title: An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy.
abstract: OBJECTIVE
  As part of our ongoing quality improvement effort, we evaluated our conventional approach to post-oesophagectomy management by comparing it to an alternative postoperative management pathway.
  
  
  METHODS
  Medical records from 386 consecutive patients undergoing oesophagectomy with gastric conduit for oesophageal cancer or Barrett's oesophagus with high-grade dysplasia were analysed retrospectively (July 2004 to August 2008). The conventional pathway involved a routine radiographic contrast swallow study at 5-7 days after oesophagectomy with initiation of oral intake if no leak was detected. In the alternative pathway, a feeding jejunostomy was placed for enteral feeding and used exclusively until oral intake was gradually initiated at home at 4 weeks after oesophagectomy. No contrast swallow was obtained in the alternative pathway group unless indicated by clinical suspicion of an anastomotic leak. Each group was analysed on an intention-to-treat basis with respect to anastomotic leak rates, length of hospitalisation, re-admission and other complications.
  
  
  RESULTS
  A total of 276 (72%) patients underwent conventional postoperative management, 110 (28%) followed the alternative pathway. Patient characteristics were similar in both the groups. The anastomotic leak rate was lower in the alternative pathway with three clinically significant leaks (2.7%) versus 33 in the conventional pathway (12.0%; p=0.01). Among patients undergoing a radiographic contrast swallow examination, a false-negative rate of 5.8% was observed. The swallow study of 14 patients (5.9%) was complicated by aspiration of oral contrast. Postoperatively, 7.3% of patients suffered from pneumonia. There were no significant differences overall in postoperative pulmonary or cardiac complications associated with either pathway. Median length of hospitalisation was 2 days shorter for the alternative pathway (7 days) than the conventional pathway (9 days; p<0.001). There was no significant difference in unplanned re-admission rates.
  
  
  CONCLUSIONS
  An alternative postoperative pathway following oesophagectomy involving delayed oral intake and avoidance of a routine contrast swallow study is associated with a shortened length of hospitalisation without a higher risk of complication after hospital discharge.
authors.affiliation: Division of General Thoracic Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: Sandra C
authors.initials: SC
authors.lastname: Tomaszek
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Cassivi
authors.forename: Mark S
authors.initials: MS
authors.lastname: Allen
authors.forename: K Robert
authors.initials: KR
authors.lastname: Shen
authors.forename: Francis C
authors.initials: FC
authors.lastname: Nichols
authors.forename: Claude
authors.initials: C
authors.lastname: Deschamps
authors.forename: Dennis A
authors.initials: DA
authors.lastname: Wigle
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000009:adverse effects; D001471:Barrett Esophagus / Q000601:surgery*; D019091:Critical Pathways; D004750:Enteral Nutrition; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission / Q000706:statistics & numerical data; D011182:Postoperative Care / Q000379:methods*; D012189:Retrospective Studies