Streamlining esophagectomy reduces hospital stay, cost associated with surgery

Thoracic surgeons at University of Iowa Hospitals and Clinics have found that by altering the pre- and post-surgical care of a patient in need of an esophagectomy they are able to reduce the length of hospital stay by more than two-thirds and have a significant impact on the overall costs.

An esophagectomy -- the removal of part or all of the esophagus -- is typically done to treat esophageal cancer. A typical hospital stay for patients having the surgery has been 12 to 14 days.

Mark Iannettoni, M.D., M.B.A., professor and head of cardiothoracic surgery and physician head of the Heart and Vascular Center at UI Hospitals and Clinics, said that by looking at the process from a systems approach, streamlining the procedure and making it more standardized -- those hospital stays have been reduced to just five days at UI Hospitals and Clinics.

With shorter hospital stays come reduced costs, Iannettoni said. Costs associated with the surgery have been cut from $67,000 to $21,000.

The streamlining starts with a more comprehensive and organized preoperative visit, he said, and continues through post-operative care and clinic visits. The surgical procedure itself has been streamlined, as well.

"We have a board with the steps of the procedure all laid out for everyone in that room," Iannettoni said. "We all know who is doing what and when to expect it to happen. It becomes a very well-choreographed dance."

One change in after-care has been the length of time a breathing apparatus remains in the patient's throat. Previously patients were intubated for two to three days and would remain in an intensive care unit until the tube was removed. Now, Iannettoni said, the tube is removed almost immediately after surgery while the patient is still in the operating room.

"There really was no need for the tube to remain," Iannettoni said.

Removing the tube reduces the risk of leakage from the surgical site, he said, as well as eliminating the need for the patient to spend any time in the intensive care unit following surgery.

When patients are released from the hospital they are ordered to abstain from food and drink for 10 days, nourished instead through a feeding tube. Iannettoni said the patients are instructed on how to use the tube before they are released.

Three surgeons at UI Hospitals and Clinics perform an average of 40 to 50 esophagectomies each year, and Iannettoni is responsible for about 75 percent of them. The average thoracic surgeon performs about eight esophagectomies each year.

"We've developed quite a niche here," Iannettoni said.