The implementation of eras in Belgian esophageal surgery centers

Esophagectomy for cancer is a highly invasive procedure with significant post-operative morbidity and mortality. The literature suggests a clear volume outcome correlation. Since 2019, esophageal surgery has been centralized in Belgium. In 2019, enhanced recovery after surgery (ERAS) guidelines were published for esophagectomy. The purpose of this study was to evaluate the level of implementation of these ERAS guidelines in Belgium. Surgeons from centralized esophageal surgery centers in Belgium were questioned. A Delphi questionnaire regarding peri-operative ERAS care and center-specific outcome data were sent to all participating surgeons. An ERAS scoring system was created to estimate and compare the level of ERAS implementation. Length of stay, post-operative pneumonia, anastomotic leakage and 30-day and 90-day mortality were evaluated. A high response rate of 94.1% was achieved. All surgeons used a peri-operative protocol in their center. The mean ERAS score for Belgian surgeons was 15.5 out of 20. The highest ERAS score per center is 18.6. Anastomotic leakage rate is 14.6% and post-operative pneumonia rate is 20.8% in Belgium. The mean length of stay is 12 days. Mortality after 30 days and 90 days are, respectively, 3.2% and 6.6%. This study gives an overview of the Belgian situation regarding the implementation of ERAS protocols in esophageal surgery centers. The overall implementation of ERAS guidelines in Belgium is good, but there is room for improvement in terms of uniformity nationally.