Institutional modified post esophagectomy care protocol offers improved perioperative outcomes – a single-center propensity score matched analysis

Abstract Background Two-field esophagectomy for esophageal cancer and tumors of the esophagogastric junction is associated with substantial postoperative morbidity and mortality. Enhanced Recovery After Surgery (ERAS ® ) protocols aim to improve perioperative outcomes through standardized multimodal care pathways. At our institution, a modified perioperative regimen has been implemented that deviates from current ERAS ® recommendations, incorporating selective oral decontamination, an enforced near-zero fluid balance, colloid administration using hydroxyethyl starch (HES), and routine nasogastric decompression. Methods We performed a retrospective analysis of 325 consecutive patients who underwent two-field esophagectomy. Of these, 279 were treated under the modified perioperative regimen, while 46 received standard care. To adjust for baseline differences, we conducted 1:1 propensity-score matching. Postoperative outcomes, including complication rates, anastomotic leakage, Comprehensive Complication Index (CCI) and textbook outcome rates were compared between groups. This trial was prospectively registered (DRKS00024369) and approved by the Medical Ethics Committee of the University of Freiburg (Reg.-Nr. 21-1093 and 21-1713). Results Prior to PSM, modified care group demonstrated a higher frequency of textbook outcomes and a significantly lower incidence of anastomotic leakage compared with standard care. Overall rates of major complications did not differ significantly between groups, though a trend toward reduced complication severity as measured by CCI was observed. After PSM, baseline characteristics were balanced. Rates of textbook outcome (Clavien-Dindo 0: 15.2% vs 28.3%, p=0.14) and severe complications (Clavien-Dindo ≥III: 39.1% vs 58.7%, p=0.095) were reduced but did not reach statistical significance. The CCI remained numerically lower in modified care (32.01 vs 35.70, p=0.061). Odds ratios for major complications (OR 0.45, 95% CI 0.20–1.04), anastomotic leakage (OR 0.30, 95% CI 0.06–1.59) and IMC readmission (OR 0.33, 95% CI 0.08-1.34) favored modified care but were not statistically significant. Fluid balance on POD4 and early parenteral nutrition were similar after matching. Acute kidney injury did not occur more frequently after HES-application. Overall and disease-free survival did not differ between groups. Conclusions The modified perioperative regimen applied in this study appears to be a safe alternative to conventional ERAS®-based pathways. While definitive superiority could not be demonstrated after propensity matching, the observed trends — particularly regarding anastomotic integrity and overall complication burden — support further prospective evaluation of this approach.