Enhanced recovery after robot-assisted minimally invasive esophagectomy

Esophagectomy is the core of curative treatment for esophageal cancer, achieving a 5-year survival rate of 40-50% when combined with neoadjuvant treatment. Previous single-center studies showed that robot-assisted minimally invasive esophagectomy (RAMIE) is superior to open esophagectomy in terms of postoperative complications and represents a good alternative to conventional minimally invasive esophagectomy (MIE). However, RAMIE remains an invasive procedure that is associated with considerable morbidity. This thesis evaluated the role of robotic surgery and several aspects of perioperative care in improving recovery for patients undergoing esophagectomy.

It was demonstrated that RAMIE can be safely implemented by following a structured training pathway. Furthermore, it was shown that the short-term outcomes of RAMIE are good on a global scale, although there is variation in the exact techniques that are used. While a (semi-)mechanical technique is mostly used to construct an intrathoracic anastomosis, a robotic hand-sewn technique was developed. Furthermore, robotic surgery facilitates demanding procedures such as an upper mediastinal lymph node dissection, which seems safe and should be further investigated regarding its oncological merits.

In the early postoperative phase, adequate feeding and pain management are important parts of the enhanced recovery pathway. Routine jejunostomy tube placement with anti-rotation fixation is advised to ensure adequate nutritional support after esophagectomy. Alternative pain management strategies should be investigated, since epidural analgesia fails in a substantial part of patients. The PEPMEN trial, which was designed as part of this thesis, currently compares epidural versus paratracheal analgesia regarding quality of recovery after (robot-assisted) minimally invasive esophagectomy.