An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy

Sandra C. Tomaszek, Stephen D. Cassivi, Mark S. Allen, K. Robert Shen, Francis C. Nichols, Claude Deschamps, Dennis A Wigle

Research output: Contribution to journalArticle

46 Citations (Scopus)

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. 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.

Original languageEnglish (US)
Pages (from-to)807-813
Number of pages7
JournalEuropean Journal of Cardio-thoracic Surgery
Volume37
Issue number4
DOIs
StatePublished - Apr 2010

Fingerprint

Esophagectomy
Deglutition
Hospitalization
Anastomotic Leak
Esophageal Neoplasms
Jejunostomy
Barrett Esophagus
Enteral Nutrition
Quality Improvement
Medical Records
Pneumonia
Stomach
Lung

Keywords

  • Nutrition
  • Oesophageal cancer
  • Oesophageal surgery
  • Outcomes
  • Postoperative care

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy. / Tomaszek, Sandra C.; Cassivi, Stephen D.; Allen, Mark S.; Shen, K. Robert; Nichols, Francis C.; Deschamps, Claude; Wigle, Dennis A.

In: European Journal of Cardio-thoracic Surgery, Vol. 37, No. 4, 04.2010, p. 807-813.

Research output: Contribution to journalArticle

Tomaszek, Sandra C. ; Cassivi, Stephen D. ; Allen, Mark S. ; Shen, K. Robert ; Nichols, Francis C. ; Deschamps, Claude ; Wigle, Dennis A. / An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy. In: European Journal of Cardio-thoracic Surgery. 2010 ; Vol. 37, No. 4. pp. 807-813.
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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. 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.",
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T1 - An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy

AU - Tomaszek, Sandra C.

AU - Cassivi, Stephen D.

AU - Allen, Mark S.

AU - Shen, K. Robert

AU - Nichols, Francis C.

AU - Deschamps, Claude

AU - Wigle, Dennis A

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N2 - 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.

AB - 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.

KW - Nutrition

KW - Oesophageal cancer

KW - Oesophageal surgery

KW - Outcomes

KW - Postoperative care

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