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Objectives: Esophagogastrectomy is a complex operation and the postoperative management is variable. We hypothesized that waiting 5 days postoperatively to obtain a contrast swallow to start oral intake and then waiting until patients were able to take sufficient oral intake before discharge prolongs hospitalization after an Ivor Lewis esophagogastrectomy. To examine this hypothesis we analyzed two methods of management of postoperative nutrition after surgery.
Methods: After IRB approval, we retrospectively queried our prospective database for patients who underwent an Ivor Lewis esophagogastrectomy for esophageal cancer. We identified 220 patients from May 2001 to December 2012. Pathway one consisted of 110 patients, operated on between May 2001 and January 2007, who had contrast examination on postoperative day (POD) # 5, and if no anastomotic leak was seen, progression of oral intake from clear liquids on POD#5, full liquids on POD#6 and soft solids on POD#7. They were discharged on a soft solid postgastrectomy diet. Pathway two consisted of 110 patients operated on between January 2007 and December 2012 who had no postoperative contrast swallow, jejunal tube feedings starting POD #1 at 20cc/hr advancing 10cc/12 hours until goal and discharge NPO on jejunal tube feedings only for 1 month then gradual increasing oral intake and eliminating tube feedings by 6 weeks postoperatively. Factors analyzed included demographics, length of stay, complications and weight changes.
Results: Overall there were 188 (85.5%) men; median age was 64 years (range 32-89). Table 1 show the patient characteristics overall and of the two pathways. Median length of stay was 10days (range 7-98) in pathway one and only 7 days (range 5-54) in pathway two. Complication rates were similar in the two groups: 37.2% in pathway one and 42.7% in pathway two. The anastomotic leak rate was higher in pathway one compared to pathway two: 4.5% vs. 1.8% respectively. There was no difference in the median weight loss from discharge to the 6 week follow-up visit between the two groups: 6.8 kg in pathway one patients vs. 6.4 kg in pathway two patients.
Conclusion: Changing the postoperative nutritional management after an Ivor Lewis esophagogastrectomy to no contrast swallow and delaying oral intake for one month results in a shorter length of stay and reduced anastomotic leaks, but no change in the overall complication rate or early postoperative weight loss.
Patient Characteristics

Characteristic	Overall (n=220)	Pathway 1 (n=110)	Pathway 2 (n=110)
Men (%)	85.5	87.2	83.6
Median age (range)	64 (32 - 89)	64 (32 - 89)	63 (33 - 84)
Preop chemo/XRT (%)	69.1	61.8	76.4
Clinical Stage ≥ IIIA	53.6	51.8	55.5
Adenocarcinoma (%)	86.8	88.2	85.5

Preop chemo/XRT - Preoperative chemotherapy and radiation therapy