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Esophagectomy; It's Not Just About Mortality Anymore: Standardized Peri-Operative Clinical Pathways Improve Outcomes in Patients with Esophageal Cancer
Donald E. Low*
Surgery, Virginia Mason Medical Center, Seattle, WA

Background: Recent reports assessing national databases have demonstrated high mortality rates in patients requiring esophagectomy. Esophageal resection (ER) remains the standard therapy for cancer, however, due to concerns regarding unacceptable levels of morbidity and mortality, many patients are relegated to less effective endoscopic or chemotherapeutic approaches.
Methods: All patients undergoing esophagectomy by a single surgeon for cancer or high-grade dysplasia between 05/91-05/06 were prospectively entered into an IRB-approved database.
Results: 340 consecutive patients, mean age 64 (33-90), underwent ER for stage 0-17, I-87, II-133, III-94, IV-9. 139 (41%) had neoadjuvant therapy. 63% were ASA class III or IV, and 5 different operative approaches were used. R0 resections were achieved in 96%. Anastomoses were cervical 60% and thoracic 40%. Patient were managed intra-operatively with a "fluid restriction" protocol. Mean intra-operative blood loss was 230 cc. 99.5% were extubated immediately and mean ICU and hospital stays were 2.25 (1-30) and 11.5 (6-49) days, respectively. 30 (8.8%) required intra- or post-operative transfusions. All patients had patient-controlled epidural analgesia and 86% were mobilized on Day 1 following surgery. Complications occurred in 153 patients (45%), most commonly atrial dysrhythmia (13%), and post-operative delirium (11%). Anastomotic leaks occurred in 13 patients (3.8%). Mortality occurred in 1 patient (.3%). No significant differences were seen in length of stay, operative time, blood loss, or complications in patients receiving neoadjuvant therapy. For stage I patients between 1998-2004 Kaplan-Meier 5-year cumulative survival 92.3%, mean survival 83.6 mos. (95% C.I.; 75.2-92 mos.).
Conclusions: Surgical treatment of esophageal cancer can be done with moderate morbidity and very low mortality and improved levels of survival, especially in early-stage patients. Surgeons must increase efforts to minimize blood loss and transfusions, improve post-operative pain control and extubation rates, and facilitate early mobilization. ER as sole therapy or in combination with radiation/chemotherapy should remain the standard of care in appropriate patients with esophageal cancer.

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