An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy

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• 作者：S ; ra C. Tomaszek ; Stephen D. Cassivi ; Mark S. Allen ; K. Robert Shen ; Francis C. Nichols III ; Claude Deschamps ; Dennis A. Wigle
• 关键词：Oesophageal cancer ; Oesophageal surgery ; Nutrition ; Postoperative care ; Outcomes
• 刊名：European Journal of Cardio-Thoracic Surgery
• 出版年：2010
• 出版时间：April 2010
• 年：2010
• 卷：37
• 期：4
• 页码：807-813
• 全文大小：130 K

文摘

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.