Fast tracking after Ivor Lewis esophagogastrectomy.
OBJECTIVE
We streamlined our care using an algorithm for the postoperative care of patients who undergo Ivor Lewis esophagogastrectomy to try to reduce hospital stay to 7 days and maintain safety and patient satisfaction.


METHODS
A consecutive series of 90 patients who underwent elective esophageal resection by one general thoracic surgeon were studied. An algorithm to guide postoperative care was used, featuring avoidance of the ICU, early ambulation, jejunal tube feeds starting on postoperative day (POD) 1, removal of nasogastric tube and epidural on POD 3, a gastrograffin swallow on PODs 4 or 5, and discharge on POD 7.


RESULTS
There were 90 patients (70 men). Fifty-two patients (58%) underwent preoperative radiation and chemotherapy. Esophagectomies were done for cancer or high-grade dysplasia. Forty-two of the last 55 patients (77%) went directly to the floor. Sixteen patients (17.7%) had major complications, which included pneumonia in 5 patients and aspiration pneumonia in 4 patients. There were no anastomotic leaks, and there were four operative deaths (4.4%). There was a greater incidence of failure to fast track, and to have a major complication in patients who underwent neoadjuvant treatment (p = 0.025 and p = 0.048, respectively). Median hospital stay was 7 days (range, 6 to 74 days). Complications or mortality could not be definitively attributed to fast tracking. Ninety-seven percent reported excellent satisfaction with their hospital stay, and four patients were readmitted within 1 month of discharge.


CONCLUSIONS
Fast tracking patients using an algorithm after esophageal resection is safe and delivers minimal morbidity and mortality, and a high patient satisfaction rate. A median hospital stay of 7 days is possible, and the ICU can be avoided in most patients.
Chief of Thoracic Surgery, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, 1900 University Blvd, THT 712, Birmingham, AL 35294, USA. Robert.cerfolio@ccc.uab.edu
Robert James
RJ
Cerfolio
Ayesha S
AS
Bryant
Cynthia S
CS
Bass
Jeana R
JR
Alexander
Alfred A
AA
Bartolucci
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D019091:Critical Pathways; D016629:Esophagectomy; D005260:Female; D005743:Gastrectomy; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D017060:Patient Satisfaction; D011182:Postoperative Care / Q000592:standards*