An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy

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. (C) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.