Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009-2017)

Outcomes after gastrectomy according to the Gastrectomy Complications Consensus Group (GCCG) in the Dutch Upper GI Cancer Audit (DUCA)

BACKGROUND

In 2019, the Gastrectomy Complications Consensus Group (GCCG) published a standardized set of complications aiming toward uniform reporting of post-gastrectomy complications. This study aimed to report outcomes after gastrectomy in the Netherlands according to GCCG definitions and compare them to previously reported national results and the European database reported by the GCCG.

METHODS

This nationwide, population-based cohort study included all patients undergoing gastrectomy for gastric cancer registered in the DUCA in 2020-2021. Postoperative morbidity and 30-day/in-hospital mortality were analyzed according to the GCCG definitions. For all patients, baseline characteristics and outcomes were compared with the GCCG cohort consisting of 27 European expert centers (GASTRODATA; 2017-2018).

RESULTS

In 2020-2021, 782 patients underwent gastrectomy in the Netherlands. Variation was seen in baseline characteristics between the Dutch and the GCCG cohort (N = 1349), most notably in minimally invasive surgery (80.6% vs 19.6%, p < 0.001). In the Netherlands, 223 (28.5%) patients developed a total of 407 complications, the most frequent being non-surgical infections (28.5%) and anastomotic leakage (13.4%). The overall complication and 30-day mortality rates were similar between the Dutch and GCCG cohort (28.5% vs 29.8%, p = 0.563; 3.7% vs 3.6%, p = 0.953). Higher surgical and endoscopic/radiologic reintervention rates were observed in the Netherlands compared to the GCCG cohort (10.7% vs 7.8%, p = 0.025; 10.9% vs 2.9%, p < 0.001).

CONCLUSION

Reporting outcomes according to the standardized GCCG definitions allows for international benchmarking. Postoperative outcomes were comparable between Dutch and GCCG cohorts, but both exceed the international benchmark for expert gastrectomy care, highlighting targets for national and international quality improvement.

Availability in ECMO Reduces the Failure to Rescue in Patients With Pulmonary Embolism After Major Surgery: A Nationwide Analysis of 2.4 Million Cases

Objective

Postoperative pulmonary embolism (PE) is a rare but potentially life-threatening complication, which can be treated with extracorporeal membrane oxygenation (ECMO) therapy, a novel therapy option for acute cardiorespiratory failure. We postulate that hospitals with ECMO availability have more experienced staff, technical capabilities, and expertise in treating cardiorespiratory failure.

Design

A retrospective analysis of surgical procedures in Germany between 2012 and 2019 was performed using hospital billing data. High-risk surgical procedures for postoperative PE were analyzed according to the availability of and expertise in ECMO therapy and its effect on outcome, regardless of whether ECMO was used in patients with PE.

Methods

Descriptive, univariate, and multivariate analyses were applied to identify possible associations and correct for confounding factors (complications, complication management, and mortality).

Results

A total of 13,976,606 surgical procedures were analyzed, of which 2,407,805 were defined as high-risk surgeries. The overall failure to rescue (FtR) rate was 24.4% and increased significantly with patient age, as well as type of surgery. The availability of and experience in ECMO therapy (defined as at least 20 ECMO applications per year; ECMO centers) are associated with a significantly reduced FtR in patients with PE after high-risk surgical procedures. In a multivariate analysis, the odds ratio (OR) for FtR after postoperative PE was significantly lower in ECMO centers (OR, 0.75 [0.70-0.81], P < 0.001).

Conclusions

The availability of and expertise in ECMO therapy lead to a significantly reduced FtR rate of postoperative PE. This improved outcome is independent of the use of ECMO in these patients.

How to identify early complications in patients undergoing distal gastrectomy?

In this editorial we comment on the article by Zhang et al published in a recent issue of the World Journal of Gastrointestinal Surgery. Gastrectomy with appropriate lymph node dissection is still standard curative treatment in locally advanced gastric cancer. Several studies point out that gastric cancer surgery is a complex procedure that leads to a high risk of morbidity and mortality. Many factors can contribute to the onset of complications with consequent effects on prognosis and increased mortality. The complications can be divided in complications related to anastomosis, to motility and to surgical site infection. The study presented by Zhang B et al represent an interesting analysis on the possibility to prevent postoperative morbidity. The study was performed on 131 patients with distal gastric cancer who underwent gastrectomy with D2 lymph node dissection. Of these patients, 16% developed early postoperative complications. The univariate analysis showed that prealbumin level, hypertension, diabetes, history of abdominal surgery, R0 resection, and blood transfusion were factors influencing early postoperative complications after distal gastrectomy. Moreover, the inclusion of the above significant variables in the logistic regression analysis revealed that hypertension, diabetes, a history of abdominal surgery, and blood transfusion were independent predictors of postoperative complications. In conclusion, preoperative and intraoperative factors can be used to establish an early postoperative nomogram model. The results of the study presented by Zhang et al suggest that the prediction model can be used to guide the detection of postoperative complications and has clinical reference value.

MIRO study: Do the results of a randomized controlled trial apply in a real population?

BACKGROUND

The aim of our study was to evaluate the external validity of the MIRO randomized controlled trial findings in a similar nationwide setting "real life" population, especially the benefit of a hybrid approach in esophageal resection for pulmonary complication. The external validity of randomized controlled trial findings to the general population with the same condition remains problematic because of the inherent selection bias and rigid inclusion criteria.

METHODS

This study was a cohort study from a National Health Database (Programme de Medicalisation des Systemes d'Informations) between 2010 and 2022. All adult patients operated on using Ivor Lewis resection for esophageal cancer were included. We first validated the detection algorithm of postoperative complications in the health database. Then, we assessed the primary outcome, which was the comparison of postoperative severe pulmonary complications, leak rate, and 30-day mortality between the 2 surgical approaches (hybrid versus open) over a decade.

RESULTS

Between 2010 and 2012, 162 of 205 patients in the MIRO trial were anonymously identified in the health care database. No difference between randomized controlled trials and healthcare database measurements was found within severe respiratory complications (24% vs 22%, respectively) nor within leak rate (10% vs 9%, respectively). After application of selection criteria according to the MIRO trial, 3,852 patients were included between 2013 and 2022. The hybrid approach was a protective factor against respiratory complications after adjustment for confounding variables (odds ratio = 0.83; 95% confidence interval = 0.71-0.98, P = .025). No significant difference in the 30-day mortality rate or 30-day leakage rate between the types of approach was reported.

CONCLUSION

This national cohort study demonstrates the external validity of the MIRO randomized controlled trial findings in a real-life population within France.

FAILURE TO RESCUE AFTER GASTRECTOMY: A NEW INDICATOR OF SURGICAL QUALITY

BACKGROUND

The main treatment modality for gastric cancer is surgical resection with lymphadenectomy. Despite advances in perioperative care, major surgical complications can occur in up to 20% of cases. To determine the quality of surgical care employed, a new indicator called failure to rescue (FTR) was proposed, which assesses the percentage of patients who die after complications occur.

AIMS

To assess the rate of FTR after gastrectomy and factors associated with its occurrence.

METHODS

Patients with gastric cancer who underwent gastrectomy with curative intent were retrospectively evaluated. According to the occurrence of postoperative complications, patients were divided into FTR group (grade V complications) and rescued group (grade III/IV complications).

RESULTS

Among the 731 patients, 114 had major complications. Of these patients, 76 (66.7%) were successfully treated for the complication (rescued group), while 38 (33.3%) died (FTR group). Patients in the FTR group were older (p=0.008; p<0.05), had lower levels of hemoglobin (p=0.021; p<0.05) and albumin (p=0.002; p<0.05), and a higher frequency of ASA III/IV (p=0.033; p<0.05). There were no differences between the groups regarding surgical and pathological characteristics. Clinical complications had a higher mortality rate (40.0% vs 30.4%), with pulmonary complications (50.2%) and infections (46.2%) being the most lethal. Patients with major complications grade III/IV had worse survival than those without complications.

CONCLUSIONS

The FTR rate was 33.3%. Advanced age, worse performance, and nutritional parameters were associated with FTR.

Does surgeon specialization add value to surgeon volume in gastric cancer surgery?

BACKGROUND

This study aimed to assess the combined impact of surgeon specialization and surgeon volume on both short- and long-term outcomes in patients underwent curative gastrectomy for gastric cancer.

METHODS

Patients with cStage1-3 gastric adenocarcinoma who underwent curative-intent surgery between January 2010 and December 2020 were evaluated. The impact of surgeon specialization and surgeon volume on clinical outcomes was scrutinized, both individually and in combination. For the purpose of assessing the combined effect, surgeons were classified into three groups: Non-specialized low-volume (NS-low), non-specialized high-volume (NS-high), and specialized high-volume (S-high). Postoperative outcomes and survival were evaluated. The adjusted effect sizes were expressed as odds ratio (OR) or hazard ratio (HR) with the corresponding 95% confidence interval.

RESULTS

Total of 537 patients operated by twelve surgeons were included in the analysis. For all cohort, the 30d-, in-hospital and 90d-mortality were 3.5%, 3%, and 6.3%, respectively. High surgeon volume alone had a significant impact (OR: 0.31 [0.10-0.82, p = 0.023]) on 30-day mortality. However, upon evaluating the combined effects of the parameters, while the most favorable 30-day mortality rate was observed in the S-high group, neither the NS-low group (OR: 3.82 [1.10-18.17, p = 0.054]) nor the NS-high group (OR: 1.37 [0.23-8.37, p = 0.724]) demonstrated a statistically significant difference when compared to the S-high group. The NS-low group showed poor results for several types of postoperative outcomes. In terms of overall survival, the S-high group outperformed, while the NS-low and NS-high groups presented with notably worse outcomes (HRs: 2.04 [1.51-2.75, p < 0.001], and 1.75 [1.25-2.44, p = 0.001], respectively).

CONCLUSION

The primary factor influencing short-term outcomes for patients who underwent gastric cancer surgery was found to be surgeon volume, while specialization provided a limited additional value. However, specialization emerges as an independent factor with a greater contribution to long-term survival than the impact attributed to high-volume.

The effect of probiotics on surgical outcomes in patients with gastric cancer: a meta-analysis of randomized controlled trials

The effect of probiotics on postoperative infectious complications and nutritional status in patients with gastric cancer is still controversial, and a comprehensive search and analysis of the current relevant evidence is necessary. Our study aimed to define the effects of probiotics on surgical outcomes in gastric cancer patients undergoing surgery. Up to June 20, 2023, Embase, PubMed, Web of Science, and Cochrane databases were searched for randomized controlled trials of probiotics in gastric cancer patients undergoing surgery. Relative risk (RR) or mean difference (MD) was used to calculate the effect sizes using RevMan 5.3. A total of nine studies reporting on 861 participants were included. Perioperative supplementation with probiotics did not improve weight loss (MD 0.73 kg; 95% CI: -0.56, 2.02) or serum prealbumin levels (MD 9.48 mg/L 95% CI: -3.43, 22.40), but did reduce the incidence of postoperative infectious complications (RR 0.46, 95% CI 0.28, 0.77), shorten the time to first exhaust (MD -11.27 h; 95% CI: -16.83, -5.70), the time to first defecation (MD -15.71 h; 95% CI: -25.62, -5.79), and the length of hospital stay (MD -0.94 days; 95% CI: -1.33, -0.55), and increase serum albumin levels (MD 0.73 g/L; 95% CI: 0.01, 1.46) in gastric cancer patients undergoing surgery. Probiotics are effective in preventing postoperative infectious complications, promoting postoperative recovery, and improving nutritional status in gastric cancer patients undergoing surgery. Our study highlights the importance of probiotics for healthcare systems and offers a potential strategy to improve the prognosis and reduce the medical burden of gastric cancer patients undergoing surgery.

Trends and perioperative mortality in gastric cancer surgery: a nationwide population‑based cohort study

This study aimed to investigate changes and perioperative mortality over a 6-year period within the Italian Hospital Information System among patients with gastric cancer (GC) who underwent gastrectomies and to identify risk factors associated with 90-day mortality. Additionally, nationwide differences between high and low-volume hospitals were evaluated. A nationwide retrospective study was conducted using patient hospital discharge records (HDRs) based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) classification. The HDRs were linked to the National Tax Registry records using deterministic record linkage. The data were obtained from the Italian National Outcomes Evaluation Programme (PNE). Multivariate logistic regression was used to examine risk factors for 90-day mortality among patients with GC who underwent partial or total gastrectomies over the period from 2018 to 2020 with adjustment for comorbidities. Overall, the number of patients with GC who underwent total or partial gastrectomies steadily decreased in Italy from 5765 in 2015 to 4291 in 2020 (p < 0.001). The use of the laparoscopic approach more than doubled from 2015 (10.8%) to 2020 (26.3%), with a concomitant conversion rate from laparoscopy to open surgery decreasing from 7.7 to 5.8%. The 30 and 90-day mortality rates remained stable over time (p > 0.05). Low-volume hospitals had higher inpatient, early, and late mortality compared to high-volume hospitals (5.9% vs 3.8%, 6.3% vs 3.8%, and 11.8% vs 7.9%, respectively; p < 0.001). Multivariate logistic regression analysis showed that an advanced age (adjusted odds ratio: 3.72; 95% [CI]: 3.15-4.39; p < 0.001), an open approach (adjusted-OR: 1.69, 95% CI: 1.43-1.99, p < 0.001) and a total gastrectomy (adjusted-OR: 1.44, 95% CI: 1.27-1.64, p < 0.001) were independent risk factors for 90-day mortality. Additionally, patients with GC who referred to high-volume hospitals were 26% less likely to die within 90 days after a gastrectomy than those who underwent surgery in low-volume hospitals. During the 6-year period, surgeons implemented a minimally invasive approach to reduce the conversion over time. Centralisation was associated with better outcomes while advanced age, an open approach, and total gastrectomy were identified as risk factors for 90-day mortality.

Nationwide volume-outcome relationship concerning in-hospital mortality and failure-to-rescue in surgery of sigmoid diverticulitis

PURPOSE

A correlation between the hospital volume and outcome is described for multiple entities of oncological surgery. To date, this has not been analyzed for the surgical treatment of sigmoid diverticulitis. The aim of this study was to explore the impact of the annual caseload per hospital of colon resection on the postoperative incidence of complications, failure to rescue, and mortality in patients with diverticulitis.

METHODS

Patients receiving colorectal resection independent from the diagnosis from 2012 to 2017 were selected from a German nationwide administrative dataset. The hospitals were grouped into five equal caseload quintiles (Q1-Q5 in ascending caseload order). The outcome analysis was focused on patients receiving surgery for sigmoid diverticulitis.

RESULTS

In total, 662,706 left-sided colon resections were recorded between 2012 and 2017. Of these, 156,462 resections were performed due to sigmoid diverticulitis and were included in the analysis. The overall in-house mortality rate was 3.5%, ranging from 3.8% in Q1 (mean of 9.5 procedures per year) to 3.1% in Q5 (mean 62.8 procedures per year; p < 0.001). Q5 hospitals revealed a risk-adjusted odds ratio of 0.85 (95% CI 0.78-0.94; p < 0.001) for in-hospital mortality compared to Q1 during multivariable logistic regression analysis. High-volume centers showed overall lower complication rates, whereas the failure-to-rescue did not differ significantly.

CONCLUSION

Surgical treatment of sigmoid diverticulitis in high-volume colorectal centers shows lower postoperative mortality rates and fewer postoperative complications.

Current Trends in Volume and Surgical Outcomes in Gastric Cancer

Gastric cancer is ranked as the fifth most frequently diagnosed type of cancer. Complete resection with adequate lymphadenectomy represents the goal of treatment with curative intent. Quality assurance is a crucial factor in the evaluation of oncological surgical care, and centralization of healthcare in referral hospitals has been proposed in several countries. However, an international agreement about the setting of “high-volume hospitals” as well as “minimum volume standards” has not yet been clearly established. Despite the clear postoperative mortality benefits that have been described for gastric cancer surgery conducted by high-volume surgeons in high-volume hospitals, many authors have highlighted the limitations of a non-composite variable to define the ideal postoperative period. The textbook outcome represents a multidimensional measure assessing the quality of care for cancer patients. Transparent and easily available hospital data will increase patients’ awareness, providing suitable elements for a more informed hospital choice.

Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer.

METHODS

Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

Thirty studies including 586 993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year.

CONCLUSIONS

The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.

Impact of the COVID pandemic on major abdominal cancer resections in Germany: a retrospective population-based cohort study

BACKGROUND

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is estimated to have claimed more than 6 million lives globally since it started in 2019. Germany was exposed to two waves of coronavirus disease 2019 in 2020, one starting in April and the other in October. To ensure sufficient capacity for coronavirus disease 2019 patients in intensive care units, elective medical procedures were postponed. The fraction of major abdominal cancer resections affected by these measures remains unknown, and the most affected patient cohort has yet to be identified.

METHODS

This is a register-based, retrospective, nationwide cohort study of anonymized 'diagnosis-related group' billing data provided by the Federal Statistical Office in Germany. Cases were identified using diagnostic and procedural codes for major cancer resections. Population-adjusted cancer resection rates as the primary endpoint were compared at baseline (2012-2019) to those in 2020.

RESULTS

A change in resection rates for all analyzed entities (esophageal, gastric, liver, pancreatic, colon, rectum, and lung cancer) was observed from baseline to 2020. Total monthly oncological resections dropped by 7.4% (8.7% normalized to the annual German population, P =0.011). Changes ranged from +3.7% for pancreatic resections ( P =0.277) to -19.4% for rectal resections ( P <0.001). Reductions were higher during lockdown periods. During the first lockdown period (April-June), the overall drop was 14.3% (8.58 per 100 000 vs. 7.35 per 100 000, P <0.001). There was no catch-up effect during the summer months except for pancreatic cancer resections. In the second lockdown period, there was an overall drop of 17.3%. In subgroup analyses, the elderly were most affected by the reduction in resection rates. There was a significant negative correlation between regional SARS-CoV-2 incidences and resections rates. This correlation was strongest for rectal cancer resections (Spearman's r : -0.425, P <0.001).

CONCLUSIONS

The pandemic lockdowns had a major impact on the oncological surgical caseload in Germany in 2020. The elderly were most affected by the reduction. There was a clear correlation between SARS-CoV-2 incidences regionally and the reduction of surgical resection rates. In future pandemic circumstances, oncological surgery has to be prioritized with an extra focus on the most vulnerable patients.

Clinical characteristics and changing trajectories of esophageal cancer and gastric cancer in China from 2010 to 2019: An analysis of a hospital-based database of 24,327 patients

Purpose

This analysis aimed to investigate the clinical characteristics and changing trajectories of gastric cancer (GC) and esophageal cancer (EC).

Methods

We collected data from a large cancer hospital in Beijing, China, from 2010 to 2019. Joinpoint regression was used to analyze the trends of histological characteristics and comorbidities.

Results

From 2010 to 2019, there were a total of 10,083 EC patients and 14,244 GC patients. Patients were mainly men and diagnosed at 55-64 years old. Metabolic comorbidity was the most common comorbidity, with hypertension being predominant. The percentages of stage I showed significant increases for EC [average annual percent change (AAPC): 10.5%] and GC (AAPC: 9.7%) patients. We also observed an increasing trend of EC and GC patients over 65 years old. For EC patients, esophageal squamous cell carcinoma (93.1%) remained as the prioritized subtype, and the middle third of the esophagus was the most common site. EC patients with three or more comorbidities increased from 0.1% to 2.2% (AAPC, 27.7%; 95% CI, 14.7% to 42.2%). For GC patients, adenocarcinoma accounts for 86.9% of the total cases, and cardia was the most common site. The ulcerative comorbidity rate decreased from 2.0% to 1.2% (AAPC, −6.1%; 95% CI, −11.6% to −0.3%).

Conclusion

ESCC remained as the prioritized histological subtype, and the middle third of the esophagus was the most common site of EC. The majority of GC patients had adenocarcinoma, and the cardia was the most common site. There was an increasing trend of patients diagnosed at stage I. These findings provide scientific evidence to guide future treatment.

Risk factors and effect of postoperative delirium on adverse surgical outcomes in older adults after elective abdominal cancer surgery in Taiwan

BACKGROUND

Postoperative delirium (POD) is a common complication in older adults, with unknown epidemiology and effects on surgical outcomes in Asian geriatric cancer patients. This study evaluated incidence, risk factors, and association between adverse surgical outcomes and POD after intra-abdominal cancer surgery in Taiwan.

METHODS

Overall, 345 patients aged ≥65 years who underwent elective abdominal cancer surgery at a medical center in Taiwan were prospectively enrolled. Delirium was assessed daily using the Confusion Assessment Method. Univariate and multivariate logistic regression analyses investigated risk factors for POD occurrence and estimated the association with adverse surgical outcomes.

RESULTS

POD occurred in 19 (5.5%) of the 345 patients. Age ≥73 years, Charlson comorbidity index ≥3, and operative time >428 min were independent predictors for POD occurrence. Patients presenting with one, two, and three risk factors had 4.1-fold (95% confidence interval [CI], 0.4-35.8, p = 0.20), 17.4-fold (95% CI, 2.2-138, p = 0.007), and 30.8-fold likelihood (95% CI, 2.9-321, p = 0.004) for POD occurrence, respectively. Patients with POD had a higher probability of prolonged hospital stay (adjusted odds ratio [OR] 2.8; 95% CI, 1.0-8.1; p = 0.037), intensive care stay (adjusted OR: 3.9; 95% CI, 1.5-10.5; p = 0.008), 30-day readmission (adjusted OR 3.1; 95% CI, 1.1-9.7; p = 0.039), and 90-day postoperative death (adjusted OR: 4.2; 95% CI, 1.0-17.7; p = 0.041).

CONCLUSION

POD occurrence was significantly associated with adverse surgical outcomes in geriatric patients undergoing elective abdominal cancer surgery, highlighting the importance of early POD identification in geriatric patients to improve postoperative care quality.

Surgical Outcomes, Long-Term Recurrence Rate, and Resource Utilization in a Prospective Cohort of 165 Patients Treated by Transanal Total Mesorectal Excision for Distal Rectal Cancer

A transanal total mesorectal excision (taTME) is a smart alternative to a conventional TME. However, worrisome reports of a high recurrence and complications triggered a moratorium in a few countries. This study assessed the outcomes and resource utilization of a taTME. Consecutive patients with distal rectal cancer treated by a taTME were prospectively included. Outcomes were reported as the median and interquartile range (IQR). One hundred sixty-five patients (67% male and 33% female) with a tumor 7 cm (IQR 5-10) from the anal verge were followed for 50 months (IQR 32-79). The resection margins were threatened in 25% of the patients, while 75% of the patients received neoadjuvant radiochemotherapy. A good mesorectal dissection and clear margins were achieved in 96% of the specimens, and 27 lymph nodes (IQR 20-38) were harvested. Ninety-day major morbidity affected 36 patients (21.8%), including 12 with anastomotic leakages (7.2%). A recurrence occurred locally in 9 patients (5.4%), and 44 patients had a distant metastasis (26.7%). The five-year disease-free survival and overall survival were 67% and 90%, respectively. A multivariate analysis found a long operation and frailty predicted an anastomotic leak, while a positive distal margin and lymph nodes predicted a local recurrence and distant metastasis. A two-team taTME saved 102 min of operative time and EUR 1385 when compared to a one-team approach. Transanal total mesorectal excision produced sound surgical quality and excellent oncologic outcomes.

Volume-outcome relationship in adrenal surgery from 2009-2017 in Germany-a retrospective study

OBJECTIVE

Adrenal resections are rare procedures of a heterogeneous nature. While recent European guidelines advocate a minimum annual caseload for adrenalectomies (6 per surgeon), evidence for a volume-outcome relationship for this surgery remains limited.

DESIGN

A retrospective analysis of all adrenal resections in Germany between 2009 and 2017 using hospital billing data was performed. Hospitals were grouped into three tertiles of approximately equal patient volume.

METHODS

Descriptive, univariate, and multivariate analyses were applied to identify a possible volume-outcome relationship (complications, complication management, and mortality).

RESULTS

Around 17 040 primary adrenal resections were included. Benign adrenal tumors (n = 8,213, 48.2%) and adrenal metastases of extra-adrenal malignancies (n = 3582, 21.0%) were the most common diagnoses. Six hundred and thirty-two low-volume hospitals performed an equal number of resections as 23 high-volume hospitals (median surgeries/hospital/year 3 versus 31, P < .001). Complications were less frequent in high-volume hospitals (23.1% in low-volume hospitals versus 17.3% in high-volume hospitals, P < .001). The most common complication was bleeding in 2027 cases (11.9%) with a mortality of 4.6% (94 patients). Overall in-house mortality was 0.7% (n = 126). Age, malignancy, an accompanying resection, complications, and open surgery were associated with in-house mortality. In univariate analysis, surgery in high-volume hospitals was associated with lower mortality (OR: 0.47, P < .001). In a multivariate model, the tendency remained equal (OR: 0.59, P = .104). Regarding failure to rescue (death in case of complications), there was a trend toward lower mortality in high-volume hospitals.

CONCLUSIONS

The annual caseload of adrenal resections varies considerably among German hospitals. Our findings suggest that surgery in high-volume centers is advantageous for patient outcomes although fatal complications are rare.

Evaluation of sarcopenia biomarkers in older patients undergoing major surgery for digestive cancer. SAXO prospective cohort study

BACKGROUND

The aim of the study was to prospectively evaluate different biomarkers to identify the most reliable for anticipating complications after major abdominal surgery for digestive cancer in older patients and compare their performance to the existing definition and screening algorithm of sarcopenia from EWGSOP.

METHODS

Ninety-five consecutive patients aged over 65 years who underwent elective surgery for digestive cancer were prospectively included in the SAXO study. Sarcopenia was defined according to EWGSOP criteria (four level from no sarcopenia to severe sarcopenia). Strength and physical performance were evaluated with the handgrip test (HGT) and gait speed test (GST), respectively. CT scan analysis was used to calculate the skeletal muscle index (SMI), intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), and subcutaneous adipose tissue (SAT). Measures were adjusted to body mass index (BMI). Complication grading was performed using the Clavien‒Dindo classification. A doubly robust estimator with multivariable regression was used to limit bias.

RESULTS

Sixteen patients presented with sarcopenia. Adjusted to BMI, sarcopenic patients had an increased IMAT^BMI (0.35 vs. 0.22; p = 0.003) and increased VAT^BMI (7.85 vs. 6.13; p = 0.048). In multivariable analysis, IMAT was an independent risk factor for minor and severe complications (OR = 1.298; 95% CI [1.031: 1.635] p = 0.027), while an increased SAT area was a protective factor (OR = 0.982; 95% CI [0.969: 0.995] p = 0.007). Twenty-two patients were obese (BMI ≥30 kg/m²). While no association was observed between obesity and sarcopenia (according to EWGSOP definition), obese patients had increased IMAT^BMI (0.31 vs. 0.23; p = 0.010) and VAT^BMI (8.40 vs. 6.49; p = 0.019). The combination of SAT, VAT and IMAT performed well to anticipate severe complication (AUC = 0.759) while AUC of EWGSOP 2010 and 2019 algorithm were 0.660 and 0.519, respectively.

DISCUSSION

Non-invasive and imaging related measures of IMAT, SAT and VAT seems to be valuable tools to refine risk-assessment of older patients in surgery and specially to detect myosteatosis in obese ones.

Short-term postoperative outcomes of gastric adenocarcinoma patients treated with curative intent in low-volume centers

BACKGROUND

Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed.

METHODS

Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry.

RESULTS

Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality.

CONCLUSIONS

Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue.

Differences in morbidity and mortality between unilateral adrenalectomy for adrenal Cushing's syndrome and bilateral adrenalectomy for therapy refractory extra-adrenal Cushing's syndrome

PURPOSE

In selected cases of severe Cushing's syndrome due to uncontrolled ACTH secretion, bilateral adrenalectomy appears unavoidable. Compared with unilateral adrenalectomy (for adrenal Cushing's syndrome), bilateral adrenalectomy has a perceived higher perioperative morbidity. The aim of the current study was to compare both interventions in endogenous Cushing's syndrome regarding postoperative outcomes.

METHODS

We report a single-center, retrospective cohort study comparing patients with hypercortisolism undergoing bilateral vs. unilateral adrenalectomy during 2008-2021. Patients with adrenal Cushing's syndrome due to adenoma were compared with patients with ACTH-dependent Cushing's syndrome (Cushing's disease and ectopic ACTH production) focusing on postoperative morbidity and mortality as well as long-term survival.

RESULTS

Of 83 patients with adrenalectomy for hypercortisolism (65.1% female, median age 53 years), the indication for adrenalectomy was due to adrenal Cushing's syndrome in 60 patients (72.2%; 59 unilateral and one bilateral), and due to hypercortisolism caused by Cushing's disease (n = 16) or non-pituitary uncontrolled ACTH secretion of unknown origin (n = 7) (27.7% of all adrenalectomies). Compared with unilateral adrenalectomy (n = 59), patients with bilateral adrenalectomy (n = 24) had a higher rate of severe complications (0% vs. 33%; p < 0.001) and delayed recovery (median: 10.2% vs. 79.2%; p < 0.001). Using the MTL30 marker, patients with bilateral adrenalectomy fared worse than patients after unilateral surgery (MTL30 positive: 7.2% vs. 25.0% p < 0.001). Postoperative mortality was increased in patients with bilateral adrenalectomy (0% vs. 8.3%; p = 0.081).

CONCLUSION

While unilateral adrenalectomy for adrenal Cushing's syndrome represents a safe and definitive therapeutic option, bilateral adrenalectomy to control ACTH-dependent extra-adrenal Cushing's syndrome or Cushing's disease is a more complicated intervention with a mortality of nearly 10%.

Radiotherapy for Pediatric Adrenocortical Carcinoma – Review of the Literature

•

Radiotherapy (RT) is mostly performed for curative intent, only few cases in palliative setting are reported.

•

The site of RT was predominantly tumor bed, abdominal cavity, and/or metastases.

•

Adjuvant RT has to be discussed—even in the context of TPSs—especially for patients with high risk factors.

•

Evidence regarding RT in in pediatric adrenocortical carcinoma is too limited to give any general recommendation. However, we suggest to consider adjuvant radiotherapy in individual patients with high risk of recurrence.

•

A systematic international study with a common data platform is needed to establish evidence. on the role of RT in the treatment of children with adrenocortical carcinoma and to improve the outcome in this rare disease.

Background and purpose

Pediatric adrenocortical carcinoma (pACC) is a rare disease with poor prognosis. Publications on radiotherapy (RT) are scarce. This review summarizes the current data on RT for pACC and possibly provides first evidence to justify its use in this setting.

Materials and methods

We searched the PubMed and Embase database for manuscripts regarding RT for pACC.

Results

We included 17 manuscripts reporting on 76 patients treated with RT, after screening 2961 references and 269 full articles. In addition, we added data of 4 unreported pACC patients treated by co-authors. All reports based on retrospective data. Median age at first diagnosis was 11.1 years (70% female); 78% of patients presented with hormonal activity. RT was mostly performed for curative intent (78%). 88% of RT were administered during primary therapy. The site of RT was predominantly the local tumor bed (76%). Doses of RT ranged from 15 to 62 Gy (median 50 Gy). Information on target volumes or fractionation were lacking. Median follow-up was 6,9 years and 64% of the patients died of disease, with 33% alive without disease. In 16 of 48 patients with available follow-up data after adjuvant RT (33%) no recurrence was reported and in 3 of 9 patients palliative RT seemed to induce some benefit for the patient.

Conclusions

Our first systematic review on RT for pACC provides too few data for any general recommendation, but adjuvant RT in patients with high risk might be considered. International collaborative studies are urgently needed to establish better evidence on the role of RT in this rare malignancy.

Postoperative mortality and morbidity after D2 lymphadenectomy for gastric cancer: A retrospective cohort study

BACKGROUND

Surgery for gastric cancer is a complex procedure and lymphadenectomy is often mandatory. Postoperative mortality and morbidity after curative gastric cancer surgery is not insignificant.

AIM

To evaluate the factors determining mortality and morbidity in a population of patients undergoing R0 resection and D2 lymphadenectomy for gastric cancer.

METHODS

A retrospective analysis of clinical data and pathological characteristics (age, sex, primary site of the tumor, Lauren histotype, number of positive lymph nodes resected, number of negative lymph nodes resected, and depth of invasion as defined by the standard nomenclature) was conducted in patients with gastric cancer. For each patient we calculated the Kattan’s score. We arbitrarily divided the study population of patients into two groups based on the nomogram score (< 100 points or ≥ 100 points). Prespecified subgroups in these analyses were defined according to age (≤ 65 years or > 65 years), and number of lymph nodes retrieved (≤ 35 lymph nodes or > 35 lymph nodes). Uni- and multivariate analysis of clinical and pathological findings were performed to identify the factors affecting postoperative mortality and morbidity.

RESULTS

One-hundred and eighty-six patients underwent a curative R0 resection with D2 lymphadenectomy. Perioperative mortality rate was 3.8% (7 patients); a higher mortality rate was observed in patients aged > 65 years (P = 0.002) and in N+ patients (P = 0.04). Following univariate analysis, mortality was related to a Kattan’s score ≥ 100 points (P = 0.04) and the presence of advanced gastric cancer (P = 0.03). Morbidity rate was 21.0% (40 patients). Surgical complications were observed in 17 patients (9.1%). A higher incidence of morbidity was observed in patients where more than 35 lymph nodes were harvested (P = 0.0005).

CONCLUSION

Mortality and morbidity rate are higher in N+ and advanced gastric cancer patients. The removal of more than 35 lymph nodes does not lead to an increase in mortality.

Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data

PURPOSE

Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume.

METHODS

We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure.

RESULTS

Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed.

CONCLUSION

RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.

Adrenocortical Carcinoma in Childhood: A Systematic Review

Adrenocortical tumors are rare in children. This systematic review summarizes the published evidence on pediatric adrenocortical carcinoma (ACC) to provide a basis for a better understanding of the disease, investigate new molecular biomarkers and therapeutic targets, and define which patients may benefit from a more aggressive therapeutic approach. We included 137 studies with 3680 ACC patients (~65% female) in our analysis. We found no randomized controlled trials, so this review mainly reflects retrospective data. Due to a specific mutation in the TP53 gene in ~80% of Brazilian patients, that cohort was analyzed separately from series from other countries. Hormone analysis was described in 2569 of the 2874 patients (89%). Most patients were diagnosed with localized disease, whereas 23% had metastasis at primary diagnosis. Only 72% of the patients achieved complete resection. In 334 children (23%), recurrent disease was reported: 81%-local recurrence, 19% (n = 65)-distant metastases at relapse. Patients < 4 years old had a different distribution of tumor stages and hormone activity and better overall survival (p < 0.001). Although therapeutic approaches are typically multimodal, no consensus is available on effective standard treatments for advanced ACC. Thus, knowledge regarding pediatric ACC is still scarce and international prospective studies are needed to implement standardized clinical stratifications and risk-adapted therapeutic strategies.