Early distribution, clinical benefits, and limits of the implementation of the standardized clinical pathway following esophagectomy

While historically associated with significant postoperative morbidity and mortality rates, esophagectomy remains a major component of the multimodality treatment for esophageal cancer. Over time, multiple advances have led to an improvement in clinical and oncological outcomes after surgery. Similar to the results demonstrated with the enhanced recovery after surgery (ERAS) protocols, standardized clinical pathways (SCPs) represent an infrastructure to provide patients with improved clinical outcomes. The aim of this report is to analyze the global application of SCPs and evaluate its effect on outcomes and to assess current levels of adoption in high volume centers. A literature review was conducted through the main search engines (PubMed, Embase, Medline and Cochrane database) to identify eligible comparative studies. All data concerning overall morbidity, length of stay (LOS), and postoperative mortality were collected and statistically analyzed. The search yielded 26 articles (among which five RCTs and six prospective trials) reporting on SCPs but focusing on different perioperative outcomes. Postoperative outcomes improved after the application of SCP, including overall morbidity (29.8% vs. 32.5%, P=0.350), and LOS (9.9±2.8 vs. 13.4±1.0, P<0.001) without significant difference in readmission rate. Anastomotic leak rate (8.3% vs. 10.3%, P=0.659) was lower within SCPs while pulmonary complication rate (17.0% vs. 22.4%, P=0.011) also demonstrated significant improvement. In conclusion, after its initiation in esophageal surgery, SCPs have demonstrated measurable clinical advantages when applied in high-volume centers.