Document Detail

An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy.
MedLine Citation:
PMID:  19900819     Owner:  NLM     Status:  MEDLINE    
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.
CONCLUSION: 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.
Sandra C Tomaszek; Stephen D Cassivi; Mark S Allen; K Robert Shen; Francis C Nichols; Claude Deschamps; Dennis A Wigle
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't     Date:  2009-11-08
Journal Detail:
Title:  European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery     Volume:  37     ISSN:  1873-734X     ISO Abbreviation:  Eur J Cardiothorac Surg     Publication Date:  2010 Apr 
Date Detail:
Created Date:  2010-03-23     Completed Date:  2011-01-20     Revised Date:  2014-09-08    
Medline Journal Info:
Nlm Unique ID:  8804069     Medline TA:  Eur J Cardiothorac Surg     Country:  Germany    
Other Details:
Languages:  eng     Pagination:  807-13     Citation Subset:  IM    
Copyright Information:
Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.
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MeSH Terms
Aged, 80 and over
Anastomosis, Surgical / adverse effects
Barrett Esophagus / surgery*
Critical Pathways
Enteral Nutrition
Esophageal Neoplasms / surgery*
Esophagectomy / adverse effects,  methods
Length of Stay / statistics & numerical data
Middle Aged
Patient Readmission / statistics & numerical data
Postoperative Care / methods*
Retrospective Studies
Grant Support
K12 CA090628/CA/NCI NIH HHS; K12 CA090628-09/CA/NCI NIH HHS

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