FTS Oesophagectomy: minimal research to date 3,4

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Terence McCormick
5 years ago
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1 Fast Track Programme in patients undergoing Oesophagectomy: A Single Centre 5 year experience Sullivan J, McHugh S, Myers E, Broe P Department of Upper Gastrointestinal Surgery Beaumont Hospital Dublin, Ireland

2 Fast Track Surgery (FTS) or Enhanced recovery after surgery (ERAS) - proposed by Kehlet et al 1 Introduction: 1) Kehlet H, Wilmore DW. Multimodal strategies to improve surgical outcome. Am J Surg 2002; 183:

3 is an interdisciplinary, multimodal concept which proposes changes to traditional peri- operative care to reduce the stress response evoked by surgery allowing for accelerated postoperative recovery, reduce general morbidity and shorter hospital stays

FTS Colorectal Surgery: FTS Oesophagectomy: minimal research to date 3,4 2) Wind.J. Elective colon surgery according to a 'fast-track' track' programme. Am J Surg.. 2009; 230: 214-222222 3) Cerfolio.

4 FTS Colorectal Surgery: FTS Oesophagectomy: minimal research to date 3,4 2) Wind.J. Elective colon surgery according to a 'fast-track' track' programme. Am J Surg ; 230: ) Cerfolio.R et al. Fast tracking after Ivor Lewis Oesophagogastrectomy. Chest. 2004; 126: ) Cheng K et al. Fast track clinical pathway implications in oesophagogastrectomy.. W J Gastro. 2009;15 (4):

5 Oesophageal resections: Demanding surgical procedure In-hospital mortality high (approx 10% in specialised centres 5 ) Prognosis is still poor High-volume institution provides the best outcomes 6 Average length of stay in most series is long and ranges from 11 to 26 days (mean 15) 5 5) Metzger R et al. High volume centers for esophagectomy: what are the number needed to achieve low postoperative mortality? Dis Esophagus 2004.) 6) Griffin SM et al.early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management. J Am Coll Surg 2002;

6 Fast Track Oesophagectomy: Lack of availability of HDU / ICU beds Resulting in repeated cancellation of surgery Coincided with FTS concept ICU 4 Bed Ward

7 Modified FTO protocol : Pre-op - Multidisplinary management POD 0 - Return to Ward ( step-down HDU ) POD 1 - Intensive physiotherapy ; chest and NG tube draining patency POD 2 - Commence Jejunal feed ; encourage ambulation POD 3 - Remove epidural and urinary catheter POD 4 - Remove chest tube ( if drainage < 100 mls ) POD 5 - Niopam swallow showing no leak oral intake

8 Aims: This study reviewed our experience of a modified fast- track programme post oesophagectomy (FTO) We aimed to assess: 1) Safety and feasibility of FTO 2) Identify patients who may require direct ICU admission

9 Patients and Methods: 112 consecutive patients identified 5 year period ( ) 2009) Data Source Theatre Logbooks / HIPE Casemix Retrospective chart review on 100 Standardised proforma to assess FTS adherence Statistical analysis using SPSS v15 with p<0.05 considered significant

10 Parameters studied : Successful completion rate of FTO Major and minor morbidity rates Mortality rates Need for ICU admission

11 Characteristics Patients Study number 100 Gender Clinical Characteristics : Male Female Average Age 64 (24 84) ASA Status Indication Operative Approach Benign Malignant THO TTO (2 stage) TTO (3 stage) Left Thoracoabdominal (Colonic interposition) 8

12 Characteristics Patients (%) Pathological 0 Stage 1 2A 2B 3 4 Location Middle 1/3 Distal 1/3 GO junction Gastric Cardia Pathology Differentiation Squamous Adeno Well Moderate Poor (17) 45 (48) 24 (25) 9 (10) 19 (20) 75 (80) 18 (19) 45 (47) 31 (34) Barrett s metaplasia 30 Neoadjuvent Treatment - Chemotherapy alone - Chemoradiotherapy (59) 13 (41)

13 Direct ICU admission rate : n = 26/100 ; 26% Direct to ward : (attempted FTO) n = 74/100 ; 74% Overall in-hospital mortality rate n = 7/100 ; 7% Overall anastamotic leak rate n = 12/100 ; 12%

14 FTO group: n = 74/100 ; (74%) The majority (81% ; n = 60/74) successfully completed ward-based post-op op recovery Admission to ICU from ward - 19% ; n = 14/74 Strict adherence to the FTO module parameters observed in 38% ; n = 23/60 FTO mean hospital stay 17 days

15 FTO Major morbidity rate: 19% ( n = 14/74 ) Major morbidities n = % Anastamotic leak 4 (5) Myocardial infarction 4 (5) Pulmonary embolism 3 (4.5) Empyema 3 (4.5)

16 FTO Minor morbidity rates: 63% ( n = 47/74 ) Minor morbidities: n = (%) RTI / Atelectasis 13 (17.5) Pulmonary effusions 10 (13.5) Cardiac arrhythmias 10 (13.5) Surgical site complication 5 (7) Pneumothorax 4 (5) Chylothorax 3 (4) Recurrent laryngeal nerve palsy 2 (3)

17 Patients ASA Operative Approach FTO failure: Reason for ICU admission ICU LOS ICU Mortalit y stage Sepsis 22 Yes stage Sepsis THO Arrhythmia stage Respiratory failure stage Sepsis THO Sepsis stage Anastamotic failure stage Respiratory failure 20 Yes stage Anastamotic failure THO Anastamotic failure stage Respiratory failure THO Respiratory failure THO Anastamotic failure 12 Yes stage Respiratory failure 5 Yes

18 A poor pre-op ASA grade was associated with a decreased tolerance of FTO ( p=0.013 ) Differences in operative approach, gender, tumour location, type or differentiation were not significantly related to decreased tolerance

19 Summary: The majority ( 81% ; 60/74 ) of patients successfully completed ward-based post-op op recovery 19% ( 14/74 ) were unable to tolerate FTO Pre-op ASA grade was predictor of later ICU admission ( p=0.013 )

20 FTO: Source Current Study ( ) FTO vs Traditional recovery protocols Patient No 74 (100) Postoperative Morbidity 63% (65%) Postoperative Mortality 5% (7%) Anastamotic leak rate 5% (12%) Mean Hospital stay 17 (21) Traditional recovery Protocols: Low et al 7 ( ) Goan et al 8 ( ) Atkins et al 9 ( ) % 0.3% 3.8% % 9.7% 27% % 5.8% 14% 15 7) Low D et al. Esophagectomy--it s not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007; 11: ) Goan G et al. An audit of surgical outcomes of esophageal squamous cell carcinoma. Eur J Cardiothorac Surg 2007; 31: ) Atkins B. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78:

21 Conclusions: FTO is feasible, safe and delivers comparable rates of morbidity and mortality than traditional recovery protocols ICU can be avoided in majority of patients (81%)

22 If majority of patients can return to ward based care directly > 1) Decreased demands for HDU / ICU beds will result in significant savings 2) Increased capacity to perform these procedures

23 Multidisciplinary team input in key to success of fast track algorithms Further analysis ( eg RCT ) is needed to identify patients who require direct ICU admission

24 Thankyou!

SETTING Fudan University Shanghai Cancer Center. RESPONSIBLE PARTY Haiquan Chen MD.

SETTING Fudan University Shanghai Cancer Center. RESPONSIBLE PARTY Haiquan Chen MD. OFFICIAL TITLE A Phase Ⅲ Study of Left Side Thoracotomy Approach (SweetProcedure) Versus Right Side Thoracotomy Plus Midline Laparotomy Approach (Ivor-Lewis Procedure) Esophagectomy in Middle or Lower