**9. Conclusion**

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

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

• Abdominal cavity drainage allows monitoring active bleeding and anastomosis leak, but it also can lead to abdominal infection and intestinal obstruction. While conventional care prefers to maintain drainage a few days, supporters of the fast-track protocol suggest that we should not leave drainage if there is no evidence of intraoperative complications. Jesus et al. [75] do not report more mortality or morbidity without using abdominal

• Chest tube causes pain and limits patient's mobility, so it has to be removed as soon as possible. A recent study has showed that it is safe to remove thoracic drainage when its volume

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

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 implementa-

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

removed when patients are able to ingest normal food.

is between 250 and 450, and there is no air leak.

tion in the immediate postoperative period.

first 24–48 h.

50 Esophageal Abnormalities

drainage.

week.

The minimally invasive approach to esophageal cancer is a safe and feasible procedure with favorable outcomes when compared to open esophagectomy. The data available reported by the different studies describe fewer respiratory complications, a reduction of hospital stay and faster patient recovery without compromising the oncologic efficacy related with harvested lymph nodes and R0 margin resection. The thoracoscopic approach in prone position is an alternative that offers more benefits than the lateral decubitus technique. Moreover, the implementation of a fast-track protocol allows an early recovery without increasing morbidity and mortality.
