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AimsFollowing (minimally invasive) esophagectomy, patients often rely on tube feeding, since oral intake is often delayed. Consequently, additional support by a dietician and home care is needed until oral intake is commenced. In this study, the effects of direct start of oral feeding compared with tube feeding following an esophagectomy was evaluated on treatment costs and health-related quality of life (QoL).MethodsPatients undergoing a minimally invasive esophagectomy were randomized in the NUTRIENT II study between controls (nil-per-mouth during 5 days and subsequent tube feeding) and a group in whom oral feeding was started directly postoperatively. Total hospital costs (including readmission and outpatient costs) and home care data for a period of 6 months after surgery were analyzed. QoL (measured using EORTC-QLQ-C30 and EORTC OG-25) was assessed preoperatively and 6 weeks, 12 weeks, and 6 months postoperatively.ResultsA total 132 patients were included (n = 65 direct oral feeding group and n = 67 control group). Mean patient hospital costs were euro26,014 in the intervention group over a 6-month period compared to euro26,989 in the control group (p = .825). Furthermore, people with direct oral feeding required significantly less home care assistance; i.e. 23 (48.9%) intervention patients versus 37 (77.1%) control patients (p = .004). Also, QoL in patients with direct oral feeding progressed more quickly when compared to the control group.LimitationsHospital costs were derived from a single hospital unit whereas costs from all the participating units may be a better reflection of the cost deviation. Availability of homecare data was limited, leading to difficulty in detecting differences in costs.ConclusionThis study suggests that direct oral feeding leads to similar total costs and a significantly reduced need for home care assistance. Furthermore, QoL in intervention group increased more quickly when compared to the control group.

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.

Summary Postoperative morbidity following esophagectomy remains substantial. Studies in major abdominal surgery have shown that prehabilitation can improve postoperative outcomes. This single-center study investigated the influence of prehabilitation on postoperative outcomes in patients undergoing minimally invasive Ivor-Lewis esophagectomy (MIE-IL). Data were collected on patients that underwent a MIE-IL and received a fully standardized enhanced recovery after surgery (ERAS) program, between October 2015 and February 2020. The intervention group comprised patients enrolled in the PREPARE prehabilitation program. The control group comprised a retrospective cohort with similar ERAS care, prior to implementation of PREPARE. Postoperative outcomes included (functional) recovery, length of hospital stay (LOHS), cardiopulmonary complications (CPC) and other predefined outcomes. The PREPARE group comprised 52 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 PREPARE and control patients, respectively. Hospital readmission rate was 9.6 vs. 14.3% (P = 0.484). A 17% reduction in thirty-day overall postoperative complication rate was observed in PREPARE patients, but this was not statistically significant (P = 0.106). Similarly, a clinically relevant reduction of 14% in CPC rate was observed (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). Prehabilitation prior to MIE-IL led to a shorter LOHS and reduced ICU readmission rate. Additionally, a clinically relevant improvement in postoperative recovery and reduced morbidity rate was observed in prehabilitated patient.

Aim Patients undergoing an esophagectomy are often kept nil-by-mouth postoperatively out of fear for increasing anastomotic leakage and pulmonary complications. This study investigates the effect of direct start of oral feeding following minimally invasive esophagectomy (MIE) compared to standard of care. Background & Methods Elements of enhanced recovery after surgery (ERAS) protocols have been successfully introduced in patients undergoing an esophagectomy. However, start of oral intake, which is an essential part of the ERAS protocols, remains a matter of debate. Patients in this multicenter, international randomized controlled trial were randomized to directly start oral feeding (intervention) after a MIE with intrathoracic anastomosis or to receive nil-by-mouth and tube feeding for five days postoperative (control group). Primary outcome was time to functional recovery. Secondary outcome parameters included anastomotic leakage, pneumonia rate and other surgical complications scored by predefined definitions. Results Baseline characteristics were similar in the intervention (n=65) and control (n=67) group. Functional recovery was seven days for patients receiving direct oral feeding compared to eight days in the control group (p-value 0.436). Anastomotic leakage rate did not differ in the intervention (18.5%) and control group (16.4%, p-value 0.757). Pneumonia rates were comparable between the intervention (24.6%) and control group (34.3%, p-value 0.221). Other morbidity rates were similar, except for chyle leakage which was more prevalent in the standard of care group (p-value 0.032). Conclusions Direct oral feeding after an esophagectomy does not affect functional recovery and did not increase incidence or severity of postoperative complications.