**8. Fast-track surgery (FTS) protocol on patient undergoing MIE**

The concept of fast-track surgery (FTS) was first introduced by Kehlet and Mogensen [65], and the objective of his study was to show less postoperative stress, reduce morbidity associated with complications, accelerate recovery, and reduce postoperative cost in patients submitted for colon surgery after a rehabilitation programme [66]. It is essentially a multidisciplinary team to perform a fast-track approach during perioperative period for reaching an optimal outcome [67]. To date, the fast-track protocol has been applied in many surgical fields such as colon, rectum, or liver, but there is limited literature talking about the safety of using this protocol in esophageal surgery, especially in those cases where a minimally invasive technique is going to be performed.

Patients must receive health instructions and adequate information about FTS in the preoperative period. As we have explained previously, it is essential to optimize nutritional support with enteral and parenteral nutrition in those patients with long-term insufficient feeding and nutritional deficiencies. Recall that this measure has not been carried out in conventional care [68].

Many anesthesiologists have always been wary of allowing an esophageal cancer patient to ingest liquids 3 h before induction of anesthesia, defending the risk of aspiration pneumonia with this maneuver. But National and European Anesthesia Societies now recommend intake of clear fluids until 2 h before the induction of anesthesia as well as a 6 h fast for solid food [69]. Following these guidelines, Pan and his group, who have recently published a FTS protocol for MIE [70], instructed patients to drink fluid meals until 6 h before surgery and a carbohydrate drink until 3 h before surgery. They do not notice more pulmonary complications in FTS group than in conventional management group.

The use of the nasogastric tube (NGT) during the postoperative period is still controversial, although data describes disturbance of water, electrolyte, and acid base, and more digestive fluid reflux using nasogastric tube, which can increase pulmonary morbidity [71]. Some studies also show that NGT can delay normal gastrointestinal function [72]. Removal of NGT in the immediate postoperative period promotes early oral diet introduction that has some physiological advantages: decreases bacterial translocation, ensures function of intestinal mucosal cells, activates digestive secretory system, reduces postoperative infection, and accelerates organ recovery [73]. Oral feeding can be initiated during the first 48 h, following a stepwise programme from water to fluid meals, and finally to semifluid meals and normal food. Pan et al. [70] do not report gastroenterological complications, including anastomosis leak, without using NGT in postoperative period, and they suggest that an early oral diet in patients with MIE is safe and feasible. Enteral nutrition through jejunostomy may be initiated on the first postoperative day, even before oral intake. Both, oral and enteral nutrition, promote faster recovery of gastrointestinal function. Lewis et al. [74] concluded in their meta-analysis that early enteral nutrition can reduce anastomosis leakage and mortality. Jejunostomy can be removed when patients are able to ingest normal food.

The evidence about restrictive fluid administration intraoperatively and postoperatively, as we have reported in section called "anesthetic challenges of MIE," show less cardiopulmonary complications with this therapy. Earlier oral and enteral nutrition promotes that postoperative intravenous fluids can be reduced to as little as possible and removed during the first 24–48 h.

Abdominal and chest tube are also points of discussion in the FTS programme:


The fast-track protocol also includes early perambulation after surgery for preventing venous thromboembolism that can be facilitated if patients are not carrying any type of drainage. Adequate analgesia can also accelerate perambulation and promote the recovery of intestinal function. Moreover, chest physiotherapy and incentive spirometry should be instituted. In their study, Pan et al. [70] reported that hospital stay and the days until intestinal activity are significantly shortened in the FTS group without an increase in morbidity and mortality. Patients undergoing MIE and fast-track protocol can be discharged earlier, even in the first week.

In summary, FTS program can be used safely in patients undergoing MIE because it promotes early recovery without increasing morbidity and mortality. We must offer the patient adequate preoperative information about the fast-track protocol to facilitate its implementation in the immediate postoperative period.
