophagectomy Impact of adherence to care pathway interventions on recovery following bowel resection within an established enhanced recovery program The feasibility of a randomized controlled trial of esophagectomy for esophageal cancer - the ROMIO (Randomized Oesophagectomy: Minimally Invasive or Open) study: protocol for a randomized controlled trial Fast-track surgery improves postoperative clinical recovery and reduces postoperative insulin resistance after esophagectomy for esophageal cancer Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial The impact of immediate extubation in the operating room after cardiac surgery on intensive care and hospital lengths of stay. Reduced use of intensive care after liver transplantation: influence of early extubation. Program of gastrointestinal rehabilitation and early postoperative enteral nutrition: a prospective study An enhanced recovery pathway decreases duration of stay after esophagectomy. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations
abstract: Background A recent development in gastrointestinal surgery is the implementation of enhanced recovery after surgery ( ERAS ) programs . Evidence regarding the benefit of these programs in patients undergoing esophageal surgery is scarce . We investigated the feasibility and possible benefit of a perioperative ERAS program in patients undergoing esophagectomy for malignant disease . Methods The ERAS program was initiated in 2009 . Patients who underwent esophagectomy and were treated according to the ERAS program were included . Items of ERAS included preoperative nutrition , early extubation , early removal of nasogastric tube , and early mobilization . Primary outcome parameters were hospital stay and the incidence of postoperative complications . Outcome parameters in the ERAS cohort were compared to a cohort of patients who underwent surgical resection in the year prior to the implementation of the ERAS protocol . A feasibility analysis was performed among a sample of ERAS patients to determine the number of achieved items per patient . Results Between 2008 and August 2010 , 181 patients in our department underwent esophagectomy .  Of these , 103 patients were included in the ERAS program ( ERAS+ group ) and were compared to 78 patients who had undergone an esophagectomy in 2008 ( ERAS– group ) .  Overall hospital stay was 14 days versus 15 days ( ERAS+ and ERAS– , respectively ; p = 0.013 ) . There were no significant differences in the incidence of postoperative complications in either group . The percentage of achieved items varied between 42 and 93 % per item . Conclusions The implementation of an ERAS program in esophageal surgery was feasible and result ed in a small but significant reduction in overall hospital stay , whereas overall morbidity was not affected Background and Objectives As a well-established technique for postoperative pain relief , the benefits of epidural analgesia ( EDA ) have been under debate recently . This study aim ed to determine whether EDA could improve perioperative outcomes and survival in patients undergoing esophagectomy . Methods From January 2010 to December 2012 , 587 consecutive cases undergoing McKeown-type esohpageactomy  were retrospectively identified from a prospect ively maintained data base . Results After propensity-matching , incorporating baseline characteristics , 178 cases were included in each group , and patients characteristics distributions were well-balanced between two groups . Compared with intravenous analgesia , the use of EDA significantly decreased the incidence of pneumonia from 32 % to 19.7 % ( P = 0.008 ) , and anastomotic leakage from 23.0 % to 14.0 % ( P = 0.029 ) . The change in CRP level of EDA group was significantly decreased ( preoperative , 6.2 vs. 6.2 ; POD 1 , 108.1 vs. 121.3 ; POD 3 , 131.5 vs. 137.8 ; POD 7 , 69.3 vs. 82.1 mg/L ; P = 0.044 ) . EDA patients had a significantly longer duration of indwelling urinary catheter ( P<0.001 ) , and lower levels in both systolic ( P = 0.001 ) and diastolic blood pressure ( P<0.001 ) . There were n't significant differences in overall survival ( log-rank P = 0.47 ) and recurrence ( Gray-test P = 0.46 ) between two groups . Conclusions These findings revealed that EDA could attenuate inflammatory response and reduce the incidence of pneumonia and anastomotic leakage after esophagectomy , at the price of delayed urinary catheter removal and lower blood pressure . EDA remains an important component of multimodal perioperative management after esophagectomy Background For esophageal cancer patients , radical esophagolymphadenectomy is the cornerstone of multimodality treatment with curative intent . Transthoracic esophagectomy is the preferred surgical approach worldwide allowing for en-bloc resection of the tumor with the surrounding lymph nodes . However , the percentage of cardiopulmonary complications associated with the transthoracic approach is high ( 50 to 70%).Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy ( RATE ) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes . RATE was accompanied with reduced blood loss , shorter ICU stay and improved lymph node retrieval compared with open esophagectomy , and the pulmonary complication rate , hospital stay and perioperative mortality were comparable . The objective is to evaluate the efficacy , risks , quality of life and cost-effectiveness of RATE as an alternative to open transthoracic esophagectomy for treatment of esophageal cancer . Methods / design This is an investigator-initiated and investigator-driven monocenter r and omized controlled parallel-group , superiority trial . All adult patients ( age ≥18 and ≤80 years ) with histologically proven , surgically resectable ( cT1 - 4a , N0 - 3 , M0 ) esophageal carcinoma of the intrathoracic esophagus and with European Clinical Oncology Group performance status 0 , 1 or 2 will be assessed for eligibility and included after obtaining informed consent . Patients ( n = 112 ) with resectable esophageal cancer are r and omized in the outpatient department to either RATE ( n = 56 ) or open three-stage transthoracic esophageal resection ( n = 56 ) . The primary outcome of this study is the percentage of overall complications ( grade 2 and higher ) as stated by the modified Clavien – Dindo classification of surgical complications . Discussion This is the first r and omized controlled trial design ed to compare RATE with open transthoracic esophagectomy as surgical treatment for resectable esophageal cancer . If our hypothesis is proven correct , RATE will result in a lower percentage of postoperative complications , lower blood loss , and shorter hospital stay , but with at least similar oncologic outcomes and better postoperative quality of life compared with open transthoracic esophagectomy . The study started in January 2012 . Follow-up will be 5 years . Short-term results will be analyzed and published after discharge of the last r and omized patient . Trial registration Dutch trial register : NTR3291 Clinical Trial.gov : BACKGROUND AND AIMS The Enhanced Recovery after Surgery ( ERAS ) program has been proposed as a postoperative recovery-enhancing strategy . We frequently apply the Modified-ERAS program following oesophagectomy . This study aims to eluci date the impact of goal -directed fluid therapy ( GDT ) for the perioperative management of oesophageal cancer on the postoperative recovery of patients undergoing oesophagectomy . METHODS This is an interventional before-after comparative observational study conducted at Kanagawa Cancer Centre , Japan . Patients who underwent elective oesophagectomy for oesophageal cancer were recruited . Group H ( retrospectively collected ) received intraoperative and postoperative management consisting of fluid administration without haemodynamic monitoring and the M-ERAS program , while Group S prospect ively received management consisting of GDT and the M-ERAS program . The primary endpoint was the speed of gastrointestinal functional recovery , while secondary endpoints were the level of postoperative mobilisation , incidence of complications , postoperative length of hospital stay ( LOS ) , and nutritional status after discharge . RESULTS The proportion of patients who completely egested Gastrografin by postoperative day 4 , the level of postoperative mobilisation , and achievement ratio for a 100-m walk on the first postoperative attempt were significantly higher in Group S than in Group H ( P = 0.034 , P = 0.0197 , and P < 0.0001 , respectively ) . No significant differences were observed in the postoperative LOS and incidence of complications within 30 days between the groups . The serum albumin levels at 6 months after discharge was higher in Group S than in Group H ( P = 0.0002 ) . CONCLUSIONS The GDT-ERAS program enhanced postoperative gastrointestinal recovery and mobilisation , as well as postoperative nutritional status and protein synthesis . The program did not affect either postoperative LOS or the incidence of complications . TRIAL REGISTRATION UMIN registration number : UMIN000013705 , https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000015999 PURPOSE To observe the clinical efficacy of the application of enhanced recovery after surgery ( ERAS ) in the perioperative period of esophageal carcinoma patients . METHODS A total of 114 patients who were admitted to Affiliated Hospital of Jining Medical University for surgical treatment of esophageal carcinoma between June 2012 and June 2016 were enrolled and r and omly divided into the intervention group and the regular group according to the difference of management procedures during the perioperative period . ERAS was carried out in 57 patients in the intervention group , while conventional management procedures were applied in 57 patients in the regular group . Thereafter , compared were the fluctuations in nutritional indicators and immunological indicators , postoperative complications , time to recovery of gastrointestinal function , length of stay ( LOS ) in hospital and cost of patients between the two groups . RESULTS Seven days post-operation in the intervention group , the evaluation indexes of nutrition status , including total protein ( TP ) , albumin ( ALB ) , prealbumin ( PA ) and transferrin ( TF ) , and of immunological functions , including immunoglobulin G ( IgG ) , immunoglobulin A ( IgA ) , immunoglobulin M ( IgM ) and total blood lymphocyte count ( TLC ) , were significantly higher than those in the regular group . As for postoperative complications , the incidence rate of the intervention group was remarkably lower than that of the regular group ; the recovery time of gastrointestinal function in the intervention group was shorter than that in the regular group ; the LOS in the intervention group was also shorter than that in the regular group ; the in-hospital cost in the intervention group was also lower than that in the regular group . All differences above were statistically significant ( p<0.05 ) . CONCLUSION During the perioperative period of esophageal carcinoma patients , ERAS should be fully applied to sustain the good status , and promote the recovery of immunological functions and gastrointestinal functions ; at the same time , ERAS also reduces the incidence rate of postoperative complications , LOS and in-hospital cost , and we maintain that ERAS should be performed in clinical practice Objective : The aim of this study was to compare open esophagectomy ( OE ) with minimally invasive esophagectomy ( MIE ) in a population -based setting . Background : R and omized controlled trials and cohort studies have shown that MIE is associated with reduced pulmonary complications and shorter hospital stay as compared to OE . Methods : Patients who underwent transthoracic esophagectomy for cancer between 2011 and 2015 were selected from the national Dutch Upper Gastrointestinal Cancer Audit . Hybrid , transhiatal , and emergency procedures were excluded . Patients who underwent  OE were compared with those treated by MIE . Propensity score matching was used to correct for differences in baseline characteristics . The primary endpoint was postoperative pulmonary complications ; secondary endpoints were morbidity , mortality , convalescence , and pathology . Results : Some 1727 patients were included . After propensity score matching the percentage of patients with 1 or more complications was 62.6 % after OE ( N = 433 ) and 60.2 % after MIE ( N = 433 ) ( P = 0.468 ) . Pulmonary complication rate did not differ between groups : 34.2 % ( OE ) versus 35.6 % ( MIE ) ( P = 0.669 ) . Anastomotic leak ( 15.5 % vs 21.2 % , P = 0.028 ) and reintervention rates ( 21.1 % vs 28.2 % , P = 0.017 ) were higher after MIE . Mortality was 3.0 % in the OE group and 4.7 % in the MIE group ( P = 0.209 ) . Median hospital stay was shorter after MIE ( 14 vs 13 days , P = 0.001 ) . Percentages of R0 resections ( 93 % ) did not differ between groups . The median ( range ) lymph node count was 18 ( 2–53 ) ( OE ) versus 20 ( 2–52 ) ( MIE ) ( P < 0.001 ) . Conclusions : This population -based study showed that mortality and pulmonary complications were similar for OE and MIE . Anastomotic leaks and re interventions were more frequently observed after MIE . MIE was associated with a shorter hospital stay Background Our aim was to investigate the influence of FTS on human cellular and humoral immunity using a r and omized controlled clinical study in esophageal cancer patients . Methods Between October 2013 and December 2014 , 276 patients with esophageal cancer in our department were enrolled in the study . The patients were r and omized into two groups : FTS pathway group and conventional pathway group . The postoperative hospital stay , hospitalization expenditure , and postoperative complications were recorded . The markers of inflammatory and immune function were measured before operation as well as on the 1st , 3rd , and 7th postoperative days ( POD ) , including serum level of interleukin-6 ( IL-6 ) , C-reactive protein ( CRP ) , serum globulin , immunoglobulin G ( IgG ) , immunoglobulin M ( IgM ) , immunoglobulin A ( IgA ) and lymphocyte sub population s ( CD3 lymphocytes , CD4 lymphocytes , CD8 lymphocytes and the CD4/CD8 ratio ) in the patients between the two groups . Results In all , 260 patients completed the study : 128 in the FTS group and 132 in the conventional group . We found implementation of FTS pathway decreases postoperative length of stay and hospital charges ( P < 0.05 ) . In addition , inflammatory reactions , based on IL-6 and CRP levels , were less intense following FTS pathway compared to conventional pathway on POD1 and POD3 ( P < 0.05 ) . On POD1 and POD3 , the levels of IgG , IgA , CD3 lymphocytes , CD4 lymphocytes and the CD4/CD8 ratio in FTS group were significantly higher than those in control group ( All P < 0.05 ) . However , there were no differences in the level of IgM and CD8 lymphocytes between the two groups . Conclusions FTS improves postoperative clinical recovery and effectively inhibited release of inflammatory factors via the immune system after esophagectomy for esophageal cancer . Trial registration ChiCTR-TRC-13003562 , the date of registration : August 29 , 2013 Enhanced recovery after surgery ( ERAS ) pathways aim to accelerate functional return and discharge from hospital . They have proven effective in many forms of surgery , most notably colorectal . However , experience in esophagectomy has been limited . A recent study reported significant reductions in pulmonary complications , mortality , and length of stay following the introduction of an ERAS protocol alone , without the introduction of any clinical changes . We instituted a similar change 16 months ago , introducing a protocol to provide a formal framework , for our existing postoperative care . This retrospective analysis compared outcome following esophagectomy for the 16 months before and 20 months after this change . Data were collected from prospect ively maintained secure web-based multidisciplinary data bases . Complication severity was classified using the Clavien-Dindo scale . Operative mortality was defined as death within 30 days of surgery , or at any point during the same hospital admission . Lower respiratory tract infection was defined as clinical evidence of infection , with or without radiological signs . Respiratory complications included lower respiratory tract infection , pleural effusion ( irrespective of drainage ) , pulmonary collapse , and pneumothorax . Statistical analysis was performed using SPSS v21 . One hundred thirty-two patients underwent esophagectomy ( 55 protocol group ; 77 before ) . All were performed open . There were no differences between the two groups in terms of age , gender , operation , use of neoadjuvant therapy , cell type , stage , tumor site , or American Society of Anesthesiologists grade . Median length of stay was 14.0 days ( protocol ) compared with 12.0 before ( interquartile range 9 - 19 and 9.5 - 15.5 , respectively ; P = 0.073 , Mann-Whitney U-test ) . Readmission within 30 days of discharge occurred in five ( 9.26 % ) and six ( 8.19 % ; P = 1.000 , Fisher 's exact test ) . There were four in-hospital deaths ( 3.03 % ) : one ( 1.82 % ) and three ( 3.90 % ) , respectively ( P = 0.641 ) . There were no differences in the severity of complications ( P = non-significant ; Pearson 's chi-squared ) . There were no differences in the type of complications occurring in either group . The protocol was completed successfully by 26 ( 47.3 % ) . No baseline factors were predictive of this . In contrast to previous studies , we did not demonstrate any improvement in outcome by formalizing our existing pathway using a written protocol . Consequently , improvements in short-term outcome from esophagectomy within ERAS would seem to be primarily due to improvements in components of perioperative care . Consequently , we would recommend that centers introducing new ( or review ing existing ) ERAS pathways for esophagectomy focus on optimizing clinical aspects of such st and ardized pathways Introduction Surgeons routinely use nasogastric ( NG ) tubes in most esophageal resection surgeries . Considering the numerous complications caused by using the tube and the uncertainty about its usefulness and the scarcity of studies conducted on the subject , particularly in patients with esophageal cancer , the necessity of using the tube in these types of cases is investigated in the present study . Methods In this clinical trial , patients with esophageal cancer were r and omized into groups with NG tube and without NG tube after surgery ; the latter were prescribed Metoclopramide , as well . The variables recorded for each patient included the first day of gas passage , defecation and bowel sounds ( BSs ) auscultation , as well as the duration of postoperative hospitalization , nausea and vomiting , abdominal distension , pulmonary complications , wound complications , anastomosis leak , and the need for placing/replacing the NG tube . Results The incidence of anastomosis leak was significantly higher in the NG-tube group ( 6 vs. 0 ; P = 0.016 ) . Other complications were not different in the two groups . The mean time of gas passage , defecation , BS auscultation , and the duration of postoperative hospitalization did not have meaningful differences in the two groups . The need for placing/replacing the NG tube was the same for both groups . Conclusions The routine application of NG tubes after surgery is not recommended for all patients . We suggest that NG tubes should be used according to the specific problems of each patient Introduction Guidelines recommend incorporation of more than 20 perioperative interventions within an enhanced recovery program ( ERP ) . However , the impact of overall adherence to the pathway and the relative contribution of each intervention are unclear . The aim of this study was to estimate the extent to which adherence to ERP elements is associated with outcomes and identify key ERP elements predicting successful recovery following bowel resection . Methods Prospect ively collected data entered in a registry specifically design ed for ERPs were review ed . Patients undergoing elective bowel resection between 2012 and 2014 were treated within an ERP comprising 23 care elements . Primary outcome was successful recovery defined as the absence of complications , discharge by postoperative day 4 and no readmission . Secondary outcomes were length of hospital stay ( LOS ) , 30-day morbidity , and severity ( Comprehensive complication index , CCI , 0–100 ) . Regression analyses were adjusted for potential confounders . Results A total of 347 patients were included in the study .  Median primary LOS was 4 days ( IQR 3–7 ) . Patients were adherent to median 18 ( IQR 16–20 ) elements . A total of 156 ( 45 % ) patients had successful recovery . Morbidity occurred in 175 ( 50 % ) patients with median CCI 8.6 ( IQR 0–22.6 ) . There was a positive association between adherence and successful recovery ( OR 1.39 for every additional element , p < 0.001 ) , LOS ( 11 % reduction for every additional element , p < 0.001 ) , 30-day postoperative morbidity ( OR 0.78 , p < 0.001 ) , and the CCI ( 17 % reduction , p < 0.001 ) . Laparoscopy ( OR 4.32 , p < 0.001 ) , early mobilization out of bed ( OR 2.25 , p = 0.021 ) , and early termination of IV fluid infusion ( OR 2.00 , p = 0.013 ) significantly predicted successful recovery . These factors were also associated with reduced morbidity and complication severity . Conclusions Increased adherence to ERP interventions was associated with successful early recovery and a reduction in postoperative morbidity and complication severity . In an established ERP where overall adherence was high , laparoscopic approach , perioperative fluid management , and patient mobilization remain key elements associated with improved outcomes Background There is a need for evidence of the clinical effectiveness of minimally invasive surgery for the treatment of esophageal cancer , but r and omized controlled trials in surgery are often difficult to conduct . The ROMIO ( R and omized Open or Minimally Invasive Oesophagectomy ) study will establish the feasibility of a main trial which will examine the clinical and cost-effectiveness of minimally invasive and open surgical procedures for the treatment of esophageal cancer . Methods / Design A pilot r and omized controlled trial ( RCT ) , in two centers ( University Hospitals Bristol NHS Foundation Trust and Plymouth Hospitals NHS Trust ) will examine numbers of incident and eligible patients who consent to participate in the ROMIO study . Interventions will include esophagectomy by : ( 1 ) open gastric mobilization and right thoracotomy , ( 2 ) laparoscopic gastric mobilization and right thoracotomy , and ( 3 ) totally minimally invasive surgery ( in the Bristol center only ) . The primary outcomes of the feasibility study will be measures of recruitment , successful development of methods to monitor quality of surgery and fidelity to a surgical protocol , and development of a core outcome set to evaluate esophageal cancer surgery . The study will test patient-reported outcomes measures to assess recovery , methods to blind participants , assessment s of surgical morbidity , and methods to capture cost and re source use . ROMIO will integrate methods to monitor and improve recruitment using audio recordings of consultations between recruiting surgeons , nurses , and patients to provide feedback for recruiting staff . Discussion The ROMIO study aims to establish efficient methods to undertake a main trial of minimally invasive surgery versus open surgery for esophageal cancer . Trial registration The pilot trial has Current Controlled Trials registration number IS RCT N59036820(25/02/2013 ) at http://www.controlled-trials.com ; the ROMIO trial record at that site gives a link to the original version of the study protocol Purpose This study aims to investigate the influence of fast-track surgery ( FTS ) on insulin resistance indicators in a prospect i ve r and omized , controlled clinical trial in esophageal cancer patients . Methods Between November 2009 and March 2011 , 34 patients underwent the FTS pathway , and 34 patients underwent the conventional pathway after esophagectomy in our department . The times to postoperative flatus and defecation , duration of postoperative hospital stay , hospitalization expenditures , and postoperative complications were recorded . Insulin resistance indicators were measured before operation as well as on the 1st , 3rd , and 7th postoperative days ( PODs ) , including serum levels of fasting blood glucose ( FBG ) , fasting insulin ( FINS ) , interleukin-6 ( IL-6 ) , and C-reactive protein ( CRP ) in patients of both groups . The insulin resistance index ( homeostasis model assessment of insulin resistance ( HOMA-IR ) ) was calculated at each time point . Results We found a significantly shorter postoperative hospital stay and faster return of gastrointestinal function in patients who underwent  FTS  ( P < 0.01 ) . In addition , the total hospitalization expenditure was significantly lower in the FTS group ( P < 0.01 ) . The preoperative insulin resistance indicators showed no significant differences between the two groups . On PODs 1 and 3 , the levels of log-HOMA-IR , FINS , IL-6 , and CRP in the FTS group were significantly lower than those in the control group ( all P < 0.05 ) . On POD 7 , the CRP level in the FTS group was significantly lower than that in the control group ( P < 0.05 ) . Conclusions FTS promotes early recovery of gastrointestinal function and reduces stress reaction and postoperative insulin resistance after esophagectomy for esophageal cancer BACKGROUND Surgical resection is regarded as the only curative option for resectable oesophageal cancer , but pulmonary complications occurring in more than half of patients after open oesophagectomy are a great concern . We assessed whether minimally invasive oesophagectomy reduces morbidity compared with open oesophagectomy . METHODS We did a multicentre , open-label , r and omised controlled trial at five study centres in three countries between June 1 , 2009 , and March 31 , 2011 . Patients aged 18 - 75 years with resectable cancer of the oesophagus or gastro-oesophageal junction were r and omly assigned via a computer-generated r and omisation sequence to receive either open transthoracic or minimally invasive transthoracic oesophagectomy . R and omisation was stratified by centre . Patients , and investigators undertaking interventions , assessing outcomes , and analysing data , were not masked to group assignment . The primary outcome was pulmonary infection within the first 2 weeks after surgery and during the whole stay in hospital . Analysis was by intention to treat . This trial is registered with the Netherl and s Trial Register , NTR TC 2452 . FINDINGS We r and omly assigned 56 patients to the open oesophagectomy group and 59 to the minimally invasive oesophagectomy group . 16 ( 29 % ) patients in the open oesophagectomy group had pulmonary infection in the first 2 weeks compared with five ( 9 % ) in the minimally invasive group ( relative risk [ RR ] 0·30 , 95 % CI 0·12 - 0·76 ; p=0·005 ) . 19 ( 34 % ) patients in the open oesophagectomy group had pulmonary infection in-hospital compared with seven ( 12 % ) in the minimally invasive group ( 0·35 , 0·16 - 0·78 ; p=0·005 ) . For in-hospital mortality , one patient in the open oesophagectomy group died from anastomotic leakage and two in the minimally invasive group from aspiration and mediastinitis after anastomotic leakage . INTERPRETATION These findings provide evidence for the short-term benefits of minimally invasive oesophagectomy for patients with resectable oesophageal cancer . FUNDING Digestive Surgery Foundation of the Unit of Digestive Surgery of the VU University Medical Centre OBJECTIVE To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery . DESIGN A nonr and omized , observational study with propensity score-guided case-control matching of prospect ively collected data . SETTING Three interrelated , university-affiliated , community hospitals . PARTICIPANTS Three thous and three hundred seventeen patients undergoing elective or urgent coronary artery , valve repair or replacement , or combined surgery between 2000 and 2006 . INTERVENTIONS  Tracheal extubation  occurred , based on history and intraoperative events , either immediately in the operating room or in the intensive care unit . MEASUREMENTS AND MAIN RESULTS Of 3,317 patients in the institutions ' Society of Thoracic Surgeons data base , 3,089 were extubated within 24 hours , 69 % of them in the operating room . Only 0.6 % of patients extubated in the operating room required reintubation , compared with 5.9 % extubated in the intensive care unit ( p < 0.0001 ) . By logistic regression , 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data , representing the likelihood of immediate extubation ( c-statistic = 0.727 ) . A " greedy 5 to 1 " propensity score-matching technique created 713 matched pairs of patients by extubation pathway . Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average ( median from 46 to 27 hours , p < 0.0001 ) and in hospital length of stay by 0.8 days on average ( median = 6 for each , p < 0.0001 ) . Cox regression , using matched pairs as strata , identified the following independent predictors of length of stay in the intensive care unit and hospital : immediate extubation in the operating room , need for reintubation , postoperative renal failure , and postoperative atrial fibrillation . CONCLUSIONS Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays . Immediate extubation rarely result ed in tracheal re-intubation Postoperative ventilation and admission to the intensive care unit ( ICU ) is the st and ard of care in liver transplantation and comprises a significant proportion of transplantation costs . Because immediate postoperative extubation has been reported previously in a selected group of liver transplant recipients , we question ed whether this protocol could be extended to a larger group of patients . We also sought to determine the proportion of patients extubated immediately after surgery that could be transferred to the surgical ward without intervening ICU care . Of 147 patients studied in a prospect i ve trial of sequential liver transplant recipients ( who were not second-transplant recipients , United Network for Organ Sharing status 1 , living donor transplant recipients , or dead before the end of surgery ) , 13 patients did not meet postsurgical criteria for early extubation and 111 patients were successfully extubated . Eighty-three extubated patients were transferred to the surgical ward after a routine admission to the postoperative care unit . Only 3 patients who were transferred to the surgical ward experienced complications that required a greater intensity of nursing care . A learning curve detected during the 3-year study period showed that attempts to extubate increased from 73 % to 96 % and triage to the surgical ward increased from 52 % to 82 % without compromising patient safety . The use of this protocol in our institution result ed in a 1-day reduction in ICU use in 75.5 % of study subjects . We therefore conclude that the majority of liver transplant recipients can be extubated safely and admitted to the surgical ward after liver transplantation surgery , thus decreasing the cost associated with ICU care Nutritional depletion is commonly observed in patients undergoing surgical treatment for a gastrointestinal malignancy . An appropriate nutritional intervention could be associated with improved postoperative outcomes . The study was aim ed to determine the effect of a program of gastrointestinal rehabilitation and early postoperative enteral nutrition upon complications and clinical outcomes in patients who experienced gastrointestinal surgery for cancer . This is a prospect i ve study ( 2013 January–2015 December ) of 465 consecutive patients su bmi tted to gastrointestinal surgery for cancer and admitted to an Oncological Intensive Care Unit . The program of gastrointestinal rehabilitation and early postoperative enteral nutrition consisted on : ( 1 ) general rules : pain relive , early mobilization , antibiotic prophylaxis , deep vein thrombosis prophylaxis and respiratory physiotherapy ; and ( 2 ) gastrointestinal rules : gastric protection , control of postoperative nausea and vomiting , early nasogastric tube remove and early enteral nutrition . The most frequent surgical sites were colorectal ( 44.9 % ) , gynecological with intestinal suturing ( 15.7 % ) and esophagus/stomach ( 11.0 % ) . Emergency surgery was performed in 12.7 % of patients . The program of intestinal rehabilitation and early postoperative enteral nutrition  reduced major complications ( 19.2 vs. 10.2 % ; p = 0.030 ) , respiratory complications ( p = 0.040 ) , delirium ( p = 0.032 ) , infectious complications ( p = 0.047 ) and gastrointestinal complications ( p < 0.001 ) . Intensive care unit mortality ( p = 0.018 ) , length of intensive care unit stay ( p < 0.001 ) and length of hospitalization ( p < 0.001 ) were reduced as well . A program of gastrointestinal rehabilitation and early postoperative enteral nutrition is associated with reduced postoperative complications and improved clinical outcomes in patients undergoing gastrointestinal surgery for cancer PURPOSE Enhanced recovery pathways ( ERP ) decrease morbidity and duration of stay after colorectal surgery . There is little information about their role in complex procedures , such as esophagectomy . The purpose of this study was to determine the impact of an ERP on duration of stay , complications , and readmissions after esophagectomy . METHODS Patients undergoing esophagectomy for cancer or high- grade dysplasia from June 2009 to December 2011 were identified from a prospect ively maintained data base . Beginning in June 2010 , all patients were enrolled in a 7-day multidisciplinary ERP including written patient education with daily treatment plan , indications for intensive care admission , early structured mobilization , and diet and drain management . Short-term ( 30-day ) outcomes were compared for patients undergoing esophagectomy pre- and post-pathway . Data are expressed as median values [ interquartile range ] . RESULTS We identified 106 patients ; 47 underwent esophagectomy before ERP implementation and 59 after . Patients were similar with respect to age , gender , diagnosis , and operative time .  Hospital stay was shorter in the ERP group ( 8 [ 7 - 17 ] vs 10 [ 9 - 17 ] days ; P = .01 ) . There were no differences in rates of complications ( 59 % vs 62 % ) or readmissions ( 6 % vs 5 % ) . CONCLUSION Implementation of a multidisciplinary ERP for esophagectomy was associated with decreased duration of stay , without an increase in complications or readmissions Background This review aims to present a consensus for optimal perioperative care in colonic surgery and to provide grade d recommendations for items for an evidence d-based enhanced perioperative protocol . Methods Studies were selected with particular attention paid to meta-analyses , r and omised controlled trials and large prospect i ve cohorts . For each item of the perioperative treatment pathway , available English- language literature was examined , review ed and grade d. A consensus recommendation was reached after critical appraisal of the literature by the group . Results For most of the protocol items , recommendations are based on good- quality trials or meta-analyses of good- quality trials ( quality of evidence and recommendations according to the GRADE system ) . Conclusions Based on the evidence available for each item of the multimodal perioperative care pathway , the Enhanced Recovery After Surgery ( ERAS ) Society , International Association for Surgical Metabolism and Nutrition ( IASMEN ) and European Society for Clinical Nutrition and Metabolism ( ESPEN ) present a comprehensive evidence -based consensus review of perioperative care for colonic surgery
target: A pattern of consistent evolution in fast-track protocol s was clearly demonstrated and these have shown variations in the core-identified components across the studies .
  In the future incremental gains through focused improvements in key components will lend itself to even better postoperative outcomes and patient experience during oesophageal cancer treatment
background: Fast track is a st and ardised goal directed patient 's care pathway that aims to facilitate recovery following surgery .
  Currently , there are large variations in the fast track protocol s used in oesophagectomy due to the complexity of the procedure .
  The objective of this systematic review is to assess the evolution of fast track protocol s  following oesophagectomy  since its implementation and the result ing effect on postoperative outcomes .