Fast track clinical pathway implications in esophagogastrectomy

Table 1 Patient characteristics

Characteristics	Patients	Complications	Failed fast track	P value
Overall	114	19	26
Gender				0.80
Male	84	14	20
Female	30	5	6
Age (yr)				0.014
≥ 65	50	11	17
< 65	64	8	9
Differentiation				1.00
Low	18	4	4
Moderate	56	8	13
High	40	7	9
Stage of cancer at time of surgery				0.58
I	8	0	0
II	16	2	4
III	78	14	18
IV	12	3	4
Preoperative complication				< 0.001
Yes	28	12	18
No	86	7	8
Pathology				1.00
Squamous cell carcinoma	87	15	20
Adenocarcinoma	18	3	4
Other	9	1	2
Operative incision				0.73
One	60	9	12
Two	36	6	9
Three	18	4	5
Tolerated fast track surgery				0.001
Yes	88	5
No	26	14

Table 2 Anesthesia and pain management

Variables	Data
Extubation	114
Immediate	68
Operation day	34
Later	12
Pain management	109
Epidural PCA	59
Vein PCA	50
Operative transfusion	114
1.5-2.5 L	81
2.5-3.5 L	28
> 3.5 L	5

Table 3 Daily guideline of postoperative care of patients with fast track surgery

Day	Daily guideline of postoperative care
POD 1	Jejunal tube feeding 500 mL (20 mL/h);physical therapy four times per day;chest tube and nasogastric tube draining patency; head of bed put at 45-60 degree; supply albumin
POD 2	Jejunal tube feeding 1000 mL (40 mL/h) ;remove urinary catheter and epidural (Or pod3 remove);encourage patient to ambulate; chest tube and nasogastric tube draining patency; continue physical therapy, promoted to lung recruitment
POD 3	Jejunal tube feeding 1500 mL (65 mL/h); remove nasogastric tube; continue physical therapy
POD 4	Jejunal tube feeding 1500 mL (65 mL/h); X-ray; remove chest tube (drainage < 100 mL)
POD 5	Jejunal tube feeding 1500 mL (65 mL/h); gastrograffin swallow; anastomosis showed no leak; advice patient to take a little liquid diet; education on aspiration precaution
POD 6	Increase liquid diet; continue to jejunal tube feeding
POD 7	Remove jejunal tube; full liquid diet

Table 4 Postoperative morbidity

Variables	Data
Pulmonary	13
Empyema	2
Atelectasis	2
Pulmonary edema	1
Pulmonary infection	3
Respiratory insufficiency	5
Anastomotic	5
Leak	4
Hemorrhage	1
Cardiac	9
Atrial arrhythmia	4
Supraventricular arrhythmia	3
Ventricular arrhythmia	2
Other	7
Chylothorax	3
Hoarseness	2
Gastric perforation	1
Ileus	1
Mortality	3
Respiratory failure	2
Multiple organs failure	1

Table 5 Published esophagogastrectomy outcomes (recently 5 years)

Source	Patient	Postoperative morbidity (%)	Postoperative morbidity (%)	Mean length of hospital stay (d)
Goan et al[6] (1994-2005)	216	49.0	9.7	None
Low et al[7] (1991-2006)	340	45.0	0.3	11.5
Ancona et al[8] (1992-2002)	522	16.3	None	14.0
Atkins et al[9] (1996-2002)	379	64.0	5.8	15.0