Surgeon Volume and Cancer Esophagectomy, Gastrectomy, and Pancreatectomy: A Population-based Study in England. Ann Surg. 2016;263:727-732. [PMID: 26501701 DOI: 10.1097/sla.0000000000001490]

How to measure quality of surgery as a component of multimodality treatment of gastric cancer

Gastric cancer (GC) is one of the most frequent reasons for cancer-related death worldwide. The multimodal therapeutic strategies are now pragmatically tailored to each patient, especially in advanced GC. A radical but safe gastrectomy remains the cornerstone of the GC treatment. Moreover, the quality-of-life (QoL) outcome measures are now routinely utilized in order to select optimal type of gastrectomy, as well as reconstruction method. Postoperative complications are frequent, and effective diagnosis and treatment of complications is crucial to lower the mortality rates. The postoperative complications prolong hospital stay and may result in poor QoL, thus eliminating the completion of perioperative adjuvant therapy. Therefore, avoiding morbidity is not only relevant for the immediate postoperative course, but can also affect long-term oncological outcome. Measuring outcome enables surgeons to: monitor their own results; compare quality of treatment between centres; facilitate improvement both for surgery alone and combined treatment; select optimal procedure for an individual patient. Textbook oncological outcome is a composite quality measure representing the ideal hospitalization for gastrectomy, as well as stage-appropriate (perioperative) adjuvant chemotherapy. Standardized system for recording complications and adherence to multimodality treatment guidelines are crucial for achieving the ultimate goal of surgical quality-improvement that can benefit patients QoL and long-term outcomes after fast and uneventful hospitalization for gastrectomy.

Refining the thoracic surgical oncology regionalization standards for esophageal surgery in Ontario, Canada: Moving from good to better

BACKGROUND

The consolidation of surgical practices has been suggested to improve patient outcomes for complex surgeries. In 2005, Ontario Health-Cancer Care Ontario released the Thoracic Surgical Oncology Standards to facilitate the regionalization process at thoracic centers in Ontario, Canada. This work describes the quality-improvement process involved in updating the minimum surgical volume and supporting requirement recommendations for thoracic centers to further optimize patient care for esophageal cancer.

METHODS

We conducted a literature review to identify and synthesize evidence informing the volume-outcome relationship related to esophagectomy. The results of this review and esophageal cancer surgery common indicators (reoperation rate, unplanned visit rate, 30-day and 90-day mortality) from Ontario's Surgical Quality Indicator Report were presented and reviewed by a Thoracic Esophageal Standards Expert Panel and Surgical Oncology Program Leads at Ontario Health-Cancer Care Ontario. Hospital outliers were identified, and a subgroup analysis was conducted to determine the most appropriate minimum surgical volume threshold based on 30- and 90-day mortality rates data from the last 3 fiscal years.

RESULTS

Based on the finding that a significant decrease in mortality occurred at 12 to 15 esophagectomies per year, the Thoracic Esophageal Standards Expert Panel reached a consensus that thoracic centers should perform a minimum of 15 esophagectomies per year. The panel also recommended that any center performing esophagectomies have at least 3 thoracic surgeons to ensure continuity in clinical care.

CONCLUSIONS

We have described the process involved in updating the provincial minimum volume threshold and the appropriate support services for esophageal cancer surgery in Ontario.

Surgeon proficiency gain and survival after gastrectomy for gastric adenocarcinoma: A population-based cohort study

OBJECTIVE

Quality of surgery is essential for survival in gastric adenocarcinoma, but studies examining surgeons' proficiency gain of gastrectomies are scarce. This study aimed to reveal potential proficiency gain curves for surgeons operating patients with gastric cancer.

METHODS

Population-based cohort study of patients who underwent gastrectomy for gastric adenocarcinoma in Sweden between 2006 and 2015 with follow-up throughout 2020. Data were retrieved from national registries and medical records. Risk prediction models were used to calculate outcome probabilities, and risk-adjusted cumulative sum curves were plotted to assess differences (change points) between observed and expected outcomes. The main outcome was long-term (>3-5 years) all-cause mortality after surgery. Secondary outcomes were all-cause mortality within 30 days, 31-90 days, 91 days to 1 year and>1-3 years of surgery, resection margin status, and lymph node yield.

RESULTS

The study included 261 surgeons and 1636 patients. The>3- to 5-year mortality was improved after 20 cases, and decreased from 12.4% before to 8.6% after this change point (p = 0.027). Change points were suggested, but not statistically significant, after 22 cases for 30-day mortality, 28 cases for 31- to 90-day mortality, 9 cases for 91-day to 1-year mortality, and 10 cases for>1- to 3-year all-cause mortality. There were statistically significant improvements in tumour-free resection margins after 28 cases (p < 0.005) and greater lymph node yield after 13 cases (p < 0.001).

CONCLUSIONS

This study reveals proficiency gain curves regarding long-term survival, resection margin status, and lymph node yield in gastrectomy for gastric adenocarcinoma, and that at least 20 gastrectomies should be conducted with experienced support before doing these operations independently.

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.

Overall morbidity after total minimally invasive keyhole oesophagectomy versus hybrid oesophagectomy (the MICkey trial): study protocol for a multicentre randomized controlled trial

BACKGROUND

Oesophageal cancer (EC) is the sixth leading cause of cancer death worldwide. Oesophageal resection is the only curative treatment option for EC which is frequently performed via an abdominal and right thoracic approach (Ivor-Lewis operation). This 2-cavity operation is associated with a high risk of major complications. To reduce postoperative morbidity, several minimally invasive techniques have been developed that can be broadly classified into either hybrid oesophagectomy (HYBRID-E) via laparoscopic/robotic abdominal and open thoracic surgery or total minimally invasive oesophagectomy (MIN-E). Both, HYBIRD-E and MIN-E, compare favourable to open oesophagectomy. However, there is still an evidence gap comparing HYBRID-E with MIN-E with regard to postoperative morbidity.

METHODS

The MICkey trial is a multicentre randomized controlled superiority trial with two parallel study groups. A total of 152 patients with oesophageal cancer scheduled for elective oesophagectomy will be randomly assigned 1:1 to the control group (HYBRID-E) or to the intervention group (MIN-E). The primary endpoint will be overall postoperative morbidity assessed via the comprehensive complication index (CCI) within 30 days after surgery. Specific perioperative parameters, as well as patient-reported and oncological outcomes, will be analysed as secondary outcomes.

DISCUSSION

The MICkey trial will address the yet unanswered question whether the total minimally invasive oesophagectomy (MIN-E) is superior to the HYBRID-E procedure regarding overall postoperative morbidity.

TRIAL REGISTRATION

DRKS00027927 U1111-1277-0214. Registered on 4th July 2022.

Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage

Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survival and is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.

Clinical decisions in pancreatic cancer surgery: a national survey and case-vignette study

Very few surveys have been carried out of oncosurgical decisions made in patients with pancreatic cancer (PC), or of the possible differences in therapeutic approaches between low/medium and high-volume centers. A survey was sent out to centers affiliated to the Spanish Group of Pancreatic Surgery (GECP) asking about their usual pre-, intra- and post-operative management of PC patients and describing five imaginary cases of PC corresponding to common scenarios that surgeons regularly assess in oncosurgical meetings. A consensus was considered to have been reached when 80% of the answers coincided. We received 69 responses from the 72 GECP centers (response rate 96%). Pre-operative management: consensus was obtained on 7/16 questions (43.75%) with no significant differences between low- vs high-volume centers. Intra-operative: consensus was obtained on 11/28 questions (39.3%). D2 lymphadenectomy, biliary culture, intra-operative biliary margin study, pancreatojejunostomy, and two loops were significantly more frequent in high-volume hospitals (p < 0.05). Post-operative: consensus was obtained on 2/8 questions (25%). No significant differences were found between low-/medium- vs high-volume hospitals. Of the 41 questions asked regarding the cases, consensus was reached on 22 (53.7%). No differences in the responses were found according to the type of hospital. Management and cases: consensus was reached in 42/93 questions (45.2%). At GECP centers, consensus was obtained on 45% of the questions. Only 5% of the answers differed between low/medium and high-volume centers (all intra-operative). A more specific assessment of why high-volume centers obtain the best results would require the design of complex prospective studies able to measure the therapeutic decisions made and the effectiveness of their execution. Clinicaltrials.gov identifier: NCT04755036.

Risk model for mortality associated with esophagectomy via a thoracic approach based on data from the Japanese National Clinical Database on malignant esophageal tumors

PURPOSE

Postoperative complications after esophagectomy can be severe or fatal and impact the patient's postoperative quality of life and long-term outcomes. The aim of the present study was to develop the best possible model for predicting mortality and complications based on the Japanese Nationwide Clinical Database (NCD).

METHODS

Data registered in the NCD, on 32,779 patients who underwent esophagectomy via a thoracic approach for malignant esophageal tumor between January, 2012 and December, 2017, were used to create a risk model.

RESULTS

The 30-day mortality rate after esophagectomy was 1.0%, and the operative mortality rate was 2.3%. Postoperative complications included pneumonia (13.8%), anastomotic leakage (13.2%), recurrent laryngeal nerve palsy (11.1%), atelectasis (4.9%), and chylothorax (2.5%). Postoperative artificial respiration for over 48 h was required by 7.8% of the patients. Unplanned intubation within 30 postoperative days was performed in 6.2% of the patients. C-indices evaluated using the test data were 0.694 for 30-day mortality and 0.712 for operative mortality.

CONCLUSIONS

We developed a good risk model for predicting 30-day mortality and operative mortality after esophagectomy based on the NCD. This risk model will be useful for the preoperative prediction of 30-day mortality and operative mortality, obtaining informed consent, and deciding on the optimal surgical procedure for patients with preoperative risks for mortality.

Current practice on the use of prophylactic drain after gastrectomy in Italy: the Abdominal Drain in Gastrectomy (ADiGe) survey

Evidence against the use of prophylactic drain after gastrectomy are increasing and ERAS guidelines suggest the benefit of drain avoidance. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Research Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. A 28-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the respondents. Most of the surgeons, regardless of age, experience, or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the participants remove the drain on postoperative day 4-6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain's role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous.

Surgeon case volume and the risk of complications following surgeries of displaced intra-articular calcaneal fracture

PURPOSE

This study aimed to address the relationship between surgeon volume and the risk of complications following surgeries of displaced intra-articular calcaneal fractures (DIACFs).

METHODS

We retrospectively reviewed the medical records and the follow-up registers for patients who underwent open reduction and internal fixation with plate/screws in our center between January 2015 and June 2020. Surgeon volume was defined as the number of surgically treated calcaneal fractures within the past 12 months, and was dichotomized on basis of the optimal cut-off value. The outcome measure was the documented overall complications within 1 year after surgery. Four logistics regression models were constructed to examine the potential relationship between surgeon volume and complications.

RESULTS

Among 585 patients, 49 had documented complications, representing an overall rate of 8.4%. The overall complication rate was 20.0% (22/111) in patients operated on by the low-volume surgeons and 5.7% (27/474) by the high-volume surgeons, with a significant difference (p < 0.001). The 4 multivariate analyses showed steady and robust inverse volume-complication relationship, with OR ranging from 3.8 to 4.4. The restricted cubic splines adjusted for total covariates showed the non-linear fitting "L-shape" or "reverse J-shape" curve (p = 0.041), and the OR was reduced until 10 cases, beyond which the curve leveled.

CONCLUSIONS

Our findings reflected the important role of maintaining necessary operative cases, potentially informing optimized surgical care management.

Risk factors and outcomes of fatal respiratory events after esophageal cancer surgery from 2011 through 2018: a nationwide cohort study in South Korea

BACKGROUND

Pulmonary complications are common after esophageal cancer surgery, but information regarding fatal respiratory events, such as postoperative acute respiratory distress syndrome (ARDS) and respiratory failure, is lacking. We aimed to investigate the prevalence, risk factors, and outcomes of fatal respiratory events after esophageal cancer surgery.

METHODS

We performed a retrospective population-based cohort study based on data from the National Health Insurance Service database in South Korea. All adult patients diagnosed with esophageal cancer who underwent esophageal surgery between January 2011 and December 2018 were included.

RESULTS

A total of 7039 patients were included in the final analysis. Among them, 100 patients (1.4%) experienced fatal respiratory adverse events (ARDS, 55 patients [0.8%]; respiratory failure, 45 patients [0.6%]). On multivariable logistic regression, residence in rural areas (vs. urban areas) at the time of surgery, open thoracotomy (vs. video-assisted thoracoscopic surgery), and lower annual case volume were associated with a higher prevalence of fatal respiratory adverse events. Moreover, postoperative fatal respiratory adverse events were related to increased in-hospital mortality, 1 year mortality, prolonged hospitalization, and increased total hospitalization costs.

CONCLUSION

In South Korea, 1.4% of patients experienced fatal respiratory events (ARDS or respiratory failure) after esophageal cancer surgery. Some factors were revealed as risk factors for fatal respiratory events, and fatal respiratory events worsened clinical outcomes after esophageal cancer surgery.

Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1 year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.

Mortality factors in pancreatic surgery: A systematic review. How important is the hospital volume?

BACKGROUND

How the extent of confounding adjustment impact (hospital) volume-outcome relationships in published studies on pancreatic cancer surgery is unknown.

METHODS

A systematic literature search was conducted for studies that investigated the relationship between volume and outcome using a risk adjustment procedure by querying the following databases: PubMed, Cochrane Central Register of Controlled Trials, Livivo, Medline and the International Clinical Trials Registry Platform (last query: 2020/09/16). Importance of risk-adjusting covariates were assessed by effect size (odds ratio, OR) and statistical significance. The impact of covariate adjustment on hospital (or surgeon) volume effects was analyzed by regression and meta-regression models.

RESULTS

We identified 87 studies (75 based on administrative data) with nearly 1 million patients undergoing pancreatic surgery that included in total 71 covariates for risk adjustment. Of these, 33 (47%) had statistically significant effects on short-term mortality and 23 (32%) did not, while for 15 (21%) factors neither effect size nor statistical significance were reported. The most important covariates for short term mortality were patient-specific factors. Concerning the covariates, single comorbidities (OR: 4.6, 95% CI: 3.3 to 6.3) had the strongest impact on mortality followed by hospital volume (OR: 2.9, 95% CI: 2.5 to 3.3) and the procedure (OR: 2.2, 95% CI: 1.9 to 2.5). Among the single comorbidities, coagulopathy (OR: 4.5, 95% CI: 2.8 to 7.2) and dementia (OR: 4.2, 95% CI: 2.2 to 8.0) had the strongest influence on mortality. The regression analysis showed a significant decrease hospital volume effect with an increasing number of covariates considered (OR: 0.06, 95% CI: 0.10 to -0.03, P < 0.001), while such a relationship was not observed for surgeon volume (P = 0.35).

CONCLUSIONS

This analysis demonstrated a significant inverse relationship between the extent of risk adjustment and the volume effect, suggesting the presence of unmeasured confounding and overestimation of volume effects. However, the conclusions are limited in that only the number of included covariates was considered, but not the effect size of the non-included covariates.

The Effect of Hospital Versus Surgeon Volume on Short-Term Patient Outcomes After Pancreaticoduodenectomy: a SEER-Medicare Analysis

BACKGROUND

The volume-outcome relationship has been well-established for pancreaticoduodenectomy (PD). It remains unclear if this is primarily driven by hospital volume or individual surgeon experience.

OBJECTIVE

This study aimed to determine the relationship of hospital and surgeon volume on short-term outcomes of patients with pancreatic adenocarcinoma undergoing PD.

METHODS

Patients >65 years of age who underwent PD for pancreatic adenocarcinoma were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2008-2015). Analyses were stratified by hospital volume and then surgeon volume, creating four volume cohorts: low-low (low hospital, low surgeon), low-high (low hospital, high surgeon), high-low (high hospital, low surgeon), high-high (high hospital, high surgeon). Propensity scores were created for the odds of undergoing surgery with high-volume surgeons. Following matching, multivariable analysis was used to assess the impact of surgeon volume on outcomes within each hospital volume cohort.

RESULTS

In total, 2450 patients were identified: 54.3% were treated at high-volume hospitals (27.0% low-volume surgeons, 73.0% high-volume surgeons) and 45.7% were treated at low-volume hospitals (76.9% low-volume surgeons, 23.1% high-volume surgeons). On matched multivariable analysis, there were no significant differences in the risk of major complications, 90-day mortality, and 30-day readmission based on surgeon volume within the low and high hospital volume cohorts.

CONCLUSION

Compared with surgeon volume, hospital volume is a more significant factor in predicting short-term outcomes after PD. This suggests that a focus on resources and care pathways, in combination with volume metrics, is more likely to achieve high-quality care for patients undergoing PD across all hospitals.

Does hospital volume affect outcomes after abdominal cancer surgery: an analysis of Swiss health insurance claims data

Background

Medical treatment quality has been shown to be better in high volume than in low volume hospitals. However, this relationship has not yet been confirmed in abdominal cancer in Switzerland and is relevant for referral of patients and healthcare planning. Thus, the present study investigates the association between hospital volumes for surgical resections of colon, gastric, rectal, and pancreatic carcinomas and outcomes.

Methods

This retrospective analysis is based on anonymized claims data of patients with mandatory health insurance at Helsana Group, a leading health insurance in Switzerland. Outcome parameters were length of hospital stay, mortality and cost during the inpatient stay as well as at 1-year follow-up. Hospital volume information was derived from the Quality Indicators dataset provided by the Swiss Federal Office of Public Health. The impact of hospital volume on the different treatment outcomes was statistically tested using generalized estimating equations (GEE) models, taking into account the non-independence of observations from the same hospital.

Results

The studies included 2′859 resections in patients aged 18 years and older who were hospitalized for abdominal cancer surgery between 2014 and 2018. Colon resections were the most common procedures (n = 1′690), followed by rectal resections (n = 709). For rectal, colon and pancreatic resections, an increase in the mean number of interventions per hospital and a reduction of low volume hospitals could be observed. For the relationship between hospital volume and outcomes, we did not observe a clear dose-response relationship, as no significantly better outcomes were observed in the higher-volume category than in the lower-volume category. Even though a positive “routine effect” cannot be excluded, our results suggest that even hospitals with low volumes are able to achieve comparable treatment outcomes to larger hospitals.

Conclusion

In summary, this study increases transparency on the relationship between hospital volume and treatment success. It shows that simple measures such as defining a minimum number of procedures only might not lead to the intended effects if other factors such as infrastructure, the operating team or aggregation level of the available data are not taken into account.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07513-5.

Gastrectomy mortality in Australia

BACKGROUND

Despite advances in medical management and endoscopic therapy, gastrectomy remains an important yet high-risk procedure for a range of benign and malignant upper gastrointestinal pathologies. No study has previously analysed Australian gastrectomy perioperative mortality rate (POMR). This retrospective, population-based cohort study was conducted to determine the Australian national gastrectomy POMR, allowing state-based and regional trends and outcomes to be assessed.

METHODS

Logistic regression models were compared using de-identified procedural data between 1 July 2005 and 30 June 2017 from the Australian Institute of Health and Welfare. Codes relating to total and subtotal gastrectomy contained in the Australian Classification of Health Interventions were used to extract patient data. Mortality rates were risk adjusted for age and gender. Temporal trends and differences between states/territories and regions were investigated.

RESULTS

The national average POMR throughout the study period was 2.1%. For subtotal gastrectomy, the national mean POMR was 1.1%, decreasing from 2.7% (2005) to 1.3% (2017). For total gastrectomy, the national mean POMR was 2.8%, decreasing from 3.3% (2005) to 1.7% (2017). POMR significantly reduced over time without variation between states or regions. Procedure volume steadily reduced in rural centres with a concomitant increase in metropolitan centres over time.

CONCLUSION

Pleasingly, the Australian gastrectomy POMR is favourable when compared to international cohorts. Improved outcomes were consistent between states and territories, and metropolitan and regional centres. Progressive metropolitan centralization of gastrectomy was demonstrated without evidence of improved outcomes.

The Impact of a Centralised Pancreatic Cancer Service: a Case Study of Wales, UK

INTRODUCTION

The centralisation of pancreatic cancer (PC) services still varies worldwide. This study aimed to assess the impact that a centralisation has had on patients in South Wales, UK.

METHODS

A retrospective cohort analysis of patients in South Wales, UK, with PC prior to (2004-2009), and after (2010-2014) the formation of a specialist centre. Patients were identified using record linkage of electronic health records.

RESULTS

The overall survival (OS) of all 3413 patients with PC increased from a median (IQR) 10 weeks (3-31) to 11 weeks (4-35), p = 0.038, after centralisation. The OS of patients undergoing surgical resection or chemotherapy alone did not improve (93 weeks (39-203) vs. 90 weeks (50-95), p = 0.764 and 33 weeks (20-57) vs. 33 weeks (19-58), p = 0.793). Surgical resection and chemotherapy rates increased (6.1% vs. 9.2%, p < 0.001 and 19.7% vs. 27.0%, p < 0.001). The 30-day mortality rate trended downwards (7.2% vs. 3.6%, p = 0.186). The percentage of patients who received no treatment reduced (75.2% vs. 69.6%, p < 0.001).

CONCLUSION

The centralisation of PC services in South Wales is associated with a small increase in OS and a larger increase in PC treatment utilisation. It is concerning that many patients still fail to receive any treatments.

Long-term effect of hospital volume on the postoperative prognosis of 158,618 patients with esophageal squamous cell carcinoma in China

Background

The impact of hospital volume on the long-term survival of esophageal squamous cell carcinoma (ESCC) has not been well assessed in China, especially for stage I-III stage ESCC. We performed a large sample size study to assess the relationships between hospital volume and the effectiveness of ESCC treatment and the hospital volume value at the lowest risk of all-cause mortality after esophagectomy in China.

Aim

To investigate the prognostic value of hospital volume for assessing postoperative long-term survival of ESCC patients in China.

Methods

The date of 158,618 patients with ESCC were collected from a database (1973-2020) established by the State Key Laboratory for Esophageal Cancer Prevention and Treatment, the database includes 500,000 patients with detailed clinical information of pathological diagnosis and staging, treatment approaches and survival follow-up for esophageal and gastric cardia cancers. Intergroup comparisons of patient and treatment characteristics were conducted with the X² test and analysis of variance. The Kaplan-Meier method with the log-rank test was used to draw the survival curves for the variables tested. A Multivariate Cox proportional hazards regression model was used to analyze the independent prognostic factors for overall survival. The relationship between hospital volume and all-cause mortality was assessed using restricted cubic splines from Cox proportional hazards models. The primary outcome was all-cause mortality.

Results

In both 1973-1996 and 1997-2020, patients with stage I-III stage ESCC who underwent surgery in high volume hospitals had better survival than those who underwent surgery in low volume hospitals (both P<0.05). And high volume hospital was an independent factor for better prognosis in ESCC patients. The relationship between hospital volume and the risk of all-cause mortality was half-U-shaped, but overall, hospital volume was a protective factor for esophageal cancer patients after surgery (HR<1). The concentration of hospital volume associated with the lowest risk of all-cause mortality was 1027 cases/year in the overall enrolled patients.

Conclusion

Hospital volume can be used as an indicator to predict the postoperative survival of ESCC patients. Our results suggest that the centralized management of esophageal cancer surgery is meaningful to improve the survival of ESCC patients in China, but the hospital volume should preferably not be higher than 1027 cases/year.

Core tip

Hospital volume is considered to be a prognostic factor for many complex diseases. However, the impact of hospital volume on long-term survival after esophagectomy has not been well evaluated in China. Based on a large sample size of 158,618 ESCC patients in China spanning 47 years (1973-2020), We found that hospital volume can be used as a predictor of postoperative survival in patients with ESCC, and identified hospital volume thresholds with the lowest risk of death from all causes. This may provide an important basis for patients to choose hospitals and have a significant impact on the centralized management of hospital surgery.

Endoscopic Management and Surgical Considerations for Familial Adenomatous Polyposis

Familial adenomatous polyposis (FAP) is the development of many adenomatous colorectal polyps. Colonoscopy is recommended to start at age 10 to 12 years at intervals of 1 to 2 years. Colectomy is clearly indicated for malignancy or significant colorectal symptoms. After colectomy, endoscopic surveillance is still critical. Duodenal and gastric polyposis is also found in almost all patients with FAP. Screening with upper endoscopy and ampullary visualization is recommended, generally determined by age and staging of duodenal polyposis, but guidelines are increasingly factoring in ampullary and gastric manifestations. Surgical management of malignancy or advanced upper tract manifestations is needed.

Comparable Esophagectomy Outcomes by Surgeon Specialty: A NSQIP Analysis

BACKGROUND

A few observational studies have found that outcomes after esophagectomies by thoracic surgeons are better than those by general surgeons.

METHODS

Non-emergent esophagectomy cases were identified in the 2016-2017 American College of Surgeons NSQIP database. Associations between patient characteristics and outcomes by thoracic versus general surgeons were evaluated with univariate and multivariate logistic regression.

RESULTS

Of 1,606 cases, 886 (55.2%) were performed by thoracic surgeons. Those patients differed from patients treated by general surgeons in race (other/unknown 19.3% vs 7.8%; P<.001) but not in other baseline characteristics (age, sex, BMI, and comorbidities). Thoracic surgeons performed an open approach more frequently (48.9% vs 30.8%, P<.001) and had operative times that were 30 minutes shorter (P<.001). General surgeons had lower rates of reoperation (11.8% vs 17.2%; P=.003) and were more likely to treat postoperative leak with interventional means (6.3% vs 3.4%, P=.01). Thoracic surgeons were more likely to treat postoperative leak with reoperation (5.9% vs 3.6%, P=.01). There were no other differences in univariate comparison of outcomes between the two groups, including leak, readmission, and death. General surgery specialty was associated with lower risk of reoperation. Our multivariable model also found no relationship between general surgeon and risk of any complication (odds ratio 1.10; 95% CI .86 to 1.42).

DISCUSSION

In our large, national database study, we found that outcomes of esophagectomies by general surgeons were comparable with those by thoracic surgeons. General surgeons managed postoperative leaks differently than thoracic surgeons.

Surgeon volume and the risk of deep surgical site infection following open reduction and internal fixation of closed tibial plateau fracture

BACKGROUND

Emerging evidences supported that the surgeon case volume significantly affected post-operative complications or outcomes following a range of elective or non-elective orthopaedic surgery; no data has been available for surgically treated tibial plateau fractures. We aimed to investigate the relationship between surgeon volume and the risk of deep surgical site infection (DSSI) following open reduction and internal fixation (ORIF) of closed tibial plateau fracture.

METHODS

This was a further analysis of the prospectively collected data. Adult patients undergoing ORIF procedure for closed tibial plateau fracture between January 2016 and December 2019 were included. Surgeon volume was defined as the number of surgically treated tibial fractures in the preceding 12 months and dichotomized on the basis of the optimal cut-off value determined by the receiver operating characteristic (ROC) curve. The outcome was DSSI within one year post-operatively. Multiple multivariate logistic models were constructed for "drilling down" adjustment of confounders. Sensitivity and subgroup analyses were performed to assess the robustness of outcome and identify the "optimal" subgroups.

RESULTS

Among 742 patients, 20 (2.7%) had a DSSI and 17 experienced re-operations. The optimal cut-off value for case volume was nine, and the low-volume surgeon was independently associated with 2.9-fold (OR, 2.9; 95%CI, 1.1 to 7.5) increased risk of DSSI in the totally adjusted multivariate model. The sensitivity analyses restricted to patients with original BMI data or those operated within 14 days after injury did not alter the outcomes (OR, 2.937, and 95%CI, 1.133 to 7.615; OR, 2.658, and 95%CI, 1.018 to 7.959, respectively). The subgroup analyses showed a trend to higher risk of DSSI for type I-IV fractures (OR, 4.6; 95%CI, 0.9 to 27.8) classified as Schatzker classification and substantially higher risk in patients with concurrent fractures (OR, 6.1; 95%CI, 1.0 to 36.5).

CONCLUSION

The surgeon volume is independently associated with the rate of DSSI, and a number of ≥ nine cases/year are necessarily kept for reducing DSSIs; patients with concurrent fractures should be preferentially operated on by high-volume surgeons.

The Relation of Surgical Volume to Competence: When Is Enough, Enough?

Given the inherent risk in surgical intervention and the need for the optimal utilization of health care resources, achieving high-quality surgical care is a priority for the American health care system, and competent surgeons are critical to reaching this goal. Despite the multifactorial nature of patient safety and satisfaction, surgeon competence is often oversimplified to an assessment of volume because of the ease of collection and comparison. In any practice model, the analysis of competence is complex, but the components of clinical skill for military surgeons further include multiple areas of expertise, which, although superficially unrelated to surgical currency, augment the overall care delivered by these clinicians. Thus, volume as a solitary indicator of skill excludes the unique circumstances encompassed in military service. In this paper, the factors comprising volume and competence are explained, as well as the additional factors unique to military medicine. Furthermore, process improvements are proposed for assessing and optimizing surgical competence in the Military Health System.

Hospital variation in sphincter-preservation rates in rectal cancer treatment: results of a population-based study in the Netherlands

Background

This study aimed to examine the sphincter-preservation rate variations in rectal cancer surgery. The influence of hospital volume on sphincter-preservation rates and short-term outcomes (anastomotic leakage (AL), positive circumferential resection margin (CRM), 30- and 90-day mortality rates) were also analysed.

Methods

Non-metastasized rectal cancer patients treated between 2009 and 2016 were selected from the Netherlands Cancer Registry. Surgical procedures were divided into sphincter-preserving surgery and an end colostomy group. Multivariable logistic regression models were generated to estimate the probability of undergoing sphincter-preserving surgery according to the hospital of surgery and tumour height (low, 5 cm or less, mid, more than 5 cm to 10 cm, and high, more than 10 cm). The influence of annual hospital volume (less than 20, 20–39, more than 40 resections) on sphincter-preservation rate and short-term outcomes was also examined.

Results

A total of 20 959 patients were included (11 611 sphincter preservation and 8079 end colostomy) and the observed median sphincter-preservation rate in low, mid and high rectal cancer was 29.3, 75.6 and 87.9 per cent respectively. After case-mix adjustment, hospital of surgery was a significant factor for patients’ likelihood for sphincter preservation in all three subgroups (P < 0.001). In mid rectal cancer, borderline higher rates of sphincter preservation were associated with low-volume hospitals (odds ratio 1.20, 95 per cent c.i. 1.01 to 1.43). No significant association between annual hospital volume and sphincter-preservation rate in low and high rectal cancer nor short-term outcomes (AL, positive CRM rate and 30- and 90-day mortality rates) was identified.

Conclusion

This population-based study showed a significant hospital variation in sphincter-preservation rates in rectal surgery. The annual hospital volume, however, was not associated with sphincter-preservation rates in low, and high rectal cancer nor with other short-term outcomes.

Quality metrics in the performance of EUS: a population-based observational cohort of the United States

BACKGROUND AND AIMS

There are few data on the quality of EUS in the community setting. We characterized EUS performance at the individual facility level in 3 large American states, using need for repeat biopsy (NRB) as a metric for procedural failure, and the rate of unplanned hospital encounters (UHEs) as a metric for adverse events.

METHODS

We collected data on 76,614 EUS procedures performed at 166 facilities in California, Florida, and New York (2009-2014). The endpoints for the study were 7-day rate of UHEs after EUS, and 30-day rate of NRB after EUS with fine-needle aspiration. Facility-level factors analyzed included annual procedure volume, urban/rural location, and free-standing status (facilities not attached to a larger hospital). Predictors for UHE and NRB were analyzed in both multivariable regression and nonparametric local regression.

RESULTS

Facility volume did not predict risk for UHEs. However, high facility volume protected against NRB (P trend <.001) even after adjustment for other facility-level factors. When regressing facility volume against risk for NRB in local regression, a join point (inflection point) was identified at 97 procedures per annum. Once facilities reached this threshold volume, there appeared little additional protective effect of higher volume. Rural facility location (odds ratio, 1.81; 95% confidence interval, 1.36-2.40) and free-standing status (odds ratio, 1.57; 95% confidence interval, 1.16-2.13) were also associated with NRB.

CONCLUSION

Facility volume does not predict risk for adverse events after EUS. However, high facility volume is associated with decreased rates of technical failure (as assessed by NRB). These data provide one of the first descriptions of EUS practice in community settings and highlight opportunities to improve endoscopic quality nationally.

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC): Pancreatic Cancer

European Cancer Organisation Essential Requirements for Quality Cancer Care (ERQCC) are written by experts representing all disciplines involved in cancer care in Europe. They give patients, health professionals, managers and policymakers a guide to essential care throughout the patient journey. Pancreatic cancer is an increasing cause of cancer mortality and has wide variation in treatment and care in Europe. It is a major healthcare burden and has complex diagnosis and treatment challenges. Care must be carried out only in pancreatic cancer units or centres that have a core multidisciplinary team (MDT) and an extended team of health professionals detailed here. Such units are far from universal in European countries. To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper, paying particular attention to multidisciplinarity and patient-centred pathways from diagnosis, to treatment, to survivorship.

Non-arbitrary minimum threshold of yearly performed pancreatoduodenectomies: National multicentric study

BACKGROUND

Annual hospital volume of pancreatoduodenectomies could influence postoperative outcomes. The aim of this study is to establish with a non-arbitrary method the minimum threshold of yearly performed pancreatoduodenectomies in order to improve several postoperative quality outcomes.

METHOD

Prospective follow-up of patients submitted to pancreatoduodenectomy in participating hospitals during 1 year. The influence of hospital volume on quality outcomes was analyzed by univariable and multivariable models. The minimum threshold of yearly performed pancreatoduodenectomies to improve outcomes was established by Akaike's information criteria.

RESULTS

Data from 877 patients operated in 74 hospitals were analyzed. Of 12 quality outcomes, 9 were influenced by hospital pancreatoduodenectomy volume on multivariable analysis. To decrease the risk of complications and the risk of retrieving an insufficient number of lymph nodes at least 31 pancreatoduodenectomies per year should be performed. To decrease the risk of prolonged length of stay, postoperative death, and affected surgical margins, at least 37, 6, and 14 pancreatoduodenectomies per year should be performed, respectively.

CONCLUSION

Several postoperative quality outcomes are influenced by the number of yearly performed pancreatoduodenectomies and could be improved by establishing a minimum threshold of procedures. Number of procedures needed to improve quality outcomes has been established by a non-arbitrary method.

Care Fragmentation and Mortality in Readmission after Surgery for Hepatopancreatobiliary and Gastric Cancer: A Patient-Level and Hospital-Level Analysis of the Healthcare Cost and Utilization Project Administrative Database

BACKGROUND

Hepatopancreatobiliary (HPB) and gastric oncologic operations are frequently performed at referral centers. Postoperatively, many patients experience care fragmentation, including readmission to "outside hospitals" (OSH), which is associated with increased mortality. Little is known about patient-level and hospital-level variables associated with this mortality difference.

STUDY DESIGN

Patients undergoing HPB or gastric oncologic surgery were identified from select states within the Healthcare Cost and Utilization Project database (2006-2014). Follow-up was 90 days after discharge. Analyses used Kruskal-Wallis test, Youden index, and multilevel modeling at the hospital level.

RESULTS

There were 7,536 patients readmitted within 90 days of HPB or gastric oncologic surgery to 636 hospitals; 28% of readmissions (n = 2,123) were to an OSH, where 90-day readmission mortality was significantly higher: 8.0% vs 5.4% (p < 0.01). Patients readmitted to an OSH lived farther from the index surgical hospital (median 24 miles vs 10 miles; p < 0.01) and were readmitted later (median 25 days after discharge vs 12; p < 0.01). These variables were not associated with readmission mortality. Surgical complications managed at an OSH were associated with greater readmission mortality: 8.4% vs 5.7% (p < 0.01). Hospitals with <100 annual HPB and gastric operations for benign or malignant indications had higher readmission mortality (6.4% vs 4.7%, p = 0.01), although this was not significant after risk-adjustment (p = 0.226).

CONCLUSIONS

For readmissions after HPB and gastric oncologic surgery, travel distance and timing are major determinants of care fragmentation. However, these variables are not associated with mortality, nor is annual hospital surgical volume after risk-adjustment. This information could be used to determine safe sites of care for readmissions after HPB and gastric surgery. Further analysis is needed to explore the relationship between complications, the site of care, and readmission mortality.

Outcomes of Complex Gastrointestinal Cancer Resection at US News & World Report Top-Ranked vs Non-Ranked Hospitals

BACKGROUND

The US News & World Report (USNWR) annual ranking of the best hospitals for gastroenterology and gastrointestinal surgery offers direction to patients and healthcare providers, especially for recommendations on complex medical and surgical gastrointestinal (GI) conditions. The objective of this study was to examine the outcomes of complex GI cancer resections performed at USNWR top-ranked, compared to non-ranked, hospitals.

STUDY DESIGN

Using the Vizient database, data for patients who underwent esophagectomy, gastrectomy, and pancreatectomy for malignancy between January and December 2018 were reviewed. Perioperative outcomes were analyzed according to USNWR rank status. Primary outcome was in-hospital mortality. Secondary outcomes include length of stay, mortality index (observed-to-expected mortality ratio), rate of serious complication, and cost. Secondary analysis was performed for outcomes of patients who developed serious complications.

RESULTS

There were 3,054 complex GI cancer resections performed at 42 top-ranked hospitals vs 3,608 resections performed at 198 non-ranked hospitals. The mean annual case volume was 73 cases at top-ranked hospitals compared to 18 cases at non-ranked hospitals. Compared with non-ranked hospitals, top-ranked hospitals had lower in-hospital mortality (0.96% vs 2.26%, respectively, p < 0.001) and lower mortality index (0.71 vs 1.53, respectively). There were no significant differences in length of stay, rate of serious complications, or direct cost between groups. In patients who developed serious morbidity, top-ranked hospitals had a lower mortality compared with non-ranked hospitals (8.2% vs 16.8%, respectively, p < 0.01).

CONCLUSIONS

Within the context of complex GI cancer resection, USNWR top-ranked hospitals performed a 4-fold higher case volume and were associated with improved outcomes. Patients with complex GI-related malignancies may benefit from seeking surgical care at high-volume regional USNWR top-ranked hospitals.

Association of surgeon and hospital volume with postoperative mortality after total gastrectomy for gastric cancer: data from 71,307 Japanese patients collected from a nationwide web-based data entry system

BACKGROUND

Despite interest in surgeon and hospital volume effects on total gastrectomy (TG), clinical significance has not been confirmed in a large-scale population. This study aimed at clarifying the association of surgeon and hospital volume on postoperative mortality after TG for gastric cancer among Japanese patients in National Clinical Database (NCD).

METHODS

Between 2011 and 2015, we retrospectively extracted data on TG for gastric cancer from the NCD. The primary outcome was operative mortality. We divided surgeon volume as the number of TGs performed by a patient's surgeon in the previous year: S1 (0-2 cases), S2 (3-9), S3 (10-25), S4 (26-79) and hospital volume by the number of TGs performed in the previous year: H1 (0-11 cases), H2 (12-26), H3 (27-146). We calculated the 95% confidence interval (CI) for the mortality rate based on odds ratios (OR) estimated from a hierarchical logistic regression model.

RESULTS

We analyzed 71,307 patients at 2051 institutions. Low-volume surgeons and hospitals had significantly older and poorer-risk patients with various comorbidities. The operative mortality rate decreased with surgeon volume, 2.5% in S1 and 0.6% in S4. The operative mortality was 3.1% in H1, 1.7% in H2, and 1.2% in H3. After risk adjustment for surgeon, hospital volume and patient characteristics, hospital volume was significantly associated with operative morality (H3: OR = 0.53, 95% CI 0.43-0.63).

CONCLUSIONS

We demonstrate hospital volume has an impact on postoperative mortality after TG in a nationwide population study. These findings suggest centralization may improve outcomes after TG.

Surgeon Quality Control and Standardization of D2 Lymphadenectomy for Gastric Cancer: A Prospective Multicenter Observational Study (KLASS-02-QC)

OBJECTIVE

To qualify surgeons to participate in a randomized trial comparing laparoscopic and open distal D2 gastrectomy for advanced gastric cancer.

SUMMARY OF BACKGROUND DATA

No studies have sought to qualify surgeons for a randomized trial comparing laparoscopic and open D2 gastrectomy for advanced gastric cancer.

METHODS

We conducted a multicenter prospective observational study evaluating unedited videos of laparoscopic and open D2 gastrectomy performed by 27 surgeons. Surgeons performed 3 of each laparoscopic and open distal gastrectomies with D2 lymphadenectomy for gastric cancer. Five peers reviewed each unedited video using a video assessment form. Based on experts' review of videos, a separate review committee decided surgeons as "Qualified" or "Not-qualified."

RESULTS

Twelve surgeons (44.4%) were qualified on initial evaluation whereas the other 15 surgeons were not. Another 9 surgeons were finally qualified after re-evaluation. The median score for Qualified was significantly higher than Not-qualified (P < 0.001).Significant differences between Qualified and Not-qualified were noted both in operation type and in all evaluation area of surgical skill, perigastric, and extra-perigastric lymphadenectomy, although the inter-rater variability of the assessment score was low (kappa = 0.285). However, Not-qualified surgeons' scores improved upon re-evaluation of resubmitted videos.When compared laparoscopy with open surgery, median scores were similar between the 2 groups (P = 0.680). However, open gastrectomy scores for surgical skills were significantly higher than for laparoscopic surgery (P = 0.016).

CONCLUSIONS

Our surgeon quality control study for gastrectomy represents a milestone in surgical standardization for surgical clinical trials. Our methods could also serve as a system for educating surgeons and assessing surgical proficiency.

After-hours esophagectomy may pose additional risk to patients with esophageal cancer

Background

The increase in the incidence of esophageal cancers (ECs) combined with fewer surgeons working at large centers will increase the likelihood of surgery for ECs being performed during later hours. This study aimed to compare esophagectomies’ operative outcomes for EC performed at different surgical starting times.

Methods

This was a single-center, retrospective study. Risk-adjusted cumulative sum curve analysis and Cox regression analysis were used to identify the potential change-point of surgical starting times. The participants were then divided into 2 groups according to the change-point time. Propensity score matching was used to control confounding factors between the 2 groups. We compared the short- and long-term outcomes in both groups.

Results

A total of 702 patients who underwent potentially radical esophagectomy from 7 May 2014 to 31 December 2017 in our institute were included. The 3-year all-cause mortality showed a significant change-point at 16:42, with an increment from 56.5% to 76.9% (P=0.043). Esophagectomy that commenced between 17:00–18:59 was associated with significantly lower overall survival (OS) [multivariate hazard ratio (HR): 2.47; 95% confidence interval (CI): 1.25 to 4.90; P=0.010] and disease-free survival (DFS) (multivariate HR: 2.14; 95% CI: 1.08 to 4.21; P=0.028). The participants were allocated to the during-hours group and the after-hours group according to the change-point of 17:00. A total of 84 participants in the during-hours group were matched to 33 participants in the after-hours group. The median operative time was shorter in the after-hours group [309 (during-hours) vs. 239 (after-hours) minutes, P=0.014); the after-hours group had a greater incidence of respiratory complications (22.63% vs. 45.45%, P=0.023) and 90-day mortality (0 vs. 9.09%, P=0.021). The 5-year OS (P=0.042) and DFS (P=0.030) were significantly higher in the during-hours group.

Conclusions

Esophagectomies started during after-hours are correlated with poorer surgical outcomes. It is recommended to cancel selective esophagectomies due to commence after 17:00.

Specific complications and limitations of robotic esophagectomy

Regardless of the approach to esophagectomy, it is an operation that may be associated with significant risk to the patient. Robotic-assisted minimally invasive esophagectomy (RAMIE) has the same potential for short- and long-term complications as does open and minimally invasive esophagectomy. These complications include among others, the risk for anastomotic leak, gastric tip necrosis, vocal cord palsy, and chylothorax. Moreover, there are additional risks that are unique to the robotic platform such as hardware or software malfunction. These risks are heavily influenced by numerous factors including the patient's comorbidities, whether neoadjuvant therapy was administered, and the extent of the surgical team's experience. The limitations of RAMIE are therefore based on the careful assessment of the patient for operability, the tumor for resectability and the team for surgical ability. This article will tackle the topic of complications and limitations of RAMIE by examining each of these issues. It will also describe the recommended terminology for reporting post-esophagectomy complications.

Impact of Surgeon Volume on Outcomes and Expenditure Among Medicare Beneficiaries Undergoing Liver Resection: the Effect of Minimally Invasive Surgery

BACKGROUND

Although the role of annual surgeon volume on perioperative outcomes after liver resection (LR) has been investigated, there is a paucity of data regarding the impact of surgeon volume on outcomes of minimally invasive LR (MILR) versus open LR (OLR).

METHODS

Patients undergoing LR between 2013 and 2015 were identified in the Medicare inpatient Standard Analytic Files. Patients were classified into three groups based on surgeons' annual caseload: low (≤ 2 cases), medium (3-5 cases), or high (≥ 6 cases). Short-term outcomes and expenditures of LR, stratified by surgeon volume and minimally invasive surgery (MIS), were examined.

RESULTS

Among 3403 surgeons performing LR on 7169 patients, approximately 90% of surgeons performed less than 5 liver resections per year for Medicare patients. Only 7.1% of patients underwent MILR (n = 506). After adjustment, the likelihood of experiencing a complication and death within 90 days decreased with increasing surgeon volume. Outcomes of open and MILR among low- or high-volume surgeon groups, including rates of complications, 30- and 90-day readmission and mortality were similar. However, the difference of average total episode payment between open and MIS was higher in the high-volume surgeon group (low volume: $2929 vs. medium volume: $2333 vs. high volume: $7055).

CONCLUSION

Annual surgeon volume was an important predictor of outcomes following LR. MILR had comparable results to open LR among both the low- and high-volume surgeons.

Role of lymphadenectomy, adjuvant chemotherapy, and treatment at high-volume centers in patients with resected pancreatic cancer-a distinct view on lymph node yield

PURPOSE

While the importance of lymphadenectomy is well-established for patients with resectable pancreatic cancer, its direct impact on survival in relation to other predictive factors is still ill-defined.

METHODS

The National Cancer Data Base 2006-2015 was queried for patients with resected pancreatic adenocarcinoma (stage IA-IIB). Patients were dichotomized into the following two groups, those with 1-14 resected lymph nodes and those with ≥ 15. Optimal number of resected lymph nodes and the effect of lymphadenectomy on survival were assessed using various statistical modeling techniques. Mediation analysis was performed to differentiate the direct and indirect effect of lymph node resection on survival.

RESULTS

A total of 21,912 patients were included; median age was 66 years (IQR 59-73), 48.9% were female. Median number of resected lymph nodes was 15 (IQR 10-22), 10,163 (46.4%) had 1-14 and 11,749 (53.6%) had ≥ 15 lymph nodes retrieved. Lymph node positivity increased by 4.1% per lymph node up to eight examined lymph nodes, and by 0.6% per lymph node above eight. Five-year overall survival was 17.9%. Overall survival was better in the ≥ 15 lymph node group (adjusted HR 0.91, CI 0.88-0.95, p < 0.001). On a continuous scale, survival improved with increasing LNs collected. Patients who underwent adjuvant chemotherapy and were treated at high-volume centers had improved overall survival compared with their counterparts (adjusted HR 0.59, CI 0.57-0.62, p < 0.001; adjusted HR 0.86, CI 0.83-0.89, p < 0.001, respectively). Mediation analysis revealed that lymphadenectomy had only 18% direct effect on improved overall survival, while 82% of its effect were mediated by other factors like treatment at high-volume hospitals and adjuvant chemotherapy.

DISCUSSION

While higher number of resected lymph nodes increases lymph node positivity and is associated with better overall survival, most of the observed survival benefit is mediated by chemotherapy and treatment at high-volume centers.

International Variation in Surgical Practices in Units Performing Oesophagectomy for Oesophageal Cancer: A Unit Survey from the Oesophago-Gastric Anastomosis Audit (OGAA)

BACKGROUND

Anastomotic leaks are associated with significant risk of morbidity, mortality and treatment costs after oesophagectomy. The aim of this study was to evaluate international variation in unit-level clinical practice and resource availability for the prevention and management of anastomotic leak following oesophagectomy.

METHOD

The Oesophago-Gastric Anastomosis Audit (OGAA) is an international research collaboration focussed on improving the care and outcomes of patients undergoing oesophagectomy. Any unit performing oesophagectomy worldwide can register to participate in OGAA studies. An online unit survey was developed and disseminated to lead surgeons at each unit registered to participate in OGAA. High-income country (HIC) and low/middle-income country (LMIC) were defined according to the World Bank whilst unit volume were defined as < 20 versus 20-59 versus ≥60 cases/year in the unit.

RESULTS

Responses were received from 141 units, a 77% (141/182) response rate. Median annual oesophagectomy caseload was reported to be 26 (inter-quartile range 12-50). Only 48% (68/141) and 22% (31/141) of units had an Enhanced Recovery After Surgery (ERAS) program and ERAS nurse, respectively. HIC units had significantly higher rates of stapled anastomosis compared to LMIC units (66 vs 31%, p = 0.005). Routine post-operative contrast-swallow anastomotic assessment was performed in 52% (73/141) units. Stent placement and interventional radiology drainage for anastomotic leak management were more commonly available in HICs than LMICs (99 vs 59%, p < 0.001 and 99 vs 83%, p < 0.001).

CONCLUSIONS

This international survey highlighted variation in surgical technique and management of anastomotic leak based on case volume and country income level. Further research is needed to understand the impact of this variation on patient outcomes.

Improvements in esophageal and gastric cancer care in Sweden-population-based results 2007-2016 from a national quality register

The Swedish National Register for Esophageal and Gastric cancer was launched in 2006 and contains data with adequate national coverage and of high internal validity on patients diagnosed with these tumors. The aim of this study was to describe the evolution of esophageal and gastric cancer care as reflected in a population-based clinical registry. The study population was 12,242 patients (6,926 with esophageal and gastroesophageal junction (GEJ) cancers and 5,316 with gastric cancers) diagnosed between 2007 and 2016. Treatment strategies, short- and long-term mortality, gender aspects, and centralization were investigated. Neoadjuvant oncological treatment became increasingly prevalent during the study period. Resection rates for both esophageal/GEJ and gastric cancers decreased from 29.4% to 26.0% (P = 0.022) and from 38.8% to 33.3% (P = 0.002), respectively. A marked reduction in the number of hospitals performing esophageal and gastric cancer surgery was noted. In gastric cancer patients, an improvement in 30-day mortality from 4.2% to 1.6% (P = 0.005) was evident. Overall 5-year survival after esophageal resection was 38.9%, being higher among women compared to men (47.5 vs. 36.6%; P < 0.001), whereas no gender difference was seen in gastric cancer. During the recent decade, the analyses based on the Swedish National Register for Esophageal and Gastric cancer database demonstrated significant improvements in several important quality indicators of care for patients with esophagogastric cancers. The Swedish National Register for Esophageal and Gastric cancer offers an instrument not only for the control and endorsement of quality of care but also a unique tool for population-based clinical research.

The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy

Background and Objectives: Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results: Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals (P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions: After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.

Centralization of Pancreatic Surgery in Europe

BACKGROUND

The objective of this article is a review and an analysis of the current state of centralization of pancreatic surgery in Europe. Numerous recent publications demonstrate higher postoperative in-hospital mortality rates in low-volume clinics after pancreatic resection than previously assumed due to their not publishing significantly worse outcomes when compared to high-volume centres. Although the benefits of centralization of pancreatic surgery in high-volume centres have been demonstrated in many studies, numerous countries have so far failed to establish centralization in their respective health care systems.

METHODS

A systematic literature search of the Medline database for studies concerning centralization of pancreatic surgery in Europe was conducted. The studies were reviewed independently for previously defined inclusion and exclusion criteria. We included 14 studies with a total of 117,634 patients. All data were extracted from or provided by health insurance company or governmental registry databases.

RESULTS

Thirteen out of the 14 studies demonstrate an improvement in their respective outcome related to volume. Twelve studies showed a significantly lower postoperative mortality rate in the highest annual volume group in comparison to overall postoperative mortality rate in the whole patient cohort.

CONCLUSION

As the available data indicate, most European countries have so far failed to establish centralization of pancreatic surgery to high-volume centres due to numerous reasons. Considering a plateau in survival rates of patients undergoing treatment for pancreatic cancer in Europe during the last 15 years, this review enforces the worldwide plea for centralization to lower post-operative mortality after pancreatic surgery.

The impact of surgical experience and frequency of practice on perioperative outcomes in pancreatic surgery

OBJECTIVE

We aimed to determine the impact of surgical experience and frequency of practice on perioperative morbidity and mortality in pancreatic surgery.

METHODS

1281 patients that underwent pancreatic resections from 1993 to 2013 were retrospectively analyzed using logistic regression models. All cases were stratified according to the surgeon's level of experience, which was based on the number of previously performed pancreatic resections and the extent of received supervision (novice: n <  20 / intensive; intermediate: n = 21-90 / decreasing; and experienced surgeon: n > 90 / none). Additional stratification was based on the frequency of practice (sporadic: 3 resections > 6 weeks, frequent: 3 resections ≤6 weeks).

RESULTS

The novice and experienced categories were related to a decreased risk of postoperative pancreatic fistulas (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.82 and 0.54, 95% CI 0.36-0.82) and in-hospital mortality (OR 0.45, 95% CI 0.17-1.16 and 0.42, 95% CI 0.21-0.83) compared to the intermediate category. Frequent practice was associated with a significantly lower risk of delayed gastric emptying (OR 0.56, 95% CI 0.38-0.83), postpancreatectomy hemorrhage (OR 0.64, 95% CI 0.42-0.98) and in-hospital mortality (OR 0.45, 95% CI 0.24-0.87).

CONCLUSIONS

Our results emphasize the importance of supervision within a pancreatic surgery training program. In addition, our data underline the need of a sufficient patient caseload to ensure frequent practice.

Regionalization of esophagectomy: where are we now?

The morbidity and mortality benefits of performing high-risk operations in high-volume centers by high-volume surgeons are evident. Regionalization is a proposed strategy to leverage high-volume centers for esophagectomy to improve quality outcomes. Internationally, regionalization occurs under national mandates. Those mandates do not exist in the United States and spontaneous regionalization of esophagectomy has only modestly occurred in the U.S. Regionalization must strike a careful balance and not limit access to optimal oncologic care to our most vulnerable cancer patient populations in rural and disadvantaged socioeconomic areas. We reviewed the recent literature highlighting: the justification of hospital and surgeon annual esophagectomy volumes for regionalization; how safety performance metrics could influence regionalization; whether regionalization is occurring in the US; what impact regionalization may have on esophagectomy costs; and barriers to patients traveling to receive oncologic treatment at regionalized centers of excellence.

The future of general surgery training: A Canadian resident nationwide Delphi consensus statement

BACKGROUND

Several models have been introduced to improve and restructure surgical training, but continued barriers exist. Residents are uniquely positioned to offer perspective on practical challenges and needs of reformatting surgical education. This study aimed to establish a nationwide, Delphi consensus statement on the perceptions of Canadian residents regarding the future of general surgery training.

METHODS

Canadian general surgery residents participated in a moderated focus group using the Nominal Group Technique to discuss early subspecialization, competency-based medical education, and transition to practice. Qualitative verbal data were transcribed, categorized into themes, and synthesized into recommendation statements. During an iterative Delphi survey, resident leaders ranked each statement on a 5-point Likert scale of agreement. The survey was terminated once consensus was achieved (≥2 survey rounds and Cronbach's α ≥ 0.80).

RESULTS

A total of 66 statements were synthesized by 16 members of the Canadian Association of General Surgeons Resident Committee. A total of 49 residents participated in the Delphi consensus, which was achieved after 2 voting rounds (Cronbach's α = 0.93). Participants agreed that (1) residency should focus on achieving standardized competencies and milestones based on resident ability to meet specific measurable metrics, (2) early streaming should be offered after "core" milestones and competencies have been achieved, and (3) an explicit period should allow transition-to-independent practice with tailored rotations, greater autonomy, and resident-run clinics. We identified 10 barriers to competency-based medical education implementation.

CONCLUSION

A nationwide consensus regarding the future of surgical training was established among current residents. These findings can inform and help implement guidelines and national curricula that meet the needs of the trainee and address the many challenges they face during their training.