MARGINAL GAINS IN ESOPHAGECTOMY: The aggregation of incremental improvements

Abstract

The number of patients diagnosed with esophageal cancer has been increasing for years. After chemotherapy and radiotherapy, patients often undergo esophagectomy. Esophagectomy is a complex and demanding procedure with various short and long-term consequences. Recent advancements such as introduction of minimally invasive surgery and enhanced recovery after surgery programs have significantly improved outcomes after surgery. Nonetheless, complications involving the lungs and leakage of the connection between the esophagus and the newly formed 'gastric conduit’ (anastomotic leakage) are still common. The research in this dissertation focused on optimizing the care pathway for esophageal cancer patients undergoing esophagectomy, according to the 'marginal gains' principle. A surgical technique, partly derived from bariatric surgery, which has been further developed at the Catharina Hospital (Eindhoven, the Netherlands), was shown to have a low percentage of anastomotic leakage. A Dutch nationwide study showed that hospitals performing both bariatric surgery and esophagectomy, tend to have better outcomes in terms of complications and hospital stay after esophagectomy. Additionally, at the Catharina Hospital, complication rate declined over the years from ±67% to ±39% (pneumonia from ±37% to ±14%) and length of hospital stay was reduced from ±9 days to ±6 days due to two fundamental innovations: prehabilitation before and directly starting oral intake after esophagectomy. Furthermore, it was found that nutritional supplements after surgery are important in reducing the risk of micronutrient deficiencies. Finally, two animal studies have indicated that there may be a role for neurostimulation: the (electrical) stimulation of nerve(s) to reduce inflammation and complications after surgery.