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Babic B, Mueller DT, Krones TL, Schiffmann LM, Straatman J, Eckhoff JA, Brunner S, Datta RR, Schmidt T, Schröder W, Bruns CJ, Fuchs HF. A senior surgical resident can safely perform complex esophageal cancer surgery after surgical mentoring program-experience of a European high-volume center. Dis Esophagus 2024; 37:doae015. [PMID: 38458619 DOI: 10.1093/dote/doae015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/16/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Previous studies have shown that surgical residents can safely perform a variation of complex abdominal surgeries when provided with adequate training, proper case selection, and appropriate supervision. Their outcomes are equivalent when compared to experienced board-certified surgeons. Our previously published training curriculum for robotic assisted minimally invasive esophagectomy already demonstrated a possible reduction in time to reach proficiency. However, esophagectomy is a technically challenging procedure and comes with high morbidity rates of up to 60%, making it difficult to provide opportunities to train surgical residents. We aimed to investigate if a surgical resident could safely perform complex esophageal surgery when a structured modular teaching curriculum is applied. A structured teaching program based on our previously published modular step-up approach was applied by two experienced board-certified esophageal surgeons. Our IRB-approved (Institutional Review Board) database was searched to identify all Ivor-Lewis esophagectomies performed by the selected surgical resident from August 2019 to July 2021. The cumulative sum method was used to analyze the learning curve of the surgical resident. Outcomes of patients operated by the resident were then compared to our overall cohort of open, hybrid, and robotic Ivor-Lewis esophagectomies from May 2016 to May 2020. The total cohort included 567 patients, of which 65 were operated by the surgical resident and 502 patients were operated by experienced esophageal cancer surgeons as the control group. For baseline characteristics, a significant difference for BMI (Body mass index) was observed, which was lower in the resident's group (25.5 kg/m2 vs. 26.8 kg/m2 (P = 0.046). A significant difference of American Society of Anesthesiologists- and Eastern Cooperative Oncology Group-scores was seen, and a subgroup analysis including all patients with American Society of Anesthesiologists I and Eastern Cooperative Oncology Group 0 was performed revealing no significant differences. Postoperative complications did not differ between groups. The anastomotic leak rate was 13.8% in the resident's cohort and 12% in the control cohort (P = 0.660). Major complications (Clavien-Dindo ≥ IIIb) occurred in 16.9% of patients in both groups. Oncological outcome, defined by harvested lymph nodes (35 vs. 32.33, P = 0.096), proportion of lymph node compliant performed operations (86.2% vs. 88.4%, P = 0.590), and R0-resection rate (96.9% vs. 96%, P = 0.766), was not compromised when esophagectomies were performed by the resident. The resident completed the learning curves after 39 cases for the total operating time, 38 cases for the thoracic operating time, 26 cases for the number of harvested lymph nodes, 29 cases for anastomotic leak rate, and finally 58 cases for the comprehensive complication index. For postoperative complications, no significant difference was seen between patients operated in the resident group versus the control group, with a third of patients being discharged with a textbook outcome in both cohorts. Furthermore, no difference in oncological quality of the resection was found, emphasizing safety and feasibility of our training program. A structured modular step-up for training a surgical resident to perform complex esophageal cancer surgery can successfully maintain patient safety and outcomes.
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Affiliation(s)
- Benjamin Babic
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
- Center for Esophagogastric Cancer Surgery, St. Elisabethen Hospital Frankfurt, Frankfurt, Germany
| | - Dolores T Mueller
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Tillman L Krones
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Lars M Schiffmann
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Jennifer Straatman
- Department for Upper GI Surgery, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Jennifer A Eckhoff
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Stefanie Brunner
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Rabi R Datta
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Thomas Schmidt
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Wolfgang Schröder
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Christiane J Bruns
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
| | - Hans F Fuchs
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine, University of Cologne, University Hospital Cologne, Cologne, Germany
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Pucher PH, Maynard N, Body S, Bowling K, Chaudry MA, Forshaw M, Hornby S, Markar SR, Mercer SJ, Preston SR, Sgromo B, van Boxel GI, Gossage JA. Association of Upper GI Surgery of Great Britain and Ireland (AUGIS) Delphi consensus recommendations on the adoption of robotic upper GI surgery. Ann R Coll Surg Engl 2024. [PMID: 38445587 DOI: 10.1308/rcsann.2024.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND The adoption of robotic platforms in upper gastrointestinal (GI) surgery is expanding rapidly. The absence of centralised guidance and governance in adoption of new surgical technologies may lead to an increased risk of patient harm. METHODS Surgeon stakeholders participated in a Delphi consensus process following a national open-invitation in-person meeting on the adoption of robotic upper GI surgery. Consensus agreement was deemed met if >80% agreement was achieved. RESULTS Following two rounds of Delphi voting, 25 statements were agreed on covering the training process, governance and good practice for surgeons' adoption in upper GI surgery. One statement failed to achieve consensus. CONCLUSIONS These recommendations are intended to support surgeons, patients and health systems in the adoption of robotics in upper GI surgery.
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Affiliation(s)
| | - N Maynard
- Oxford University Hospitals NHS Trust, UK
| | - S Body
- University Hospitals Dorset NHS Foundation Trust, UK
| | - K Bowling
- Torbay and South Devon NHS Foundation Trust, UK
| | | | | | - S Hornby
- Gloucestershire Hospitals NHS Foundation Trust, UK
| | - S R Markar
- Oxford University Hospitals NHS Trust, UK
- University of Oxford, UK
| | | | | | - B Sgromo
- Oxford University Hospitals NHS Trust, UK
| | | | - J A Gossage
- Guy's and St Thomas' NHS Foundation Trust, UK
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Ross SB, Slavin M, Sucandy I, Crespo KL, Syblis CC, Saravanan S, Rosemurgy AS. Comparative Analysis of NSQIP National Outcomes and Projected Outcomes versus Our Institutional Outcomes for Robotic Gastrectomy: The Future of Gastric Resection. Am Surg 2023; 89:3757-3763. [PMID: 37217206 DOI: 10.1177/00031348231175139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
BACKGROUND The robotic approach has vast applications in surgery; however, the utility of robotic gastrectomy has yet to be clearly defined. This study aimed to compare outcomes following robotic gastrectomy at our institution to the national patient-specific predicted outcomes data provided by the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP). METHODS We prospectively studied 73 patients who underwent robotic gastrectomy under our care. ACS NSQIP outcomes after gastrectomy and predicted outcomes for our patients were compared with our actual outcomes utilizing students t test and chi-square analysis, where applicable. Data are presented as median (mean ± SD). RESULTS Patients were 65 (66 ± 10.7) years old with a BMI of 26 (28 ± 6.5) kg/m2. 35 patients had gastric adenocarcinomas and 22 had gastrointestinal stromal tumors Operative duration was 245 (250 ± 114.7) minutes, estimated blood loss was 50 (83 ± 91.6) mL, and there were no conversions to 'open'. 1% of patients experienced superficial surgical site infections compared to the NSQIP predicted rate of 10% (P < .05). Length of stay (LOS) was 5 (6 ± 4.2) days vs NSQIP's predicted LOS of 8 (8 ± 3.2) days (P < .05). Three patients died during their postoperative hospital course (4%), due to multi-system organ failure and cardiac arrest. 1-year, 3-year, and 5-year estimated survival for patients with gastric adenocarcinoma was 76%, 63%, and 63%, respectively. DISCUSSION Robotic gastrectomy yields salutary patient outcomes and optimal survival for varying gastric diseases, particularly gastric adenocarcinoma. Our patients experienced shorter hospital stays and reduced complications relative to patients in NSQIP and predicted outcome for our patients. Gastrectomy undertaken robotically is the future of gastric resection.
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Affiliation(s)
- Sharona B Ross
- Advent Health Tampa, Digestive Health Institute, Tampa, FL, USA
| | - Moran Slavin
- Advent Health Tampa, Digestive Health Institute, Tampa, FL, USA
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Iswanto Sucandy
- Advent Health Tampa, Digestive Health Institute, Tampa, FL, USA
| | | | | | - Sneha Saravanan
- Advent Health Tampa, Digestive Health Institute, Tampa, FL, USA
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Müller DT, Brunner S, Straatman J, Babic B, Eckhoff JA, Reisewitz A, Storms C, Schiffmann LM, Schmidt T, Schröder W, Bruns CJ, Fuchs HF. Analysis of training pathway to reach expert performance levels based on proficiency-based progression in robotic-assisted minimally invasive esophagectomy (RAMIE). Surg Endosc 2023; 37:7305-7316. [PMID: 37580580 PMCID: PMC10462523 DOI: 10.1007/s00464-023-10308-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 07/12/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Robotic-assisted minimally invasive esophagectomy (RAMIE) was first introduced in 2003 and has since then shown to significantly improve the postoperative course. Previous studies have shown that a structured training pathway based on proficiency-based progression using individual skill levels as measures of reach of competence can enhance surgical performance. The aim of this study was to evaluate and help understand our pathway to reach surgical expert levels using a proficiency-based approach introducing RAMIE at our German high-volume center. METHODS All patients undergoing RAMIE performed by two experienced surgeons for esophageal cancer since the introduction of the robotic technique in 2017 was included in this analysis. Intraoperative outcomes and postoperative outcomes were included in the analysis. The cumulative sum method was used to analyze how many cases are needed to reach expert levels for different performance characteristics and skill sets during robotic-assisted minimally invasive esophagectomy. RESULTS From 06/2017 to 03/2022, a total of 154 patients underwent RAMIE at our facility and were included in the analysis. An advancement in performance level was observed for total operating time after 70 cases and for thoracic operative time after 79 cases. Lymph node yield showed an increase up until case 60 in the CUSUM analysis. Length of hospital stay stabilized after case 55. The CCI score inflection point was at case 55 in both CUSUM and regression analyses. Anastomotic leak rate stabilized at case 38 and showed another inflection point after case 83. CONCLUSION Our data and analysis showed the progression from proficient to expert performance levels during the implementation of RAMIE at a European high-volume center. Further analysis of surgeons, especially with a different training status has yet to reveal if the caseloads found in this study are universally applicable. However, skill acquisition and respective measures of such are diverse and as a great range of number of cases was observed, we believe that the learning curve and ascent in performance levels cannot be defined by one parameter alone.
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Affiliation(s)
- Dolores T Müller
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Stefanie Brunner
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Jennifer Straatman
- Afdeling Heelkunde, Amsterdam Universitair Medisch Centrum, Amsterdam, The Netherlands
| | - Benjamin Babic
- Center for Esophagogastric Cancer Surgery, St. Elisabethen Hospital Frankfurt, Frankfurt, Germany
| | - Jennifer A Eckhoff
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Alissa Reisewitz
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christian Storms
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Lars M Schiffmann
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Thomas Schmidt
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Wolfgang Schröder
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Christiane J Bruns
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hans F Fuchs
- Department for General, Visceral, Cancer and Transplant Surgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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