Optimizing perioperative settings after (minimally invasive) esophagectomy: Short-term improvements and long-term outcomes

Abstract

An esophagectomy – the surgical removal of the esophagus – is a complex procedure, frequently accompanied by complications. To reduce these complications, quick recovery (i.e. ERAS) protocols are being adopted. While oral nutrition is initiated directly after surgery as part of ERAS in almost all other types of major (abdominal) surgery, no clear consensus has been reached in esophageal cancer surgery. The current thesis demonstrates that direct oral feeding after an esophagectomy results in a similar time to recovery, complication rate and nutritional status when compared with the standard of care being tube feeding and no oral intake for 5 days after surgery. A subsequent study in an extended patient cohort showed marked improved outcomes after surgery for patients with direct oral feeding. Also, in patients who started directly with oral feeding the hospital costs were similar, while their quality of life improved more quickly. Moreover, these patients needed significantly less home care and the accompanying cost where therefor reduced. Adding a prehabilitation program – aimed to improve physical, nutritional and mental fitness prior to undergoing major surgery – led to a shorter hospital admission and less Intensive Care Unit readmission. Although ERAS and prehabilitation improved short-term outcomes, it is unknown what the long-term implication is for esophagectomy patients. This thesis shows complications after an esophagectomy to be related with worse long-term survival, despite patients having overcome this complication. This effect was found in patients undergoing surgery irrespective of the surgical technique used. This emphasizes the need for continuous reduction of complications after esophagectomy.