Evolution of standardized clinical pathways: refining multidisciplinary care and process to improve outcomes of the surgical treatment of esophageal cancer.
BACKGROUND
The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience.


METHODS
All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991-1996, Gp2 1997-2002, Gp3 2003-2007, and Gp4 2008-2012).


RESULTS
Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5-50) to 8 (5-115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively.


CONCLUSIONS
The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.
Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA.
Sheraz R
SR
Markar
Henner
H
Schmidt
Sonia
S
Kunz
Artur
A
Bodnar
Michal
M
Hubka
Donald E
DE
Low
D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002294:Carcinoma, Squamous Cell / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D059248:Chemoradiotherapy / Q000592:standards; D016009:Chi-Square Distribution; D015331:Cohort Studies; D003131:Combined Modality Therapy; D019091:Critical Pathways / Q000592:standards*; D016208:Databases, Factual; D018572:Disease-Free Survival; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery* / Q000628:therapy; D016629:Esophagectomy / Q000379:methods / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D033183:Interdisciplinary Communication; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D020360:Neoadjuvant Therapy / Q000592:standards*; D009361:Neoplasm Invasiveness / Q000473:pathology; D009367:Neoplasm Staging; D058996:Quality Improvement; D012189:Retrospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult