Pre‐operative variables and complications after oesophagectomy

Sinclair et al. reported pre-operative predictors of outcome following oesophagectomy 1. We have recently introduced a standardised enhanced recovery after surgery (ERAS) pathway for our oesophageal resection patients at Gloucestershire Royal Hospital, which achieved a 28% reduction in length of stay (LOS) in our initial cohort of 20 patients to a median LOS of eight days. Our pathway involves significant pre-operative workup; however, like many other trusts, we do not have routine access to cardiopulmonary exercise testing (CPEX) to help predict higher risk patients. Instead, we rely on echocardiography, pulmonary function tests and risk prediction scoring such as O-POSSUM 2. This score, despite being derived to predict morbidity and mortality in patients undergoing oesophageal and gastric resection, has been shown to overpredict mortality 3. All our patients have their tracheas extubated under ‘ideal’ circumstances according to our local protocol, receive level-3 care (minimum level 2) postoperatively, with those patents perceived as being at increased risk receiving intra-operative cardiac output monitoring in addition to standard ERAS care. The analysis by Sinclair et al. demonstrates that FEV1, age and renal function were associated with cardiovascular and other complications. Did the authors identify thresholds for these that conferred increased risk to the patient, and whether these could be used to inform the multidisciplinary team when planning peri-operative management?