Optimizing perioperative care in esophagectomy: a narrative review.

BACKGROUND AND OBJECTIVE: Perioperative management of esophageal cancer surgery is continuously evolving. Advances in patient preparation, surgical techniques, and the implementation of enhanced recovery after surgery (ERAS) protocols have collectively improved postoperative outcomes and recovery. Minimally invasive esophagectomy has been widely adopted due to its association with reduced surgical trauma, less blood loss, shorter hospital stay, and, in some studies, lower complication rates. Despite these advances, esophagectomy remains a high-risk procedure with substantial morbidity, underscoring the need for continued optimization of perioperative care. This review focuses on recent developments in perioperative care and their impact on outcomes in esophageal cancer surgery.

METHODS: This narrative review provides an overview of the literature on perioperative optimization in esophageal cancer surgery, with emphasis on developments from the past several years, and is structured around key domains including prehabilitation, surgical techniques, ERAS protocols, and emerging experimental strategies.

KEY CONTENT AND FINDINGS: Structured prehabilitation programs combining physical training, psychological support, and nutritional optimization have demonstrated complementary benefits in enhancing functional reserve and surgical tolerance. Current clinical practice increasingly focuses on technical refinement of minimally invasive esophagectomy, with growing adoption of robot-assisted techniques to enhance surgical precision and postoperative outcomes. Within ERAS, postoperative nutritional management is one of the least consistently implemented components, although direct oral feeding after minimally invasive esophagectomy has been shown to be safe and feasible and may enhance recovery and even long-term outcomes. In parallel with these advances, experimental strategies have been explored to further attenuate perioperative inflammation. Neuromodulation of the sympathetic nervous system has shown potential to modulate the postoperative immune response and holds promise for further improving postoperative outcomes.

CONCLUSIONS: Perioperative care for esophagectomy has evolved towards a multimodal and patient-centered approach. Optimization of prehabilitation, minimally invasive (including robotic) techniques and ERAS-based perioperative care may further improve postoperative outcomes. Neuromodulation may represent a promising adjunct but requires further clinical validation. Continued refinement of perioperative pathways may contribute not only to faster recovery, but also to improved long-term outcomes.