Esophagectomy – McGill esophagectomy pathway

Table 1 – Summary of the elements of the enhanced recovery program for esophagectomy

Pre and Intra-operative
Nutritional management
  • Routine nutritionist consultation at time of diagnosis and during neoadjuvant therapy
  • Fast track neoadjuvant chemotherapy to enable greater oral intake (10)
Patient education
  • Education booklet provided
  • Web based interactive program provided
  • Pathway is reviewed with patient at preoperative visit
Analgesia
  • Routine dual thoracic epidural catheter insertion to cover abdominal land thoracic fields (12)
Fluid management
  • Avoid fluid overload, balanced fluid administration – aim for (4-6ml/kg/hr)
Minimally invasive approach
  • Selected for high grade dysplasia or early clinical T1-T2 N0 stage cancer
Postoperative
Intensive care unit
  • Extubation in the operating room and observation in post-anesthesia care unit for 6 hours
  • Avoidance of routine intensive care unit admission
Thoracic drainage
  • Avoidance of rigid chest tubes and pleural drainage systems
  • Use of one large capacity (400ml), large bore (19Fr) soft closed suction drain
  • Remove thoracic drain when full diet tolerated and drainage < 450 ml / 24 hours
Conduit decompression
  • Nasogastric tube removed on postoperative day 2 if no conduit over-distension on X-ray
Urinary Catheter
  • Removed on postoperative day 1
Oral intake
  • No routine surgical jejunostomy
  • Once nasogastric tube removed (postoperative day 2):
    • Water on postoperative day 2
    • Clear fluid diet on postoperative day 3
    • Solid post-esophagectomy diet on postoperative day 5
Radiology
  • Daily portable upright chest X-ray until removal of chest tube
  • No routine contrast esophagram prior to solid intake (18)
Mobilization
  • Every postoperative day: Incentive spirometry every hour when awake
  • Day 1: Sit in chair for 30 minutes 2 times, ambulate ½ length of hallway 2 times
  • Day 2: Sit in chair for 30 minutes 3 times, ambulate ½ length of hallway 3 times
  • Day 3: Sit in chair for 60 minutes 3 times, ambulate full length of hallway 4 times
  • Day 4-5: Sit in chair for 60 minutes for all meals (3 times), ambulate full length of hallway 4 times
  • Day 6: Discharge

 

 



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