Enhanced recovery after surgery pathway in esophagectomy in a high volume center: clinical keys to early leak diagnosis after esophagectomy

At present, standard treatment for potentially curable esophageal cancer includes neoadjuvant chemoradiotherapy followed by esophagectomy with lymphadenectomy. One of the complications with potentially serious consequences after esophagectomy is an anastomotic leakage. This complication is associated with prolonged hospital stay, morbidity, and mortality. In the postoperative period it can be challenging to recognize this complication and make a differentiation from other complications, such as pneumonia. Early recognition is a prerequisite for prompt treatment, which is known to lead to improved results. Nowadays, most centers performing esophagectomies use a standardized enhanced recovery after surgery (ERAS) program to treat patients peri-operatively. These programs should also include strategies to early detect and treat anastomotic leakage. This article describes the ERAS program developed at the upper GI unit of the University Medical Centre Utrecht, the Netherlands. It explores the various aspects of such a pathway, such as postoperative monitoring, nasogastric tube management, feeding protocols, early warning signs and diagnostics to be used in case of suspicion of a complication. In addition, the ERAS program is clarified with available relevant literature on different topics of the perioperative management for esophagectomy patients. The main focus of this article is the early recognition and detection of anastomotic leakage, which enables aggressive treatment.