METHODS

Patient recruitment

A total of 110 aged patients (defined as >60 years of age according to the Asia-Pacific classification) who underwent esophagectomy in the Thoracic Department of Fujian Medical University Union Hospital from January 2015 to June 2016 were randomly divided into two groups of 55 patients each: an observation group (treated with the mERAS protocol) and a control group (with conventional nursing care). Inclusion criteria included (I) age >60 years; (II) esophageal squamous cell carcinoma diagnosed pathologically on preoperative biopsy; (III) preoperative medical examinations—e.g., thoracic and upper abdominal enhanced computed tomography—that showed no evidence of apparent tumor invasion or distant metastasis; (IV) pulmonary and cardiac function examinations indicating that the patient was able to tolerate the surgery; (V) minimally invasive esophagectomy was performed. Exclusion criteria were as follows: (I) an illiterate patient or one who was unable to communicate; (II) adjuvant therapy was applied; (III) presence of a malignant tumor within the previous 5 years; (IV) presence of serious preoperative complications; (V) conventional thoracotomy was performed. All operations were performed by experienced surgeons in our department. The institutional review board of Fujian Medical University Union Hospital, China, approved the study.


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Nursing methods

The mERAS protocol in our study was based on protocols described for patients who had undergone colonic surgery or esophagectomy in reported studies and in our own previous experience.

Control group

The general nursing routine for esophageal surgery was used for the postoperative care of the control patients. It focuses on the following points.

Preoperative nursing: (I) respiratory tract preparation: no smoking for at least 2 weeks prior to surgery; atomization twice a day during the preoperative period; correct instructions about back-slapping and effective cough and sputum production. (II) Bowel preparation: perform a clean enema 1 day preoperatively; food-fast for 12 h; liquid-fast for 8 h.

Postoperative nursing: (I) monitor vital signs: heart rate, blood pressure, oxygen saturation. At 6 h after vital signs remain stable, elevate the head of bed 30°. (II) Maintain airway patency. (III) Maintain pipeline patency: avoid curling and slipping; pay extra attention while caring for chest closed drainage, monitoring the amount, character, and color of the shunt fluid. (IV) Intestinal nutrition: initially commence constant injection of 5% glucose and sodium chloride (GNS) until 500 mL through a jejunal stoma after postoperative flatus. Then, replace GNS with total parenteral nutrition (TPN), such as Peptison and Nutrison (both: Nutricia, Dublin, Ireland). In both groups, postoperative nutrition supply (including calorie and protein supply) was comparable. Calorie intake requirements are 20–25 kcal/kg/d during stress including 1.2 to 1.5 g/kg/d of protein enterally or 0.25 to 0.30 g of nitrogen/kg/d parenterally. An average intake of 1,500 kcal/d is recommended.

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Observation group

For the observational group, in addition to the postoperative general nursing routine after esophageal surgery, we conducted an ERAS ideas-guided nursing plan.

Preoperative nursing: this protocol included the following activities. (I) Mental nursing: educate the patient about the hospitalization and offer preoperative direction. Inform the patients and their family members of the content of ERAS; make sure they fully understood the relevant information and the entire therapeutic process. We played videos related to the surgery, providing direct perception of the entire process, from the ward to operation room, surgical operation, postanesthesia care unit, and finally back to the ward, with the purpose of relieving their stress and fear. (II) Central catheter, peripherally inserted: the catheter was routinely applied preoperatively in preparation for venous nutrition both before and after the operation. (III) Preoperative nutrition evaluation: we evaluated the patient’s nutritional status using the abridged Patient-Generated Subjective Global Assessment. For malnourished patients, TPN (Kabiven™; Fresenius Kabi AG, Homburg, Germany) was dripped in through the peripherally inserted central catheter to reverse the malnutrition. (IV) Preoperative intestinal preparation: the patient was given an intestinal cleansing agent, which was ingested orally on the afternoon of the day before surgery as a clean enema (a cleansing enema is forbidden). The patient food fasts for 6 h before surgery and liquid-fasts for 4 h.

Intraoperative nursing: in the observation group, the Bair Hugger Normothermia System (3M Bair Hugger, www.bairhugger.com) and warmed intravenous fluid were used to prevent hypothermia during the operation. Pneumatic compression stockings were also used in the observation group, which was not standard protocol in the control group.

Postoperative nursing: in addition to the general postoperative nursing routine, the following must be given extra attention. (I) Keep the patient warm after surgery by maintaining the temperature of the ward room at 24–26 °C; (II) apply the pneumatic pump to knead the lower limbs 6 h postoperatively while the vital signs are stable. Active limb exercises on the bed are encouraged as they could prevent the formation of deep venous thrombosis; (III) provide effective analgesia after surgery; (IV) encourage early ambulation. Therefore, on postoperative day (POD) 1, the patient is helped to sit on the bedside, with the lower limbs hanging down. On POD 2 the patient is helped to stand near the bed and on POD 3 to walk beside bed, step by step. We encourage POD1 or POD2 ambulation, if the patient recovered well; (V) provide early enteral nutrition. We started enteral nutrition through a jejunal tube 6–12 h postoperatively to promote intestinal peristalsis. It is begun with 5% GNS 500 mL and, when the patient shows no abdominal distention or diarrhea, switched to TPN (e.g., Peptison, Nutrison). We calculated the postoperative calorie and protein supply for every patient in observation group with the same guideline with the control group; (VI) on POD 1, remove the earlier inserted tubes, urethral catheter, and drainage tube; (VII) after POD 3, instruct the patients to practice chewing and swallowing to prevent a deglutition disorder and choking when swallowing Urografin for the gastrointestinal imaging examination; (VIII) for the control group, on POD 7, after esophageal radiography shows no leakage, routinely encourage the patients to start oral feeding. If the intake is good, the nasogastric tubes are removed, and the patient is discharged from the hospital.

In the observation group, after cervicothoracic computed tomography showed no leakage on POD 7, the nasogastric tubes were removed, and the patients were discharged from the hospital. We prolonged oral fasting time, until esophageal radiography (performed on PODs 10–14) confirmed that there were no signs of leakage. With that confirmation, the patients were encouraged to start oral feeding.

Surgical procedures and techniques

All of the patients received thoracoscopic and laparoscopic minimally invasive esophagectomy. We did the skeletonization of recurrent laryngeal nerves (RLN) and en bloc resection of the para-nerve lymph nodes and soft tissues, using esophageal suspension method, of which we had reported the feasibility and safety in extensive thoracoscopic lymphadenectomy along the RLN in the semi-prone position (4). We commonly used the gastric tube to do the reconstruction. We commonly did the 2-field lymph node dissection. If the preoperative examinations showed possible metastatic supraclavicular lymph nodes, the tumor located in the upper segment of esophagus or intraoperative frozen pathological results showed positive right RLN lymph node, we would do the 3-field lymph node dissection. Patients were extubated immediately after the operation or on arrival in the ward of intensive care unit.

Discharge criteria

Discharge criteria in both groups included adequate pain control with or without oral analgesics, absence of nausea, adequate calorie intake (orally or via enteral catheter), passage of flatus and/or stool, self-mobilization, self-support and patient’s consent.