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Surgical innovation and pioneering are important for improving patient outcome, but can be associated with learning curves. Although learning curves in surgery are a recognized problem, the impact of surgical learning curves is increasing, due to increasing complexity of innovative surgical procedures, the rapid rate at which new interventions are implemented and a decrease in relative effectiveness of new interventions compared to old interventions. For minimally invasive esophagectomy (MIE), there is now robust evidence that implementation can lead to significant learning associated morbidity (morbidity during a learning curve, that could have been avoided if patients were operated by surgeons that have completed the learning curve). This article provides an overview of the evidence of the impact of learning curves after implementation of MIE. In addition, caveats for implementation and available evidence regarding factors that are important for safe implementation and safe pioneering of MIE are discussed., Competing Interests: Conflict-of-interest statement: The authors have no conflict of interest to declare. The work has not been previously published and has not been submitted for publication elsewhere.

Background: Esophagectomy has a high incidence of postoperative morbidity. Complications lead to a decreased short-term survival, however the influence of those complications on long-term survival is still unclear. Most of the performed studies are small, single center cohort series with inconclusive or conflicting results. Minimally invasive esophagectomy (MIE) has been shown to be associated with a reduced postoperative morbidity. In this study, the influence of complications on long-term survival for patients with esophageal cancer undergoing a MIE were investigated., Methods: Data was collected from the EsoBenchmark database, a collaboration of 13 high-volume centers routinely performing MIE. Patients were included in this database from June 1, 2011 until May 31, 2016. Complications were scored according to the Clavien-Dindo (CD) classification for surgical complications. Major complications were defined as a CD grade ≥ 3. The data were corrected for 90-day mortality to correct for the short-term effect of postoperative complications on mortality. Overall survival was analyzed using the Kaplan Meier, log rank- and (uni- and multivariable) Cox-regression analyses., Results: A total of 926 patients were eligible for analysis. Mean follow-up time was 30.8 months (SD 17.9). Complications occurred in 543 patients (59.2%) of which 39.3% had a major complication. Anastomotic leakage (AL) occurred in 135 patients (14.5%) of which 9.2% needed an intervention (CD grade ≥ 3). A significant worse long-term survival was observed in patients with any AL (HR 1.73, 95% CI 1.29-2.32, P < 0.001) and for patients with AL CD grade ≥3 (HR 1.86, 95% CI 1.32-2.63, P < 0.001). Major cardiac complications occurred in 18 patients (1.9%) and were related to a decreased long-term survival (HR 2.72, 95% CI 1.38-5.35, p 0.004). For all other complications, no significant influence on long-term survival was found., Conclusion: The occurrence and severity of anastomotic leakage and cardiac complications after MIE negatively affect long-term survival of esophageal cancer patients., Disclosure: All authors have declared no conflicts of interest.

A nil-by-mouth regime with enteral nutrition via an artificial route is frequently applied following esophagectomy. However, early initiation of oral feeding could potentially improve recovery and has shown to be beneficial in many types of abdominal surgery. Although short-term nutritional safety of oral intake after an esophagectomy has been documented, long-term effects of this feeding regimen are unknown. In this cohort study, data from patients undergoing minimal invasive Ivor-Lewis esophagectomy between 04-2012 and 09-2015 in three centers in Netherlands were collected. Patients in the oral feeding group were retrieved from a previous prospective study and compared with a cohort of patients with early enteral jejunostomy feeding but delayed oral intake. Body mass index (BMI) measurements, complications, and nutritional re-interventions (re- or start of artificial feeding, start of total parenteral nutrition) were gathered over the course of one year after surgery. One year after surgery the median BMI was 22.8 kg/m2 and weight loss was 7.0 kg (9.5%) in 114 patients. Patients in the early oral feeding group lost more weight during the first postoperative month (P = 0.004). However, in the months thereafter this difference was not observed anymore. In the early oral feeding group, 28 patients (56%) required a nutritional re-intervention, compared to 46 patients (72%) in the delayed oral feeding group (P = 0.078). During admission, more re-interventions were performed in the delayed oral feeding group (17 vs. 46 patients P < 0.001). Esophagectomy reduces BMI in the first year after surgery regardless of the feeding regimen. Direct start of oral intake following esophagectomy has no impact on early nutritional re-interventions and long-term weight loss., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and aim Despite recent advancements in perioperative care, postoperative morbidity following an esophagectomy remains substantial. Studies in other major abdominal surgery, have shown that prehabilitation can improve short-term outcomes. This single-center cohort study investigated the effect of prehabilitation in patients undergoing minimally invasive Ivor-Lewis esophagectomy (MIE-IL). Methods Data were collected on consecutive patients receiving a standardized ERAS program that included direct start of oral feeding following MIE-IL (from postoperative day one), between October 2015 and February 2020. The intervention group comprised patients enrolled in the PREPARE prehabilitation program that was implemented in 2018 as the standard care pathway for all patients. The control group comprised a retrospective cohort prior to implementation of PREPARE. Postoperative outcomes included (functional) recovery, length of hospital stay (LOHS), cardiopulmonary complications (CPC) and other predefined outcomes. Results The PREPARE group comprised 52 patients and control group 43 patients. Median time to functional recovery was 6 vs. 7 days (P  = 0.074) and LOHS 7 vs. 8 days (P  = 0.039) in the PREPARE and control group, respectively. Hospital readmission rate was 9.6% vs. 14.3% (P  = 0.484). Although thirty-day overall postoperative complication rate did not differ statistically significantly (P  = 0.106), a clinically relevant reduction of 17% was observed in PREPARE patients. Similarly, CPC rate was 14% lower in the PREPARE group (P  = 0.190). Anastomotic leakage rate was similar (9.6% vs 14.0%; P  = 0.511). Despite no difference in severity (Clavien-Dindo) of complications (P  = 0.311), ICU readmission rate was lower in PREPARE patients (3.8% vs. 16.3%, P  = 0.039). In the PREPARE group wherein maximum oxygen uptake capacity (VO2max) was assessed preoperatively during a Steep Ramp Test, VO2max was lower at baseline in patients diagnosed with postoperative complications (P  = 0.011). There were no data on VO2max in the control group. Conclusion Prehabilitating patients prior to a MIE-IL led to a shorter LOHS and reduced ICU readmission rate. Additionally, a clinically relevant improvement in (functional) recovery and reduction in postoperative morbidity was observed in patients that were prehabilitated. [ABSTRACT FROM AUTHOR]