Skip to main content

Advertisement

SpringerLink
Log in

Evolution of Standardized Clinical Pathways: Refining Multidisciplinary Care and Process to Improve Outcomes of the Surgical Treatment of Esophageal Cancer

  • Original Article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience.

Study Design

All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991–1996, Gp2 1997–2002, Gp3 2003–2007, and Gp4 2008–2012).

Results

Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5–50) to 8 (5–115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively.

Conclusions

The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

References

  1. Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. International journal of cancer Journal international du cancer 2010; 127:2893–2917.

    Article  CAS  PubMed  Google Scholar 

  2. Simard EP, Ward EM, Siegel R, Jemal A. Cancers with increasing incidence trends in the United States: 1999 through 2008. CA Cancer J Clin 2012 [Epub ahead of print]

  3. Brown LM, Devesa SS, Chow WH. Incidence of adenocarcinoma of the esophagus among white Americans by sex, stage, and age. J Natl Cancer Inst. 2008; 100:1184–1187.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA Cancer J Clin 2011; 61:69–90.

    Article  PubMed  Google Scholar 

  5. Kohn GP, Galanko JA, Meyers MO, Feins RH, Farrell TM. National trends in esophageal surgery–are outcomes as good as we believe? J Gastrointest Surg 2009, 13:1900–1910

    Article  PubMed  Google Scholar 

  6. Siegel R, Naishadham D, Jemal A. Cancer statistics 2013. CA Cancer J Clin 2013; 63: 11–30

    Article  PubMed  Google Scholar 

  7. Holscher AH, Bollschweiler E. Choosing the best treatment for esophageal cancer : criteria for selecting the best multimodal therapy. Recent results in cancer research Fortschritte der Krebsforschung Progres dans les recherches sur le cancer 2012; 196:169–177.

    CAS  PubMed  Google Scholar 

  8. Varghese TK, Jr., Wood DE, Farjah F, Oelschlager BK, Symons RG, MacLeod KE, Flum DR, Pellegrini CA. Variation in esophagectomy outcomes in hospitals meeting Leapfrog volume outcome standards. Ann Thorac Surg 2011, 91:1003–1009

    Article  PubMed  Google Scholar 

  9. Finks JF, Osbourne NH, Birkmeyer JD. Trends in hospital volume and operative mortality for high-risk surgery. N Engl J Med 2011; 364: 2128–37

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  10. Jamieson GG, Mathew G, Ludemann R, Wayman J, Myers JC, Devitt PG. Postoperative mortality following oesophagectomy and problems in reporting its rate. Br J Surg 2004; 91:943–947.

    Article  CAS  PubMed  Google Scholar 

  11. Hulscher JB, Tijssen JG, Obertop H, van Lanschot JJ. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg 2001; 72:306–313.

    Article  CAS  PubMed  Google Scholar 

  12. Chu KM, Law SY, Fok M, Wong J. A prospective randomized comparison of transhiatal and transthoracic resection for lower-third esophageal carcinoma. Am J Surg 1997; 174: 320–324.

    Article  CAS  PubMed  Google Scholar 

  13. Omloo JM, Lagarde SM, Hulscher JB, Reitsma JB, Fockens P, van Dekken H, Ten Kate FJ, Obertop H, Tilanus HW, van Lanschot JJ. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the mid/distal esophagus: five-year survival of a randomized clinical trial. Ann Surg 2007; 246: 992–1000

    Article  PubMed  Google Scholar 

  14. Holscher AH, Metzger R, Brabender J, Vallbohmer D, Bollschweiler E. High-volume centers–effect of case load on outcome in cancer surgery. Onkologie 2004; 27:412–416.

    Article  CAS  PubMed  Google Scholar 

  15. Metzger R, Bollschweiler E, Vallbohmer D, Maish M, DeMeester TR, Holscher AH. High volume centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus 2004, 17:310–314.

    Article  CAS  PubMed  Google Scholar 

  16. Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000–2011. J Gastointest Surg 2012, 16: 1055–1063.

    Article  Google Scholar 

  17. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998; 280: 1747–1751

    Article  CAS  PubMed  Google Scholar 

  18. Lauder CI, Marlow NE, Maddern GJ, Barraclough B, Collier NA, Dickinson IC, Fawcett J, Graham JC. Systematic review of the impact of volume of oesophagectomy on patient outcome. ANZ J Surg 2010; 80: 317–323.

    Article  PubMed  Google Scholar 

  19. Massarweh NN, Flum DR, Symons RG, Varghese TK, Pellegrini CA. A critical evaluation of the impact of Leapfrog's evidence-based hospital referral. J Am Coll Surg 2011; 212: 150–159

    Article  PubMed  Google Scholar 

  20. Allareddy V, Ward MM, Allareddy V, Konety BR. Effect of meeting Leapfrog volume thresholds on complication rates following complex surgical procedures. Ann Surg 2010; 251:377–383.

    Article  PubMed  Google Scholar 

  21. Gustafsson UO, Scott MJ, Schwenk W, Demartines N, Roulin D, Francis N, McNaught CE, MacFie J, Liberman AS, Soon M, Hill A, Kennefy RH, Lobo DN, Fearon K, Ljungqvist O; Enhanced Recovery After Surgery Society. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS((R))) Society recommendations. World J Surg 2013; 37(2):259–284.

    Article  CAS  PubMed  Google Scholar 

  22. Aarts MA, Okrainec A, Glicksman A, Pearsall E, Victor JC, McLeod RS. Adoption of enhanced recovery after surgery (ERAS) strategies for colorectal surgery at academic teaching hospitals and impact on total length of hospital stay. Surg Endosc 2012; 26:442–450.

    Article  PubMed  Google Scholar 

  23. Li C, Ferri LE, Mulder DS, Ncuti A, Neville A, Lee L, Kaneva P, Watson D, Vassiliou M, Carli F, Feldman LS. An enhanced recovery pathway decreases duration of stay after esophagectomy. Surgery 2012; 152:606–614

    Article  PubMed  Google Scholar 

  24. Rotter T, Kinsman L, James E, Machotta A, Gothe H, Willis J, Snow P, Kugler J. Clinical pathways: effects on professional practice, patient outcomes, length of stay and hospital costs. Cochrane database Syst Rev 2010 17; (3): CD006632.

  25. Munitiz V, Martinez-de-Haro LF, Ortiz A, Ruiz-de-Angulo D, Pastor P, Parrilla P. Effectiveness of a written clinical pathway for enhanced recovery after transthoracic (Ivor Lewis) oesophagectomy. Br J Surg 2010; 97:714–718.

    Article  CAS  PubMed  Google Scholar 

  26. Cerfolio RJ, Bryant AS, Bass CS, Alexander JR, Bartolucci AA. Fast tracking after Ivor Lewis esophagogastrectomy. Chest 2004; 126: 1187–1194.

    Article  PubMed  Google Scholar 

  27. Low DE, Kunz S, Schembre D, Otero H, Malpass T, Hsi A, Song G, Hinke R, Kozarek RA. Esophagectomy–it’s not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007, 11: 1395–1402

    Article  PubMed  Google Scholar 

  28. Mackenzie H, Miskovic D, Ni M, Parvaiz A, Acheson AG, Jenkins JT, Griffith J, Coleman MG, Hanna GB. Clinical and educational proficiency gain of supervised laparoscopic colorectal surgical trainees. Surg Endosc 2013; 27: 2704–2711

    Article  PubMed  Google Scholar 

  29. Cole SJ, Mackenzie H, Ha J, Hanna GB, Miskovic D. Randomized controlled trial on the effect of coaching in simulated laparoscopic training. Surg Endosc 2014; 28: 979–986

    Article  PubMed  Google Scholar 

  30. Buchs NC, Pugin F, Bucher P, Hagen ME, Chassot G, Koutny-Fong P, Morel P. Learning curve for robot-assisted Roux-en-Y gastric bypass. Surg Endosc 2012; 26: 1116–1121

    Article  PubMed  Google Scholar 

  31. Okrainec A, Ferri LE, Feldman LS, Fried GM. Defining the learning curve in laparoscopic paraesophageal hernia repair: a CUSUM analysis. Surgical Endosc 2011; 25: 1083–1087

    Article  Google Scholar 

  32. Wouters MW, Gooiker GA, van Sandick JW, Tollenaar RA. The volume-outcome relation in the surgical treatment of esophageal cancer: a systematic review and meta-analysis. Cancer 2012; 118: 1754–1763

    Article  PubMed  Google Scholar 

  33. Jiang K, Cheng L, Wang JJ, Li JS, Nie J. Fast track clinical pathway implications in esophagogastrectomy. World J Gastroenterol 2009; 15: 496 – 501

    Article  PubMed Central  PubMed  Google Scholar 

  34. Tomaszek SC, Cassivi SD, Allen MS, Shen KR, Nichols FC 3rd, Deschamps C, Wigle DA. An alternative postoperative pathway reduces length of hospitalisation following oesophagectomy. Eur J Cardiothorac Surg 2010; 37: 807 – 13

    Article  PubMed Central  PubMed  Google Scholar 

  35. Zehr JK, Dawson PB, Yang SC, Heitmiller RF. Standardized clinical care pathways for Major Thoracic Cases Reduce Hospital Costs. Ann Thorac Surg 1998; 66: 914 – 9

    Article  CAS  PubMed  Google Scholar 

  36. Wang G, Jiang ZW, Xu J, Gong JF, Bao Y, Xie LF, Li JS. Fast-track rehabilitation program vs. conventional care after colorectal resection: a randomized clinical trial. World J Gastroenterol 2011; 17: 671 – 6

    Article  PubMed Central  PubMed  Google Scholar 

  37. Muehling B, Schelzig H, Steffen P, Meierhenrich R, Sunder-Plassmann L, Orend KH. A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair. World J Surg. 2009; 33: 577 – 85

    Article  PubMed  Google Scholar 

  38. Kwaan M, Vickers SM. Enhanced recovery programs: major benefits demonstrated again. Arch Surg 2011; 146 (5): 577–8

    Article  PubMed  Google Scholar 

  39. Dunst CM, Swanstrom LL. Minimally invasive esophagectomy. J Gastrointest Surg 2010; 14 Suppl 1; S127–32

    PubMed  Google Scholar 

  40. Luketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, Schuchert MJ, Nason KS. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg 2012; 256: 95–103

    Article  PubMed  Google Scholar 

  41. Wright CD, Kucharczuk JC, O’Brien SM, Grab JD, Allen MS; Society of Thoracic Surgeons General Thoracic Surgery Database. Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. J Thorac Cardiovasc Surg 2009; 137: 587–595

    Article  PubMed  Google Scholar 

  42. National Oesophago-Gastric Cancer Annual report 2004. http://www.augis.org/pdf/audits/2004_AUGIS_O_G_audit.pdf

  43. Markar SR, Low DE. Physiology not chronology, dictates outcomes after esophagectomy for esophageal cancer: outcomes in patients 80 years and older. Ann Surg Oncol 2013; 20: 1020–1026

    Article  PubMed  Google Scholar 

  44. Kuppusamy MK, Felisky CD, Helman JD, Deeter M, Koehler RP, Low DE. Assessment of intra-operative haemodynamic changes associated with transhiatal and transthoracic oesophagectomy. Eur J Cardiothorac Surg 2010; 38: 665–668

    Article  PubMed  Google Scholar 

  45. Neal JM, Wilcox RT, Allen HW, Low DE. Near-total esophagectomy: the influence of standardized multimodal management and intraoperative fluid restriction. Reg Anesth Pain Med 2003; 28: 328–334

    PubMed  Google Scholar 

  46. Komatsu Y, Orita H, Sakurada M, Maekawa H, Hoppo T, Sato K. Intraoperative blood transfusion contributes to decreased long-term survival of patients with esophageal cancer. World J Surg 2012; 36: 844–850

    Article  PubMed  Google Scholar 

  47. Preston SR, Markar SR, Baker CR, Soon Y, Singh S, Low DE. Impact of a multidisciplinary standardized clinical pathway on perioperative outcomes in patients with oesophageal cancer. Br J Surg 2013; 100 (1): 105–12

    Article  CAS  PubMed  Google Scholar 

  48. Kenney C, Berwick DM. Transforming Health Care: Virginia Mason Medical Center’s pursuit of the perfect Patient experience. New York CRC Press; 2010 1st Edition

    Book  Google Scholar 

Download references

Funding

None.

Conflict of Interest

None.

Author information

Authors and Affiliations

  1. Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA

    Sheraz R. Markar, Henner Schmidt, Sonia Kunz, Artur Bodnar, Michal Hubka & Donald E. Low

Authors
  1. Sheraz R. Markar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Henner Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sonia Kunz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Artur Bodnar
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michal Hubka
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Donald E. Low
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Donald E. Low.

Additional information

Presentation: Surgical Section, Royal Society for Medicine, London, UK 2013 and European Society for Diseases of the Esophagus, Rotterdam, Netherlands 2013.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Markar, S.R., Schmidt, H., Kunz, S. et al. Evolution of Standardized Clinical Pathways: Refining Multidisciplinary Care and Process to Improve Outcomes of the Surgical Treatment of Esophageal Cancer. J Gastrointest Surg 18, 1238–1246 (2014). https://doi.org/10.1007/s11605-014-2520-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-014-2520-6

Keywords

Search

Navigation