Enhanced Recovery After Surgery (ERAS) novel protocol for management of esophageal replacement in children: A single surgeon's experience of 116 cases

BACKGROUND Perioperative management of esophageal replacement is challenging due to significant disturbance in internal milieu of the body. To mitigate mediastinal dissection induced systemic inflammatory response, there is an unmet need to design and test a goal directed, resource conscious protocol for enhanced recovery, which will serve as a template to reduce morbid surgical complications and length of hospital stay. METHODS A retrospective cohort study was designed by convenience sampling method to group patients to compare outcomes of pediatric esophageal replacement using conventional protocol vs enhanced recovery after surgery novel protocol. Primary outcome measure was post-operative total length of stay in hospital. Secondary outcome measures were frequency of cardio-pulmonary complications, anastomotic leaks, infections, mortality, and initiation of early enteral jejunostomy feeding. RESULTS A total of 116 children with corrosive esophageal injury [n= 21(19 %)] and esophageal atresia [n=95(81%)] were analyzed in this study. Novel protocol group(n=62) when compared to conventional protocol group (n=54) had lower mean total length of stay days (13.05 ±7.92 days vs.21.96 ± 6.5 days p<0.0001), shorter mean ICU days (5.74 ± 4.16 days vs 7.13 ± 3.16 days; p≤0.048) and. Novel protocol group had lower cardiac [3/62 (5%) vs 12/54(22%) p=0.012]; and pulmonary [4/62 (6.5%) vs 13/54(24%) p=0.007] complications. Novel protocol group had lower mean days to initiation of enteral feeding (3.13 ±0.71 vs 5.45 ± 0.75 days; p<0.0001) and lower rates of post-operative infections [5/62(8%) vs 18/54 (33%); p=0.001]. CONCLUSIONS Enhanced recovery after surgery novel protocol has the potential to change clinical practice due to mitigation of major complications.