Toward standardization in esophageal cancer surgery: patterns of practice across high-volume European centers

Esophageal cancer (EC) remains a leading cause of cancer-related mortality worldwide. For patients with locally advanced, non-metastatic EC, advances in perioperative care, and surgical techniques have led to improved outcomes; however, significant variation persists, and standardization remains limited. This study aimed to characterize current practice patterns among expert surgeons at high-volume European centers through a structured, in-depth survey. Eight expert upper gastrointestinal surgeons from European centers performing >60 esophagectomies annually participated in comprehensive interviews. Topics included preoperative care pathways for distal esophageal/gastroesophageal junction adenocarcinoma, technical aspects of Ivor Lewis esophagectomy, and postoperative recovery protocols. Additional focus areas included multidisciplinary team involvement, allied health integration, research program participation, and follow-up strategies. Widespread agreement (7-8 of 8 centers) was observed in several domains: national EC care regionalization, multidisciplinary cancer conference review of all patients, institutional EC research programs, use of prospective national/international databases, application of CROSS chemoradiotherapy for squamous cell carcinoma, and perioperative FLOT chemotherapy for adenocarcinoma. Common surgical techniques included minimally invasive Ivor Lewis esophagectomy, two-field lymphadenectomy with en-bloc thoracic duct ligation, nasogastric tube placement, omental wrap of the anastomosis, and Enhanced Recovery After Surgery-based postoperative protocols. The majority of centers (5-6/8) performed routine preoperative optimization (nutrition, smoking cessation, frailty screening, oral hygiene/microbiome assessment), jejunostomy placement, and postoperative contrast swallow studies. Areas with notable variability (≤4/8 centers) included intraoperative crural closure, pyloric drainage procedures, gastric conduit sizing, postoperative pain management, and follow-up imaging timelines. High-volume European centers demonstrated strong alignment in several programmatic and perioperative elements of EC care, particularly around enhanced recovery pathways and preoperative optimization. Nonetheless, key intraoperative and postoperative variations persist, highlighting opportunities for future research, consensus building, and standardization to improve patient outcomes.