Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs.

Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs.

Schmidt HM, El Lakis MA, Markar SR, Hubka M, Low DE. Accelerated Recovery Within Standardized Recovery Pathways After Esophagectomy: A Prospective Cohort Study Assessing the Effects of Early Discharge on Outcomes, Readmissions, Patient Satisfaction, and Costs. The Annals of Thoracic Surgery. 2016;102(3):931-9

What is already known:

Oesophagectomy is high risk and complex surgery, and has been associated with significant impact in terms of morbidity and mortality in the past. The introduction of enhanced recovery programmes has dramatically improved outcomes in this high risk group, including post-op complications, first-day mobilisation, and length of stay in both critical care and hospital.

What this paper adds:

This prospective cohort study from Virgina Mason MC, Seattle, is based on previously published outcome data of patients in their institution that identified a subgroup of patients that exceeded their day-7 discharge goal. The study attempts to identify these patients capable of achieving ‘accelerated recovery’ (AR), as well as assessing outcomes in this group compared to those in ‘targeted recovery’ (TR) and ‘delayed recovery’ (DR) groups (defined as those with discharge days of 5 or 6 (AR), 7 or 8 (TR) and 9 or more (DR).

They found that AR patients made up 46% of their cohort, and were younger, more likely to have neoadjuvant chemotherapy, shorter operations, and less blood loss. All groups were comparable regarding comorbidities, cancer stage, and treatment approach, while DR patients were more likely to have complications. AR patients were more likely to be discharged home, with comparable 30-day readmission rates between groups. Overall costs (mean and readmission) were lower in the AR group.

It is exciting to see evidence that (already impressive) lengths of stay may be further improved in a significant subset of patients undergoing oesophagectomy, with associated decreased treatment costs. The authors conclude that ERAS programs should be designed to accommodate patients appropriate for AR. The question may be, given that a number of the variables associated with ‘accelerated recovery’ are intraoperative (though length of surgery and blood loss may be predicted to some extent), how these findings might best be translating to service provision and planned stays in hospital in this group.

Tom Barnes, East Surrey Hospital @TomBarn75870085