1. Early Experience of Enhanced Recovery following Oesophagectomy Charles Rayner Foundation Year 2 Doctor Northern Oesophago-Gastric Unit, RVI

2. What is Enhanced Recovery after Surgery (ERAS)? “A multimodal perioperative care pathway designed to achieve early recovery for patients undergoing major surgery” ERAS® Society www.erassociety.org

3. Improve Outcomes and Efficiency Ensuring patient-centred care Early return to premorbid state – Restoring patient’s physiology – Improving response to complications Reduce complications Reduce hospital stay Reduce costs

4. Benefits of Enhanced Recovery Majority of publications involve colorectal surgery – Reduce postoperative complications by up to 50% – Reduce length of stay 1 Two recent Cochrane reviews for colorectal surgery – Fewer (minor) complications – Reduced mortality (not significant) – Reduced length of hospital stay Few publications for upper GI surgery 1. Varadhan et al Clin Nutr 2010

5. Upper GI ERAS AuthorsOesophagus? Gastric? MorbidityLength of StayOther Cerfolio USA 2004 O (90)Low USA 2007/2010 O (340/463)Low Munitiz Spain 2010 O (74) (Conv 74) Reduced Grantcharov Canada 2010 G (32)Low Liu China 2010 G (33) (Conv 30) No differenceReducedQuicker gut function Wang China 2011 G (45) (Conv 47) Reduced (ns)Reduced Barlow UK 2011 O (58), G (38)Reduced Yamada Japan 2012 G (91) (Conv 100) No difference Quicker gut function Less pain Preston UK 2013 O (12) (Conv 24) Reduced

6. Our Vision Patient empowerment – Active role – Realistic, achievable goals Staff expectation Early start Early mobilisation Optimal fluid management Feeding protocol Reduce morbidity & mortality Reduce length of stay

7. Management AdmissionDay before surgery Surgery start time9.30-11.00am OperationIvor lewis Retraction scapulaAlways Feeding jejunostomy Varies Intraoperative fluidsVaries Postoperative mobilisation Varies IVT Day 0125ml/h Fluid managementVaries Drain removalVaries

8. Management AdmissionDay before surgery Surgery start time9.30-11.00am08.00am OperationIvor lewisIvor Lewis Retraction scapulaAlwaysRarely Feeding jejunostomy VariesAlways Intraoperative fluidsVariesMeasured Postoperative mobilisation VariesPriority IVT Day 0125ml/h1ml/kg/h Fluid managementVariesStandardised Drain removalVariesUsually days 3 & 5-6

9. Aim Examine outcomes following introduction of an enhanced recovery pathway for patients undergoing oesophagectomy

10. Methods Prospective database Group 1: Jan – Jun 2013 Group 2: May – Oct 2012 Demographics Lengths of critical care and hospital stay Morbidity (Accordion) 30-day readmission rates In-hospital mortality

11. Demographics Group 1Group 2 No. of patients2120 Male : Female14 : 713 : 7 Median age / years64 (42 – 77)69.5 (21 – 79) Current smokers43 Ex-smokers95 BMI / kg/m 2 25.2 (19.0 – 36.2)25.8 (20.3 – 37.5)

12. Outcomes Group 1Group 2 Complications1017 Accordion grade 288 Accordion grade 311 Accordion grade 413 Accordion grade 502 Mortality00 Critical care stay / days2 (1 – 27)3 (1-45) Hospital stay / days10 (6 – 41)14 (8-73) Readmissions31

13. Group 1 Readmissions ReasonTime after discharge / days Length of readmission / days 1Chest infection1412 2Delayed gastric emptying178 3Poor oral intake214

14. Summary Formal enhanced recovery pathway can be introduced safely Major complications, lengths of critical care and hospital stay have reduced Small numbers Continued prospective evaluation

15. Acknowledgements S Wahed, A Immanuel, SM Griffin, B Dent, A Hood