Clinical application of enhanced recovery after surgery in thoracoscopic and laparoscopic esophagectomy for esophageal cancer / 中华消化外科杂志

ABSTRACT

Objective To investigate the application value and feasibility of enhanced recovery after surgery (ERAS) in thoracoscopic and laparoscopic esophagectomy for esophageal cancer.Methods The clinical data of 304 patients with esophageal cancer who were admitted to the Affiliated Cancer Hospital of Zhengzhou University from December 2013 and July 2014 were retrospectively analyzed.All the patients underwent esophagogastric partial resection, esophagogastric cervical anastomosis and 2-field lymph node dissection under general anesthesia.The management of 195 patients guided by ERAS were allocated to the ERAS group and 109 patients receiving perioperative traditional treatments were allocated to the control group.Observing indicators included (1) enteral and parenteral nutritional support treatments;(2) nutrient indexs levels of serum albumin (Alb) and prealbumin;(3) the recovery of gastrointestinal function time to anal exsufflation and defecation;(4) postoperative complications and the grading according to Clavien standard;(5) duration of postoperative hospital stay and treatment expenses;(6) risk factors affecting postoperative complications by multivariate analysis;(7) independent risk factors affecting occurrence rate of postoperative complications by univariate analysis.Measurement data with normal distribution were presented as (x) ± s and analyzed using the t test.Nonnormal distribution data were analyzed by the Wilcoxon rank sum test.Comparison of repeated data was analyzed by the repeated measures ANOVA.Categorical variables were analyzed using the chi-square test or Fisher's exact probability.The multiple linear regression analysis and Logistic regression were used to measure the multivariate analysis of continuous variables and binary variable, respectively.Results (1) During the enteral and parenteral nutritional support treatments, 11 patients with surgery-related complications in the ERAS group didn't receive oral intake at postoperative day 1,26 proceeded the intravenous rehydration at postoperative day 4 due to calorie intake less than 80％ of calorie requirement, and enteral nutritional support treatment was well-tolerated in the control group.(2) Comparison of nutrient indexs the levels of serum Alb and prealbumin at postoperative day 1, 3 and 5 were (37.2±3.9)g/L, (39.1 ±3.5)g/L, (38.5 ±3.0)g/L and (0.20 ±0.06)g/L, (0.13 ±0.04)g/L, (0.13 ±0.04)g/L in the ERAS group, (37.7 ±2.8)g/L, (39.0 ±3.6)g/L, (38.4 ±3.8)g/L and (0.18 ± 0.06) g/L, (0.13 ± 0.04) g/L, (0.13 ± 0.04) g/L in the control group, respectively, showing no significant difference in the postoperative changing trends between the 2 groups (F =0.357, 0.453, P ＞ 0.05).(3) The recovery of gastrointestinal function time to first anal exsufflation and first defecation were (2.1 ± 0.8) days and (3.4 ± 1.2) days in the ERAS group, (3.2 ± 0.9) days and (5.5 ± 1.5) days in the control group, respectively,showing significant differences between the 2 groups (t =-10.505,-13.174, P ＜0.05).(4) There was no death in the perioperative period.The overall incidences of postoperative complications and number of patients with severe complications were 26.15％ (51/195) and 8 in the ERAS group, 30.28％ (33/109) and 8 in the control group, with no significant difference between the 2 groups (x2=0.594, 1.469, P ＞ 0.05).Eight and 10 patients in the ERAS and control groups underwent gastrointestinal decompression, 6 and 8 patients in the ERAS and control groups underwent retreatment in the intensive care unit (ICU), 3 and 2 patients in the ERAS and control groups were readmitted to the hospital at 3 weeks after discharge, with no significant difference in the above indexes (x2=0.185, 2.892, P ＞0.05).(5)The duration of postoperative hospital stay and treatment expenses were (6.8 ±2.4)days and (25 088 ±10 336)yuan in the ERAS group, (11.1 ±3.4)days and (38 819± 14 854)yuan in the control group, showing significant differences between the 2 groups (t =-12.782,-9.452,P ＜ 0.05).(6) The age, gender, preoperative weight loss ＞ 10％, tumor staging, tumor differentiation,neoadjuvant chemotherapy and time of food intake were risk factors affecting incidence of postoperative complication in patients with esophageal cancer by the univariate analysis (x2=2.484, 2.333, 0.061, 8.553,2.459, 0.163, 3.462, P ＜ 0.05).(7) The age, preoperative weight loss ＞ 10％, tumor staging and neoadjuvant chemotherapy were independent risk factors affecting incidence of postoperative complication in patients with esophageal cancer by the multivariate analysis (OR =0.365, 10.761,0.290, 8.140, 95％ confidence interval0.198-0.671, 4.122-28.095, 0.130-0.645, 3.946-16.791, P ＜0.05), but time of food intake was not an independent risk factor (OR =0.540, 95％ CI 0.280-1.041, P ＞ 0.05).Conclusions ERAS in the esophageal minimally invasive surgery for esophageal cancer is safe and feasible, with the advantages of shorter recovery time of gastrointestinal function and duration of hospital stay, lower treatment expenses and a better application value compared with traditional treatment.