Clinical value of enhanced recovery after surgery in radical resection of esophageal carcinoma

Objective:To explore the clinical value of enhanced recovery after surgery (ERAS) in radical resection of esophageal carcinoma.
Methods:The retrospective cohort study was conducted. The clinicopathological data of 131 patients who underwent radical resection of esophageal carcinoma at the Sichuan Cancer Hospital from April 2011 to August 2014 were collected. Thirtythree patients receiving conventional perioperative management between April 2011 and April 2012 were allocated into the conventional group, 26 receiving modified perioperative management between May 2012 and December 2012 were allocated into the modified group and 72 receiving ERAS perioperative management between January 2013 and August 2014 were allocated into the ERAS group. The standards of thoracic drainagetube removal and discharge were applied to the patients in the 3 groups. Observation indicators: (1) changing of postoperative serum indexes: lymphocyte count at postoperative day 1, 4 and 7, lymphocyte ratio, levels of hemoglobin (Hb), total protein (TP) and albumin (Alb). (2) postoperative recovery: time to initial anal exsufflation, time for initial defecation, time of indwelling thoracic drainagetube, time of indwelling enteral nutritional tube, postoperative infusion time, number of cases with postoperative pulmonary infection, number of cases with postoperative anastomotic leakage (at neck and within the chest), duration of postoperative hospital stay, changes of body mass at admission and discharge and number of cases with readmission within 1 month after discharge. (3) followup situations. The followup using outpatient examination and telephone interview was performed to detect the readmission due to complications, survival of patients and tumor recurrence or metastases up to August 2016. Measurement data with normal distribution were represented as ±s. Comparisons among groups were done using AVONA, and pairwise comparison was analyzed using the LSDt test. Repeated measurement data were analyzed by the repeated measures ANOVA. Comparison of count data was analyzed using the chisquare test.
Results:(1) Changing of postoperative serum indexes: lymphocyte count at postoperative day 1, 4 and 7, lymphocyte ratio, levels of Hb, TP and Alb were (0.5±0.3)×109/L-(1.0±0.3)×109/L, 4.7%±2.2%-12.9%±4.3%, (117±9)g/L-(107±14)g/L, (51±3)g/L-(55±6)g/L, (30.2±2.2)g/L-(29.7±2.7)g/L in the conventional group and (0.5±0.3)×109/L-(1.0±0.4)×109/L, 4.5%±2.4%-12.8%±5.1%, (119±11)g/L-(107±17)g/L, (53±5)g/L-(54±4)g/L, (31.2±2.7)g/L-(28.7±2.8)g/L in the modified group and (0.6±0.3)×109/L-(1.0±0.4)×109/L, 5.8%±2.1%-13.7%±4.5%, (114±14)g/L-(102±18)g/L, (52±5)g/L-(56± 5)g/L, (30.8±2.1)g/L-(29.7±3.1)g/L in the ERAS group, respectively, with no statistically significant difference in changing trends among the 3 groups (F=0.209, 1.451, 2.327, 0.312, 0.475, P>0.05). (2) Postoperative recovery: number of cases with postoperative pulmonary infection, number of cases with postoperative anastomotic leakage at neck and within the chest and number of cases with readmission within 1 month after discharge were respectively 5, 2, 1, 0 in the conventional group and 2, 3, 0, 1 in the modified group and 3, 6, 1, 1 in the ERAS group, respectively, with no statistically significant difference among the 3 groups (χ²=3.873, 0.445, 0.430, 1.451, P>0.05). Time of indwelling thoracic drainagetube, time of indwelling enteral nutritional tube, postoperative infusion time and duration of postoperative hospital stay were (8.1±1.8)days, (11.0±1.7)days, (9.5±1.4)days, (12.1±1.7)days in the conventional group and (8.2±2.5)days, (10.2±2.2)days, (8.7±1.4)days, (12.6±5.9)days in the modified group and (6.8±1.8)days, (7.2±1.8)days, (6.7±2.1)days, (9.6±3.5)days in the ERAS group, respectively, with statistically significant differences among the 3 groups (F=5.709, 4.335, 15.756, 8.905, P<0.05). There were statistically significant differences in the above indicators between ERAS group and conventional group (t=-1.269,-1.504,-2.647,-2.742, P<0.05) and between ERAS group and modified group (t=-1.297,-1.797,-1.862,-3.190, P<0.05), and no statistically significant difference between conventional group and modified group (t=-0.027,-0.593,-0.785,-0.449, P>0.05). (3) Followup situations: 131 patients were followed up for 10- 64 months with a median time of 23 months. During the followup, 19 patients died, 3 had tumor recurrence, 4 had lymph node metastasis and 16 had other organ metastasis.
Conclusion:ERAS is safe and feasible in radical resection of esophageal carcinoma, and it can obviously improve the recovery of patients and reduce duration of postoperative hospital stay.