ERAS for Esophagectomy/UGI

Jon O. Wee, MDSection Chief, Esophageal SurgeryDirector of Robotics in Thoracic SurgeryCo-Director of Minimally Invasive Thoracic SurgeryAssociate Program DirectorDivision of Thoracic SurgeryBrigham and Women’s HospitalAssistant Professor of Surgery Harvard Medical School

Disclosures

• I have the following relevant financial relationship(s) with commercial interest(s) involved in products and/or services discussed in this CME activity:

• Consultant with: Medtronic and Ethicon

ERAS for Upper GI

• Esophagectomy

• Gastrectomy

• Bariatric

• Czerny and Billroth first to resect cervical esophagus in 1870’s

• First successful resection of midesophageal carcinoma by Frank Torek in 1913• Left chest, no ventilation, no chest

tube• 2hr 43 min.• Hot coffee enema with whisky and

strychnine• 8 days after resection, cervical

esophagostomy and gastrostomy connected by a rubber tube

• Lived for 13 yrs and died at age 80.• Squamous cell ca

• 1942 Oschner and Debakeysummarized Torek operation. • 17 of 58 pts survived. 71% mortality.

Esophageal Cancer and Surgery

Salvage esophageal surgery after CRT : Is it a viable optionMarkar et al JCO 2015

• For XRT > 55 Gy (17.5%)

• SALV STD P value• Mortality 28 % 4% <0.001

• Morbidity 76% 61% 0.039

• Leak 28% 15% 0.023

• SS infection 30% 16% 0.02

• Pulm comp 56% 40% 0.038

• Esophagectomy • 30 dy mortality 2.4% to 5%

• 90 dy of 4.5% to 13%

• BWH 0.5% and 2.5%

• Studies have suggested improved leak rate, pulm complications, LOS

EsophagectomyPre-op nutritional assessment

Identify nutritional deficits and consider feeding tube for high risk

Approach:

Open and minimally invasive approach acceptable but MIE may have benefits without clear significant disadvantage

EsophagectomyAvoid neck drains

Consider early day 2 NG removal

Minimal use of chest drains

Early enteral feeding day 3 to 6

Fluids:

Avoid positive fluid balance >2 kg/dy

No GDFT studies include esophagectomies

Optimize stroke volume during abdominal phase

Thoracic phase, avoid aggressive fluids, use pressors

Vent:

Avoid hypoxia, allow hypercapnia

Low Vt 4-5 cc/kg ( one lung vent)

O2 sat >92%

PEEP of 5cm H2O

Esophagectomy

Pain control:

Thoracic Epidural first line approach

Regular acetaminophen

NSAIDS individualized

Gabapentinoids , ketamine, magnesium, and lidocaine unclear with no clear recommendation

No rec of oral vs jejunostomy nutrition

Esophagectomy

No bowel prep pre-op unless using colon

Clear drink , carbohydrate drink up to 2 hours pre-op

Avoid long acting anxiolytics (weak rec)

Beta-blocker in pts with high risk pts with CAD or those already on it.

EsopahgectomyAvoid hypothermia, temp above 36C

Glucose control <180mg/dl

Foley:

In pts with a thoracotomy or who have epidural, there is significant risk of replacement in males

Consider removal in 48 hrs, but need strict monitoring and assess for reinsertion or suprapubic catheter.

Esophagectomy at BWH

• Minimally Invasive Esophagectomy

• Thoracic Epidural (Exparel)

• No GDFT yet

• Early mobilization• At chair or walking by POD 1

• J tube feeding started POD 3

Open versus Minimally Invasive Esophagectomies

0

25

50

75

100

Academic Year (July 1, 2001 - June 30, 2012)

Open

Hybrid+MIEPercentage of

Total

Esophagectomies

Postoperative Complications

Perioperative Outcomes

Early oral feeding

• Controversial

• Zhang et al – early feeding not associated with anastomotic complications

• Sun et al • Compared early (POD1) vs late (POD7) feeding

• No increased morbidity• High QOL with early feeding

• Even early J tube feedings are often deviated due to complications• Berkelman, et al. (Netherlands)• Of 189 pts, 109 (59%)had to adjust due to anastomtic leakge, chyle leak, ARDS

Early Oral Feeding

• Nutrient II trial• Direct oral feeding after MIE• International, multicenter, randomized (132 pts)

• Early oral feeding day 1 vs day 5

• Recovery no different (day 7 vs 8, p=.4)

• Anastomotic leakage no diff (18.5% vs 16.4%, p=.8)

• Pneumonia no diff (24.6% vs 34.4%, p=.2)

• Early feeding does not seem to increase risk

Ann Surg 2019 May

Esophagectomy

• Oesophago-gastric Anastomosis Study Group

• International registry collaboration.

• High income vs Low income

• Median annual cases 26

• 48% had ERAS program and 22% had ERAS nurse

• High Income units used more stapled anastomosis (66 vs 31%)

• Routine contrast study in 52%

World J Surg 2019 Nov.

Implementation remains an issue

• Implementation of ERA for gastric ca in Korea (Jeong,Kim 2019)• 89 surgeons responded from 161

• 65% area aware, 51% apply it

• Well adopted concepts• Pre-op education (91%), no fasting (68.5%), intra-op normothermia (80%),

thromboembolic prophylaxis (97%), early ambulation (64%), removal of foley (69%), avoid NG (77%)

• Not well adopted concepts• Avoid bowel prep (42%), pre-op carbo drink (10%), avoid drains (31%), epidural (16%),

Single antibiotic dose (19%), post-op O2 (37%), early post-op diet (15%), restrict IV fluid (54%)

ERAS for Esophagectomy/UGI

• Adoption is slow

• Less esophagectomy patients and general high acuity compared to gastric and obesity patients

• Early oral feeding, gastric decompression, intraoperative fluid management, post-op fluid management among issues that are difficult to change

• Pre-op nutrition, early mobilization, early enteral feeding are better adopted

• Foley catheter use post-op with epidurals still controversial

Thank You