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
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: 630-641641
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.R et al. Fast tracking after Ivor Lewis Oesophagogastrectomy. Chest. 2004; 126: 1187-11941194 4) Cheng K et al. Fast track clinical pathway implications in oesophagogastrectomy.. W J Gastro. 2009;15 (4): 496-501
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;
Fast Track Oesophagectomy: Lack of availability of HDU / ICU beds Resulting in repeated cancellation of surgery Coincided with FTS concept ICU 4 Bed Ward
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
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
Patients and Methods: 112 consecutive patients identified 5 year period (2005-2009) 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
Parameters studied : Successful completion rate of FTO Major and minor morbidity rates Mortality rates Need for ICU admission
Characteristics Patients Study number 100 Gender Clinical Characteristics : Male Female Average Age 64 (24 84) 71 29 ASA Status 1 2 3 12 56 32 Indication Operative Approach Benign Malignant THO TTO (2 stage) TTO (3 stage) Left Thoracoabdominal 6 94 57 13 24 6 (Colonic interposition) 8
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 3 15 27 18 23 8 16 (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 37 19 (59) 13 (41)
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%
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
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)
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)
Patients ASA Operative Approach FTO failure: Reason for ICU admission ICU LOS ICU Mortalit y 1 3 3 stage Sepsis 22 Yes 2 2 3 stage Sepsis 24 3 3 THO Arrhythmia 9 4 3 3 stage Respiratory failure 18 5 3 3 stage Sepsis 7 6 3 THO Sepsis 11 7 2 3 stage Anastamotic failure 35 8 2 2 stage Respiratory failure 20 Yes 9 3 2 stage Anastamotic failure 5 10 3 THO Anastamotic failure 4 11 2 3 stage Respiratory failure 6 12 3 THO Respiratory failure 4 13 3 THO Anastamotic failure 12 Yes 14 2 3 stage Respiratory failure 5 Yes
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
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 )
FTO: Source Current Study (2004-2009) 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 (1991-2006) Goan et al 8 (1994-2005) Atkins et al 9 (1996-2002) 340 45% 0.3% 3.8% 11.5 216 49% 9.7% 27% 23 379 64% 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: 1395-1402 8) Goan G et al. An audit of surgical outcomes of esophageal squamous cell carcinoma. Eur J Cardiothorac Surg 2007; 31: 536-544 9) Atkins B. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78: 1170-1176
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%)
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
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
Thankyou!