ERAS for Esophagectomy/UGI Jon O. Wee, MD Section Chief, Esophageal Surgery Director of Robotics in Thoracic Surgery Co-Director of Minimally Invasive Thoracic Surgery Associate Program Director Division of Thoracic Surgery Brigham and Women’s Hospital Assistant Professor of Surgery Harvard Medical School
ERAS for Esophagectomy/UGI
Jan 30, 2023
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PowerPoint PresentationERAS for Esophagectomy/UGI
Jon O. Wee, MD Section Chief, Esophageal Surgery Director of Robotics in Thoracic Surgery Co-Director of Minimally Invasive Thoracic Surgery Associate Program Director Division of Thoracic Surgery Brigham and Women’s Hospital Assistant Professor of Surgery Harvard Medical School
Disclosures
• Consultant with: Medtronic and Ethicon
ERAS for Upper GI
• Esophagectomy
• Gastrectomy
• Bariatric
• Czerny and Billroth first to resect cervical esophagus in 1870’s
• First successful resection of midesophageal carcinoma by Frank Torek in 1913 • Left chest, no ventilation, no chest
tube • 2hr 43 min. • Hot coffee enema with whisky and
strychnine • 8 days after resection, cervical
esophagostomy and gastrostomy connected by a rubber tube
• Lived for 13 yrs and died at age 80. • Squamous cell ca
• 1942 Oschner and Debakey summarized Torek operation. • 17 of 58 pts survived. 71% mortality.
Esophageal Cancer and Surgery
Salvage esophageal surgery after CRT : Is it a viable option Markar et al JCO 2015
• For XRT > 55 Gy (17.5%)
• SALV STD P value • Mortality 28 % 4% <0.001
• Morbidity 76% 61% 0.039
• Leak 28% 15% 0.023
• Esophagectomy • 30 dy mortality 2.4% to 5%
• 90 dy of 4.5% to 13%
• BWH 0.5% and 2.5%
Esophagectomy Pre-op nutritional assessment
Identify nutritional deficits and consider feeding tube for high risk
Approach:
Open and minimally invasive approach acceptable but MIE may have benefits without clear significant disadvantage
Esophagectomy Avoid neck drains
Minimal use of chest drains
Early enteral feeding day 3 to 6
Fluids:
No GDFT studies include esophagectomies
Optimize stroke volume during abdominal phase
Thoracic phase, avoid aggressive fluids, use pressors
Vent:
O2 sat >92%
Regular acetaminophen
NSAIDS individualized
No rec of oral vs jejunostomy nutrition
Esophagectomy
Clear drink , carbohydrate drink up to 2 hours pre-op
Avoid long acting anxiolytics (weak rec)
Beta-blocker in pts with high risk pts with CAD or those already on it.
Esopahgectomy Avoid hypothermia, temp above 36C
Glucose control <180mg/dl
Foley:
In pts with a thoracotomy or who have epidural, there is significant risk of replacement in males
Consider removal in 48 hrs, but need strict monitoring and assess for reinsertion or suprapubic catheter.
Esophagectomy at BWH
• Minimally Invasive Esophagectomy
• Thoracic Epidural (Exparel)
• No GDFT yet
• J tube feeding started POD 3
Open versus Minimally Invasive Esophagectomies
0
25
50
75
100
Open
• Zhang et al – early feeding not associated with anastomotic complications
• Sun et al • Compared early (POD1) vs late (POD7) feeding
• No increased morbidity • High QOL with early feeding
• Even early J tube feedings are often deviated due to complications • Berkelman, et al. (Netherlands) • Of 189 pts, 109 (59%)had to adjust due to anastomtic leakge, chyle leak, ARDS
Early Oral Feeding
• Nutrient II trial • Direct oral feeding after MIE • International, multicenter, randomized (132 pts)
• Early oral feeding day 1 vs day 5
• Recovery no different (day 7 vs 8, p=.4)
• Anastomotic leakage no diff (18.5% vs 16.4%, p=.8)
• Pneumonia no diff (24.6% vs 34.4%, p=.2)
• Early feeding does not seem to increase risk
Ann Surg 2019 May
• Median annual cases 26
• High Income units used more stapled anastomosis (66 vs 31%)
• Routine contrast study in 52%
World J Surg 2019 Nov.
Implementation remains an issue
• Implementation of ERA for gastric ca in Korea (Jeong,Kim 2019) • 89 surgeons responded from 161
• 65% area aware, 51% apply it
• Well adopted concepts • Pre-op education (91%), no fasting (68.5%), intra-op normothermia (80%),
thromboembolic prophylaxis (97%), early ambulation (64%), removal of foley (69%), avoid NG (77%)
• Not well adopted concepts • Avoid bowel prep (42%), pre-op carbo drink (10%), avoid drains (31%), epidural (16%),
Single antibiotic dose (19%), post-op O2 (37%), early post-op diet (15%), restrict IV fluid (54%)
ERAS for Esophagectomy/UGI
• Adoption is slow
• Less esophagectomy patients and general high acuity compared to gastric and obesity patients
• Early oral feeding, gastric decompression, intraoperative fluid management, post-op fluid management among issues that are difficult to change
• Pre-op nutrition, early mobilization, early enteral feeding are better adopted
• Foley catheter use post-op with epidurals still controversial
Thank You
Jon O. Wee, MD Section Chief, Esophageal Surgery Director of Robotics in Thoracic Surgery Co-Director of Minimally Invasive Thoracic Surgery Associate Program Director Division of Thoracic Surgery Brigham and Women’s Hospital Assistant Professor of Surgery Harvard Medical School
Disclosures
• Consultant with: Medtronic and Ethicon
ERAS for Upper GI
• Esophagectomy
• Gastrectomy
• Bariatric
• Czerny and Billroth first to resect cervical esophagus in 1870’s
• First successful resection of midesophageal carcinoma by Frank Torek in 1913 • Left chest, no ventilation, no chest
tube • 2hr 43 min. • Hot coffee enema with whisky and
strychnine • 8 days after resection, cervical
esophagostomy and gastrostomy connected by a rubber tube
• Lived for 13 yrs and died at age 80. • Squamous cell ca
• 1942 Oschner and Debakey summarized Torek operation. • 17 of 58 pts survived. 71% mortality.
Esophageal Cancer and Surgery
Salvage esophageal surgery after CRT : Is it a viable option Markar et al JCO 2015
• For XRT > 55 Gy (17.5%)
• SALV STD P value • Mortality 28 % 4% <0.001
• Morbidity 76% 61% 0.039
• Leak 28% 15% 0.023
• Esophagectomy • 30 dy mortality 2.4% to 5%
• 90 dy of 4.5% to 13%
• BWH 0.5% and 2.5%
Esophagectomy Pre-op nutritional assessment
Identify nutritional deficits and consider feeding tube for high risk
Approach:
Open and minimally invasive approach acceptable but MIE may have benefits without clear significant disadvantage
Esophagectomy Avoid neck drains
Minimal use of chest drains
Early enteral feeding day 3 to 6
Fluids:
No GDFT studies include esophagectomies
Optimize stroke volume during abdominal phase
Thoracic phase, avoid aggressive fluids, use pressors
Vent:
O2 sat >92%
Regular acetaminophen
NSAIDS individualized
No rec of oral vs jejunostomy nutrition
Esophagectomy
Clear drink , carbohydrate drink up to 2 hours pre-op
Avoid long acting anxiolytics (weak rec)
Beta-blocker in pts with high risk pts with CAD or those already on it.
Esopahgectomy Avoid hypothermia, temp above 36C
Glucose control <180mg/dl
Foley:
In pts with a thoracotomy or who have epidural, there is significant risk of replacement in males
Consider removal in 48 hrs, but need strict monitoring and assess for reinsertion or suprapubic catheter.
Esophagectomy at BWH
• Minimally Invasive Esophagectomy
• Thoracic Epidural (Exparel)
• No GDFT yet
• J tube feeding started POD 3
Open versus Minimally Invasive Esophagectomies
0
25
50
75
100
Open
• Zhang et al – early feeding not associated with anastomotic complications
• Sun et al • Compared early (POD1) vs late (POD7) feeding
• No increased morbidity • High QOL with early feeding
• Even early J tube feedings are often deviated due to complications • Berkelman, et al. (Netherlands) • Of 189 pts, 109 (59%)had to adjust due to anastomtic leakge, chyle leak, ARDS
Early Oral Feeding
• Nutrient II trial • Direct oral feeding after MIE • International, multicenter, randomized (132 pts)
• Early oral feeding day 1 vs day 5
• Recovery no different (day 7 vs 8, p=.4)
• Anastomotic leakage no diff (18.5% vs 16.4%, p=.8)
• Pneumonia no diff (24.6% vs 34.4%, p=.2)
• Early feeding does not seem to increase risk
Ann Surg 2019 May
• Median annual cases 26
• High Income units used more stapled anastomosis (66 vs 31%)
• Routine contrast study in 52%
World J Surg 2019 Nov.
Implementation remains an issue
• Implementation of ERA for gastric ca in Korea (Jeong,Kim 2019) • 89 surgeons responded from 161
• 65% area aware, 51% apply it
• Well adopted concepts • Pre-op education (91%), no fasting (68.5%), intra-op normothermia (80%),
thromboembolic prophylaxis (97%), early ambulation (64%), removal of foley (69%), avoid NG (77%)
• Not well adopted concepts • Avoid bowel prep (42%), pre-op carbo drink (10%), avoid drains (31%), epidural (16%),
Single antibiotic dose (19%), post-op O2 (37%), early post-op diet (15%), restrict IV fluid (54%)
ERAS for Esophagectomy/UGI
• Adoption is slow
• Less esophagectomy patients and general high acuity compared to gastric and obesity patients
• Early oral feeding, gastric decompression, intraoperative fluid management, post-op fluid management among issues that are difficult to change
• Pre-op nutrition, early mobilization, early enteral feeding are better adopted
• Foley catheter use post-op with epidurals still controversial
Thank You
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