Implementation of an enhanced recovery after surgery protocol for esophagectomy:An Evaluation in a High-Volume Tertiary Center

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols aim to optimize perioperative care, accelerate recovery, and reduce length of hospital stay (LOS). This study evaluates the implementation and evolution of an ERAS protocol for esophageal resection in a Western a high-volume tertiary center. METHODS: This retrospective cohort study analyzed all consecutive patients who underwent esophagectomy for esophageal cancer in the University Medical Center Utrecht between May 2015 and December 2023, divided into four cohorts based on protocol changes. Robot assisted minimally invasive esophagectomy with cervical esophagogastrostomy and epidural pain management was the standard of care. An ERAS protocol, focused on preoperative optimization of nutritional and physical fitness, intrathoracic anastomosis, and multidisciplinary postoperative support, was implemented in October 2016. The first cohort served as the pre-ERAS baseline, with subsequent cohorts indicating a change in protocol. Data was extracted from a prospectively maintained database. The primary outcome was median LOS. Secondary outcomes included perioperative dietary, surgical, clinical, and physiotherapeutic measures. RESULTS: A total of 526 patients were included. Median LOS decreased from 16 (IQR 11-25) days pre-ERAS to 13 (IQR 9-21),11 (IQR 8-15) and 11 (IQR 8-18) days in successive cohorts (p<0.001; HR 0.68, 95%CI 0.52-0.90, p=0.007). This reduction remained significant after adjusting for covariates (HR 0.58, 95%CI 0.44-0.77, p<.001). Median LOS of patients with textbook outcome decreased from 11 days (IQR 11-14) pre-ERAS to 10 (IQR 8-13), 10 (IQR 8-12), and 8 (IQR 7-11) days in subsequent cohorts (P<.001). Several secondary ERAS outcomes improved over the years (dietitian involvement, surgical approach, extubation in the operating room, drain/line management). A reduction in postoperative complications was observed (from 81% to 74%, P=0.033), while mortality and readmission rates remained stable. CONCLUSION: Following ERAS implementation for esophagectomy, median LOS decreased from 16 to 11 days over 7 years, with stable readmission rates. These results support ERAS as a valuable tool to optimize perioperative care leading to a significant reduction in length of postoperative hospital stay.