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Manara M, Bona D, Bonavina L, Aiolfi A. Impact of pulmonary complications following esophagectomy on long-term survival: multivariate meta-analysis and restricted mean survival time assessment. Updates Surg 2024; 76:757-767. [PMID: 38319522 PMCID: PMC11129973 DOI: 10.1007/s13304-024-01761-2] [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: 10/16/2023] [Accepted: 01/16/2024] [Indexed: 02/07/2024]
Abstract
Pulmonary complications (PC) are common after esophagectomy and their impact on long-term survival is not defined yet. The present study aimed to assess the effect of postoperative PCs on long-term survival after esophagectomy for cancer. Systematic review of the literature through February 1, 2023, was performed. The included studies evaluated the effect of PC on long-term survival. Primary outcome was long-term overall survival (OS). Cancer-specific survival (CSS) and disease-free survival (DFS) were secondary outcomes. Restricted mean survival time difference (RMSTD), hazard ratio (HR), and 95% confidence intervals (CI) were used as pooled effect size measures. Eleven studies were included (3423 patients). Overall, 674 (19.7%) patients developed PC. The RMSTD analysis shows that at 60-month follow-up, patients not experiencing PC live an average of 8.5 (95% CI 6.2-10.8; p < 0.001) months longer compared with those with PC. Similarly, patients not experiencing postoperative PC seem to have significantly longer CSS (8 months; 95% CI 3.7-12.3; p < 0.001) and DFS (5.4 months; 95% CI 1.6-9.1; p = 0.005). The time-dependent HRs analysis shows a reduced mortality hazard in patients without PC at 12 (HR 0.6, 95% CI 0.51-0.69), 24 (HR 0.64, 95% CI 0.55-0.73), 36 (HR 0.67, 95% CI 0.55-0.79), and 60 months (HR 0.69, 95% CI 0.51-0.89). This study suggests a moderate clinical impact of PC on long-term OS, CSS, and DFS after esophagectomy. Patients not experiencing PC seem to have a significantly reduced mortality hazard up to 5 years of follow-up.
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Affiliation(s)
- Michele Manara
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Via C. Belgioioso N. 173, 20151, Milan, Italy.
| | - Davide Bona
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Via C. Belgioioso N. 173, 20151, Milan, Italy
| | - Luigi Bonavina
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Policlinico San Donato, University of Milan, Milan, Italy
| | - Alberto Aiolfi
- Division of General Surgery, Department of Biomedical Science for Health, I.R.C.C.S. Ospedale Galeazzi-Sant'Ambrogio, University of Milan, Via C. Belgioioso N. 173, 20151, Milan, Italy
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Bona D, Manara M, Bonitta G, Guerrazzi G, Guraj J, Lombardo F, Biondi A, Cavalli M, Bruni PG, Campanelli G, Bonavina L, Aiolfi A. Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis. Cancers (Basel) 2024; 16:1468. [PMID: 38672550 PMCID: PMC11048031 DOI: 10.3390/cancers16081468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain. AIM To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence. RESULTS Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low. CONCLUSIONS This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.
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Affiliation(s)
- Davide Bona
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Michele Manara
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Gianluca Bonitta
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Guglielmo Guerrazzi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Juxhin Guraj
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Francesca Lombardo
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
| | - Antonio Biondi
- Department of General Surgery and Medical Surgical Specialties, G. Rodolico Hospital, Surgical Division, University of Catania, 95131 Catania, Italy;
| | - Marta Cavalli
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Surgery, University of Insubria, 20157 Milan, Italy
| | - Piero Giovanni Bruni
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Surgery, University of Insubria, 20157 Milan, Italy
| | - Giampiero Campanelli
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Surgery, University of Insubria, 20157 Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General and Foregut Surgery, IRCCS Policlinico San Donato, University of Milan, 20097 Milan, Italy
| | - Alberto Aiolfi
- I.R.C.C.S. Ospedale Galeazzi—Sant’Ambrogio, Division of General Surgery, Department of Biomedical Science for Health, University of Milan, 20157 Milan, Italy; (D.B.); (M.M.); (G.B.); (G.G.)
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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Nevins EJ, Chmelo J, Prasad P, Brown J, Phillips AW. Long-term survival is not affected by severity of complications following esophagectomy. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108232. [PMID: 38430703 DOI: 10.1016/j.ejso.2024.108232] [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] [Received: 10/07/2023] [Revised: 01/09/2024] [Accepted: 02/25/2024] [Indexed: 03/05/2024]
Abstract
INTRODUCTION Outcomes following esophagectomy for esophageal cancer have continued to improve over the last 30 years. Post-operative complications impact upon peri-operative and short-term survival but the effect on long-term survival remains debated. This study aims to investigate the effect of post-operative complications on long-term survival following esophagectomy. MATERIALS AND METHODS All patients who underwent an esophagectomy between January 2010 and January 2019 were included from a single high-volume center. Data was collected contemporaneously. Patients were separated into three groups; those who experienced no, or very minor complications (Clavien-Dindo 0 or 1), minor complications (Clavien-Dindo 2), and major complications (Clavien-Dindo 3-4), at 30 days. To correct for short-term mortality effects, those who died during the index hospital admission were excluded. Overall survival was analyzed using Kaplan-Meier and log rank testing. RESULTS The study cohort comprised 721 patients. There were 42.4% (306/721), 29.5% (213/721) and 25.7% (185/721) in the Clavien-Dindo 0-1, Clavien-Dindo 2, and Clavien-Dindo 3-4 group respectively. Seventeen patients (2.4%) died during their index hospital admission and were therefore excluded. There was no significant difference between median survival across the 3 groups (50, 57 and 52 months). Across all 3 groups, overall long-term survival rates were equivalent at 1 (87.5%, 84.9%, 83.2%), 3 (59.7%, 59.6%, 54.2%), and 5 years (43.9%, 48.9%, 45.7%) (p = 0.806). The only factors independently associated with survival in this cohort, were male gender, Charlson comorbidity index, and overall pathological stage of disease. CONCLUSION Long-term survival is not affected by peri-operative complications, irrespective of severity, following esophagectomy. Further study into the long-term quality of life is required.
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Affiliation(s)
- Edward J Nevins
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Jakub Chmelo
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Pooja Prasad
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Joshua Brown
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Alexander W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle Upon Tyne NHS Foundation Trust, Newcastle Upon Tyne, UK; School of Medical Education, Newcastle University, Newcastle Upon Tyne, UK.
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Gu HY, Luo J, Qiang Y. Postoperative complications analysis of circular stapled versus linear stapled anastomosis for patients undergoing esophagectomy: a systematic review and meta-analysis. J Cardiothorac Surg 2023; 18:242. [PMID: 37559141 PMCID: PMC10413733 DOI: 10.1186/s13019-023-02309-y] [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] [Received: 08/08/2022] [Accepted: 06/28/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND The choice of anastomosis technique after esophagectomy is closely associated with the postoperative complications. Whether circular stapled or linear stapled anastomosis is the optimal technique has not been established. Therefore, we conducted this meta-analysis to show the latest and most comprehensive published assessment of circular stapled anastomosis in comparison with linear stapled anastomosis in postoperative complications. METHODS Databases (PubMed, Embase, Web of science, Cochrane Library) were searched for all randomized controlled trials and comparative studies comparing circular stapled anastomosis with linear stapled anastomosis after esophagectomy. The odd ratio and mean difference with 95% confidence interval were calculated. We used the Higgins I² statistics to assess the statistical heterogeneity between studies. Review manager (version 5.4) software was used in this analysis. RESULTS Sixteen studies with 2322 patients were included in our study. The study demonstrated that the use of linear stapled technique after esophagectomy could reduce the risk of both anastomotic leakage (P = 0.0003) and stricture (P < 0.00001) compared with circular stapled technique. Stratification by anastomotic site showed that no matter what kind of anastomotic site (cervical or thoracic anastomosis) was used, linear stapled anastomosis could effectively reduce the anastomotic stricture in comparison with circular stapled anastomosis. Moreover, linear stapled anastomosis could decrease the risk of thoracic anastomotic leakage. There were no significant differences between circle stapled anastomosis and linear stapled anastomosis in reflux esophagitis (P = 0.17), pneumonia (P = 0.91), operation time (P = 0.41) and hospital stay (P = 0.38). CONCLUSIONS The study suggested that linear stapled anastomosis could be considered to be an optimal treatment associated with a reduced risk of anastomotic leakage and stricture in comparison with circular stapled anastomosis.
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Affiliation(s)
- Hao-Yu Gu
- Medical College, Nantong University, Nantong City, Nantong, 226000, Jiangsu, P.R. China
| | - Jing Luo
- Department of Cardiothoracic Surgery, Nanjing Jinling Hospital, East Region Military Command General Hospital, Nanjing, 210000, Jiangsu, P.R. China.
| | - Yong Qiang
- Department of Cardiothoracic Surgery, Nanjing Jinling Hospital, East Region Military Command General Hospital, Nanjing, 210000, Jiangsu, P.R. China.
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Cuesta AJ, Guevara O, Buitrago G. HOSPITAL VOLUME, POSTOPERATIVE MORTALITY, AND COSTS AFTER GASTRECTOMY FOR GASTRIC CANCER IN COLOMBIA: IS THERE ANY ASSOCIATION? ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1745. [PMID: 37436278 DOI: 10.1590/0102-672020230027e1745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/28/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND There are no information in the literature associating the volume of gastrectomies with survival and costs for the health system in the treatment of patients with gastric cancer in Colombia. AIMS The aim of this study was to analyze how gastrectomy for gastric cancer is associated with hospital volume, 30-day and 180-day postoperative mortality, and healthcare costs in Bogotá, Colombia. METHODS A retrospective cohort study based on hospital data of all adult patients with gastric cancer who underwent gastrectomy between 2014 and 2016 using a paired propensity score. The surgical volume was identified as the average annual number of gastrectomies performed by the hospital. RESULTS A total of 743 patients were included in the study. Hospital mortality at 30 and 180 days postoperatively was 36 (4.85%) and 127 (17.09%) patients, respectively. The average health care cost was USD 3,200. A total of 26 or more surgeries were determined to be the high surgical volume cutoff. Patients operated on in hospitals with a high surgical volume had lower 6-month mortality (HR 0.44; 95%CI 0.27-0.71; p=0.001), and no differences were found in health costs (mean difference 398.38; 95%CI-418.93-1,215.69; p=0.339). CONCLUSIONS This study concluded that in Bogotá (Colombia), surgery in a high-volume hospital is associated with better 6-month survival and no additional costs to the health system.
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Affiliation(s)
- Antonio Jose Cuesta
- Universidad Nacional de Colombia, Faculty of Medicine, Department of Surgery - Bogotá, Colombia
- Hospital Universitario Nacional de Colombia - Bogotá, Colombia
| | - Oscar Guevara
- Universidad Nacional de Colombia, Faculty of Medicine, Department of Surgery - Bogotá, Colombia
- Hospital Universitario Nacional de Colombia - Bogotá, Colombia
| | - Giancarlo Buitrago
- Universidad Nacional de Colombia, Faculty of Medicine, Department of Surgery - Bogotá, Colombia
- Hospital Universitario Nacional de Colombia - Bogotá, Colombia
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Morse RT, Mouw TJ, Moreno M, Erwin JT, Cao Y, DiPasco P, Al-Kasspooles M, Hoover A. Neoadjuvant Radiotherapy Facility Type Affects Anastomotic Complications After Esophagectomy. J Gastrointest Surg 2023; 27:1313-1320. [PMID: 36973500 DOI: 10.1007/s11605-023-05660-6] [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: 08/31/2022] [Accepted: 02/28/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Esophagectomy is a complex oncologic surgery that results in lower perioperative morbidity and mortality when performed in high-volume hospitals by experienced surgeons; however, limited data exists evaluating the importance of neoadjuvant radiotherapy delivery at high- versus low-volume centers. We sought to compare postoperative toxicity among patients treated with preoperative radiotherapy delivered at an academic medical center (AMC) versus community medical centers (CMC). METHODS Consecutive patients undergoing esophagectomy for locally advanced esophageal or gastroesophageal junction (GEJ) cancer at an academic medical center between 2008 and 2018 were reviewed. Associations between patient factors and treatment-related toxicities were calculated in univariate (UVA) and multivariable analyses (MVA). RESULTS One hundred forty-seven consecutive patients were identified: 89 CMC and 58 AMC. Median follow-up was 30 months (0.33-124 months). Most patients were male (86%) with adenocarcinoma (90%) located in the distal esophagus or GEJ (95%). Median radiation dose was 50.4 Gy between groups. Radiotherapy at CMCs resulted in higher rates of re-operation after esophagectomy (18% vs 7%, p = 0.055) and increased rates of anastomotic leak (38% vs 17%, p < 0.01). On MVA, radiation at a CMC remained predictive of anastomotic leak (OR 6.13, p < 0.01). CONCLUSION Esophageal cancer patients receiving preoperative radiotherapy had higher rates of anastomotic leaks when radiotherapy was completed at a community medical center versus academic medical center. Explanations for these differences are uncertain but further exploratory analyses regarding dosimetry and radiation field size are warranted.
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Affiliation(s)
- Ryan T Morse
- Department of Radiation Oncology, University of North Carolina Chapel Hill, 101 Manning Drive, Chapel Hill, NC, 27514, USA.
| | - Tyler J Mouw
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Matthew Moreno
- Department of Plastic Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Jace T Erwin
- University of Kansas School of Medicine, University of Kansas Medical Center, Kansas City, USA
| | - Ying Cao
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
| | - Peter DiPasco
- Department of Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Mazin Al-Kasspooles
- Department of Surgery, University of Kansas Medical Center, Kansas City, USA
| | - Andrew Hoover
- Department of Radiation Oncology, University of Kansas Medical Center, Kansas City, USA
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Pickering OJ, van Boxel GI, Carter NC, Mercer SJ, Knight BC, Pucher PH. Learning curve for adoption of robot-assisted minimally invasive esophagectomy: a systematic review of oncological, clinical, and efficiency outcomes. Dis Esophagus 2023; 36:6961031. [PMID: 36572404 DOI: 10.1093/dote/doac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/25/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Robot-assisted minimally invasive esophagectomy (RAMIE) is gaining increasing popularity as an operative approach. Learning curves to achieve surgical competency in robotic-assisted techniques have shown significant variation in learning curve lengths and outcomes. This study aimed to summarize the current literature on learning curves for RAMIE. METHODS A systematic review was conducted in line with PRISMA guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles reporting on learning curves in RAMIE were identified and scrutinized. Studies were eligible if they reported changes in operative outcomes over time, or learning curves, for surgeons newly adopting RAMIE. RESULTS Fifteen studies reporting on 1767 patients were included. Nine studies reported on surgeons with prior experience of robot-assisted surgery prior to adopting RAMIE, with only four studies outlining a specified RAMIE adoption pathway. Learning curves were most commonly analyzed using cumulative sum control chart (CUSUM) and were typically reported for lymph node yields and operative times, with significant variation in learning curve lengths (18-73 cases and 20-80 cases, respectively). Most studies reported adoption without significant impact on clinical outcomes such as anastomotic leak; significant learning curves were more likely in studies, which did not report a formal learning or adoption pathway. CONCLUSION Reported RAMIE adoption phases are variable, with some authors suggesting significant impact to patients. With robust training through formal programmes or proctorship, however, others report RAMIE adoption without impact on clinical outcomes. A formalized adoption curriculum appears critical to prevent adverse effects on operative efficiency and patient care.
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Affiliation(s)
- Oliver J Pickering
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Gijs I van Boxel
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Nick C Carter
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Stuart J Mercer
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Benjamin C Knight
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Philip H Pucher
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
- Department of Pharmacology and Biosciences, University of Portsmouth, Portsmouth, UK
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10
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Wang Q, Mine S, Nasu M, Fukunaga T, Nojiri S, Zhang CD. Association of hospital volume and long-term survival after esophagectomy: A systematic review and meta-analysis. Front Surg 2023; 10:1161938. [PMID: 37151870 PMCID: PMC10160622 DOI: 10.3389/fsurg.2023.1161938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/27/2023] [Indexed: 05/09/2023] Open
Abstract
Background It remains controversial whether esophageal cancer patients may benefit from esophagectomy in specialized high-volume hospitals. Here, the effect of hospital volume on overall survival (OS) of esophageal cancer patients post esophagectomy was assessed. Methods PubMed, Embase, and Cochrane Library were systematically searched for relevant published articles between January 1990 and May 2022. The primary outcome was OS after esophagectomy in high- vs. low-volume hospitals. Random effect models were applied for all meta-analyses. Subgroup analysis were performed based on volume grouping, sample size, study country, year of publication, follow-up or study quality. Sensitivity analyses were conducted using the leave-one-out method. The Newcastle-Ottawa Scale was used to assess the study quality. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidance, and was registered (identifier: INPLASY202270023). Results A total of twenty-four studies with 113,014 patients were finally included in the meta-analysis. A significant improvement in OS after esophagectomy was observed in high-volume hospitals as compared to that in their low-volume counterparts (HR: 0.77; 95% CI: 0.71-0.84, P < 0.01). Next, we conducted subgroup analysis based on volume grouping category, consistent results were found that high-volume hospitals significantly improved OS after esophagectomy than their low-volume counterparts. Subgroup analysis and sensitivity analyses further confirmed that all the results were robust. Conclusions Esophageal cancer should be centralized in high-volume hospitals.
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Affiliation(s)
- Qing Wang
- Department of Esophageal and Gastroenterological Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
- Department of Thoracic Surgery, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Shinji Mine
- Department of Esophageal and Gastroenterological Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Motomi Nasu
- Department of Esophageal and Gastroenterological Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tetsu Fukunaga
- Department of Esophageal and Gastroenterological Surgery, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shuko Nojiri
- Medical Technology Innovation Center, Juntendo University, Tokyo, Japan
| | - Chun-Dong Zhang
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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11
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Marano L, Verre L, Carbone L, Poto GE, Fusario D, Venezia DF, Calomino N, Kaźmierczak-Siedlecka K, Polom K, Marrelli D, Roviello F, Kok JHH, Vashist Y. Current Trends in Volume and Surgical Outcomes in Gastric Cancer. J Clin Med 2023; 12:jcm12072708. [PMID: 37048791 PMCID: PMC10094776 DOI: 10.3390/jcm12072708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/27/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
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.
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Affiliation(s)
- Luigi Marano
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Luigi Verre
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Ludovico Carbone
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Gianmario Edoardo Poto
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Daniele Fusario
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | | | - Natale Calomino
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Karolina Kaźmierczak-Siedlecka
- Department of Medical Laboratory Diagnostics-Fahrenheit Biobank BBMRI.pl, Medical University of Gdansk, 80-308 Gdańsk, Poland
| | - Karol Polom
- Department of Surgical Oncology, Medical University of Gdansk, 80-308 Gdańsk, Poland
| | - Daniele Marrelli
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Franco Roviello
- Department of Medicine, Surgery and Neuroscience, University of Siena, 53100 Siena, Italy
| | - Johnn Henry Herrera Kok
- Department of General and Digestive Surgery, Complejo Asistencial Universitario de León, 24071 León, Spain
| | - Yogesh Vashist
- Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh 11211, Saudi Arabia
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12
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Risk Factors for Tumor Positive Resection Margins After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: Results From the Dutch Upper GI Cancer Audit: A Nationwide Population-Based Study. Ann Surg 2023; 277:e313-e319. [PMID: 34334634 PMCID: PMC9831046 DOI: 10.1097/sla.0000000000005112] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To identify risk factors for tumor positive resection margins after neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal cancer. SUMMARY BACKGROUND DATA Esophagectomy after nCRT is associated with tumor positive resection margins in 4% to 9% of patients. This study evaluates potential risk factors for positive resection margins after nCRT followed by esophagectomy. METHODS All patients who underwent an elective esophagectomy following nCRT in 2011 to 2017 in the Netherlands were included. A multivariable logistic regression was performed to assess the association between potential risk factors and tumor positive resection margins. RESULTS In total, 3900 patients were included. Tumor positive resection margins were observed in 150 (4%) patients. Risk factors for tumor positive resection margins included tumor length (in centimeters, OR: 1.1, 95% CI: 1.0-1.1), cT4-stage (OR: 3.0, 95% CI: 1.2-6.7), and an Ivor Lewis esophagectomy (OR: 1.6, 95% CI: 1.0-2.6). Predictors associated with a lower risk of tumor positive resection margins were squamous cell carcinoma (OR: 0.4, 95% CI: 0.2-0.7), distal tumors (OR: 0.5, 95% CI: 0.3-1.0), minimally invasive surgery (OR: 0.6, 95% CI: 0.4-0.9), and a hospital volume of >60 esophagectomies per year (OR: 0.6, 95% CI: 0.4-1.0). CONCLUSIONS In this nationwide cohort study, tumor and surgical related factors (tumor length, histology, cT-stage, tumor location, surgical procedure, surgical approach, hospital volume) were identified as risk factors for tumor positive resection margins after nCRT for esophageal cancer. These results can be used to improve the radical resection rate by careful selection of patients and surgical approach and are a plea for centralization of esophageal cancer care.
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13
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Madsen HJ, Lambert-Kerzner A, Mucharsky E, Gergen AK, Dyas AR, McCarter M, Stewart C, Pratap A, Mitchell J, Randhawa S, Meguid RA. Barriers and Facilitators in Implementation of an Esophagectomy Care Pathway: a Qualitative Analysis. J Gastrointest Surg 2023; 27:213-221. [PMID: 36443554 PMCID: PMC9707093 DOI: 10.1007/s11605-022-05537-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 11/01/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION A new postoperative esophagectomy care pathway was recently implemented at our institution. Practice pattern change among provider teams can prove challenging; therefore, we sought to study the barriers and facilitators toward pathway implementation at the provider level. METHODS This qualitative study was guided by the Theoretical Domains Framework (TDF) to study the adoption and implementation of a post-esophagectomy care pathway. Sixteen in-depth interviews were conducted with providers involved with the pathway. Matrix analysis was used to analyze the data. RESULTS Providers included attending surgeons (n = 6), advanced practice providers (n = 8), registered dietitian (n = 1), and clinic staff (n = 1). TDF domains that were salient across our findings included knowledge, beliefs about consequences, social influences, and environmental context and resources. Identified facilitators included were electronic health record tools, such as note templates including pathway components and a pathway-specific order set, patient satisfaction, and preliminary data indicating clinical benefits such as a reduced anastomotic leak rate. The major barrier reported was a hesitance to abandon previous practice patterns, most prevalent at the attending surgeon level. CONCLUSION The TDF enabled us to identify and understand the individuals' perceived barriers and facilitators toward adoption and implementation of a postoperative esophagectomy pathway. This analysis can help guide and improve adoption of surgical patient care pathways among providers.
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Affiliation(s)
- Helen J Madsen
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA. .,Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Anne Lambert-Kerzner
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ellison Mucharsky
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anna K Gergen
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Martin McCarter
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Camille Stewart
- Department of Surgery, Division of Surgical Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Akshay Pratap
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - John Mitchell
- Department of Surgery, Division of Thoracic Surgery, University of Colorado, Aurora, CO, USA
| | - Simran Randhawa
- Department of Surgery, Division of Thoracic Surgery, University of Colorado, Aurora, CO, USA
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA.,Department of Surgery, Division of Thoracic Surgery, University of Colorado, Aurora, CO, USA
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14
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Perry C, Boaden RJ, Black GB, Clarke CS, Darley S, Ramsay AI, Shackley DC, Vindrola-Padros C, Fulop NJ. "Attending to History" in Major System Change in Healthcare in England: Specialist Cancer Surgery Service Reconfiguration. Int J Health Policy Manag 2022; 11:2829-2841. [PMID: 35297232 PMCID: PMC10105206 DOI: 10.34172/ijhpm.2022.6389] [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] [Received: 05/21/2021] [Accepted: 02/19/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The reconfiguration of specialist hospital services, with service provision concentrated in a reduced number of sites, is one example of major system change (MSC) for which there is evidence of improved patient outcomes. This paper explores the reconfiguration of specialist oesophago-gastric (OG) cancer surgery services in a large urban area of England (Greater Manchester, GM), with a focus on the role of history in this change process and how reconfiguration was achieved after previous failed attempts. METHODS This study draws on qualitative research from a mixed-methods evaluation of the reconfiguration of specialist cancer surgery services in GM. Forty-six interviews with relevant stakeholders were carried out, along with ~160 hours of observations at meetings and the acquisition of ~300 pertinent documents. Thematic analysis using deductive and inductive approaches was undertaken, guided by a framework of 'simple rules' for MSC. RESULTS Through an awareness of, and attention to, history, leaders developed a change process which took into account previous unsuccessful reconfiguration attempts, enabling them to reduce the impact of potentially challenging issues. Interviewees described attending to issues involving competition between provider sites, change leadership, engagement with stakeholders, and the need for a process of change resilient to challenge. CONCLUSION Recognition of, and response to, history, using a range of perspectives, enabled this reconfiguration. Particularly important was the way in which history influenced and informed other aspects of the change process and the influence of stakeholder power. This study provides further learning about MSC and the need for a range of perspectives to enable understanding. It shows how learning from history can be used to enable successful change.
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Affiliation(s)
- Catherine Perry
- Applied Research Collaboration Greater Manchester, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Division of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & Health, University of Manchester, Manchester, UK
| | - Ruth J. Boaden
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Georgia B. Black
- Department of Applied Health Research, University College London (UCL), London, UK
| | - Caroline S. Clarke
- UCL Research Department of Primary Care and Population Health, University College London (UCL), London, UK
| | - Sarah Darley
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Angus I.G. Ramsay
- Department of Applied Health Research, University College London (UCL), London, UK
| | - David C. Shackley
- Christie NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, Manchester Academic Health Science Centre (MAHSC), Manchester, UK
| | | | - Naomi J. Fulop
- Department of Applied Health Research, University College London (UCL), London, UK
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15
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Clarke CS, Melnychuk M, Ramsay AIG, Vindrola-Padros C, Levermore C, Barod R, Bex A, Hines J, Mughal MM, Pritchard-Jones K, Tran M, Shackley DC, Morris S, Fulop NJ, Hunter RM. Cost-Utility Analysis of Major System Change in Specialist Cancer Surgery in London, England, Using Linked Patient-Level Electronic Health Records and Difference-in-Differences Analysis. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2022; 20:905-917. [PMID: 35869355 PMCID: PMC9307119 DOI: 10.1007/s40258-022-00745-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Studies have shown that centralising surgical treatment for some cancers can improve patient outcomes, but there is limited evidence of the impact on costs or health-related quality of life. OBJECTIVES We report the results of a cost-utility analysis of the RESPECT-21 study using difference-in-differences, which investigated the reconfiguration of specialist surgery services for four cancers in an area of London, compared to the Rest of England (ROE). METHODS Electronic health records data were obtained from the National Cancer Registration and Analysis Service for patients diagnosed with one of the four cancers of interest between 2012 and 2017. The analysis for each tumour type used a short-term decision tree followed by a 10-year Markov model with 6-monthly cycles. Costs were calculated by applying National Health Service (NHS) Reference Costs to patient-level hospital resource use and supplemented with published data. Cancer-specific preference-based health-related quality-of-life values were obtained from the literature to calculate quality-adjusted life-years (QALYs). Total costs and QALYs were calculated before and after the reconfiguration, in the London Cancer (LC) area and in ROE, and probabilistic sensitivity analysis was performed to illustrate the uncertainty in the results. RESULTS At a threshold of £30,000/QALY gained, LC reconfiguration of prostate cancer surgery services had a 79% probability of having been cost-effective compared to non-reconfigured services using difference-in-differences. The oesophago-gastric, bladder and renal reconfigurations had probabilities of 62%, 49% and 12%, respectively, of being cost-effective at the same threshold. Costs and QALYs per surgical patient increased over time for all cancers across both regions to varying degrees. Bladder cancer surgery had the smallest patient numbers and changes in costs, and QALYs were not significant. The largest improvement in outcomes was in renal cancer surgery in ROE, making the relative renal improvements in LC appear modest, and the probability of the LC reconfiguration having been cost-effective low. CONCLUSIONS Prostate cancer reconfigurations had the highest probability of being cost-effective. It is not clear, however, whether the prostate results can be considered in isolation, given the reconfigurations occurred simultaneously with other system changes, and healthcare delivery in the NHS is highly networked and collaborative. Routine collection of quality-of-life measures such as the EQ-5D-5L would have improved the analysis.
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Affiliation(s)
- Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.
| | - Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | | | | | - Ravi Barod
- Specialist Centre for Kidney Cancer, Royal Free London NHS Foundation Trust, London, UK
| | - Axel Bex
- Division of Surgery and Interventional Science, Royal Free London NHS Foundation Trust, University College London, London, UK
| | - John Hines
- University College London Hospitals NHS Foundation Trust, London, UK
- London Cancer, University College London, Cancer Collaborative, London, UK
- Bart's Health, NHS Trust, London, UK
| | - Muntzer M Mughal
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Kathy Pritchard-Jones
- University College London Hospitals NHS Foundation Trust, London, UK
- UCL Partners Academic Health Science Network, London, UK
| | - Maxine Tran
- Specialist Centre for Kidney Cancer, Royal Free Hospital, London, UK
- Faculty of Medical Sciences, Division of Surgery and Interventional Science, University College London, London, UK
| | - David C Shackley
- Greater Manchester Cancer, (hosted by) Christie NHS Foundation Trust, Manchester, UK
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Stephen Morris
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Rachael M Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
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16
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Lacueva FJ, Escrig-Sos J, Marti-Obiol R, Zaragoza C, Mingol F, Oviedo M, Peris N, Civera J, Roig A. Short-term postoperative outcomes of gastric adenocarcinoma patients treated with curative intent in low-volume centers. World J Surg Oncol 2022; 20:344. [PMID: 36253780 PMCID: PMC9575241 DOI: 10.1186/s12957-022-02804-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 09/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Quality standards in postoperative outcomes have not yet been defined for gastric cancer surgery. Also, the effect of centralization of gastric cancer surgery on the improvement of postoperative outcomes continues to be debated. Short-term postoperative outcomes in gastric carcinoma patients in centers with low-volume of annual gastrectomies were assessed. The effect of age on major postoperative morbidity and mortality was also analyzed. METHODS Patients with gastric or gastroesophageal junction Siewert III type carcinomas who underwent surgical treatment with curative intent between January 2013 and December 2016 were included. Data were obtained from the population-based surgical registry Esophagogastric Carcinoma Registry of the Comunitat Valenciana (RECEG-CV). The RECEG-CV gathers information on demographic characteristics and comorbidity, preoperative study and neoadjuvant treatment, surgical procedure, pathological study, postoperative outcomes, and follow-up. Seventeen hospitals belonging to the public network participated in this registry. RESULTS Data from 591 patients were analyzed. Postoperative major morbidity occurred in 154 (26.1%) patients. Overall 30-day or in-hospital mortality, and 90-day postoperative mortality rates were 8.6% and 10.1% respectively. Failure-to-rescue was 39% and it was significantly higher in patients aged 75 years or older in comparison with younger patients (55.3% vs 23.1% p < 0.001). In the multivariable analysis, age ≥ 75 years (p = 0.029), laparoscopic approach (p = 0.005), and total gastrectomy (p = 0.005) were associated with major postoperative morbidity. Age ≥ 75 years (p = 0.027), pulmonary complications (p = 0.001), cardiac complications (p = 0.001), leakage (p = 0.003), and hemorrhage (p = 0.013) were associated with postoperative mortality. CONCLUSIONS Centralization of gastric adenocarcinoma treatment in centers with higher annual caseload should be considered to improve the short-term postoperative outcomes in low-volume centers. Patients aged 75 or older had a significantly increased risk of major postoperative morbidity and mortality, and higher failure-to-rescue.
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Affiliation(s)
| | - Javier Escrig-Sos
- Hospital General Universitario de Castellón, Castellón de la Plana, Spain
| | | | | | - Fernando Mingol
- Hospital Universitario y Politécnico La Fe de Valencia, Valencia, Spain
| | - Miguel Oviedo
- Hospital General Universitario de Valencia, Valencia, Spain
| | - Nuria Peris
- Hospital Universitario Doctor Peset de Valencia, Valencia, Spain
| | - Joaquin Civera
- Hospital Universitario Arnau de Vilanova de Valencia, Valencia, Spain
| | - Amparo Roig
- Hospital Lluis Alcanyis de Xativa, Valencia, Spain
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17
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Kitti PM, Anttonen AM, Leskelä RL, Saarto T. End-of-life care of patients with esophageal or gastric cancer: decision making and the goal of care. Acta Oncol 2022; 61:1173-1178. [PMID: 36005550 DOI: 10.1080/0284186x.2022.2114379] [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: 11/01/2022]
Abstract
BACKGROUND Overall survival (OS) with advanced esophageal or gastric cancer is poor. To avoid overly aggressive treatments at the end-of-life and assure adequate end-of-life quality, the decision to focus on symptom-centered palliative care (PC) and terminate anticancer treatments, i.e., the PC decision, should be made in time. MATERIAL AND METHODS We reviewed the charts of patients (N = 160) with esophageal or gastric cancer treated at the Department of Oncology at Helsinki University Central Hospital in 2013 and deceased by December 2014. The use of acute services (Emergency department (ED) visits and hospitalizations) and places of death were compared according to the timing of the PC decision. Reasons for ED visits and hospitalizations were collected. RESULTS The median OS from diagnosis of advanced cancer was 6 months. Anti-cancer treatments were never started for 34% of the patients. The PC decision was made early (>30 days before death) for 54% of the patients and late (≤30 days before death) or not at all for 46%. Patients with late or no PC decision died more often in tertiary/secondary hospital (29 versus 7%, p = 0.001) and had more ED visits (49 versus 29%, p < 0.001) and hospitalizations (53 versus 28%, p = 0.001) in their last month, and visited the PC unit less often (18 versus 69%, p < 0.001), than the patients with early PC decision. The ED visits were most commonly related to cancer progression, and clinical deterioration (17%), fever (16%), and dysphagia (15%) were the most common symptoms. CONCLUSION The decision to focus on PC and terminate anticancer treatments, i.e., the PC decision, was made late or not at all in every other patient, leading to increased tertiary/secondary hospital service use and deaths at tertiary/secondary hospital. Early decision-making increased end-of-life care at specialized PC services or at home, implying better end-of-life care.
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Affiliation(s)
- Pauliina M Kitti
- Department of Oncology, HUS Comprehensive Cancer Centre and University of Helsinki, Helsinki, Finland
| | - Anu M Anttonen
- Department of Oncology, HUS Comprehensive Cancer Centre and University of Helsinki, Helsinki, Finland
| | | | - Tiina Saarto
- Department of Oncology, HUS Comprehensive Cancer Centre and University of Helsinki, Helsinki, Finland
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18
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Arnold M, Morgan E, Bardot A, Rutherford MJ, Ferlay J, Little A, Møller B, Bucher O, De P, Woods RR, Saint-Jacques N, Gavin AT, Engholm G, Achiam MP, Porter G, Walsh PM, Vernon S, Kozie S, Ramanakumar AV, Lynch C, Harrison S, Merrett N, O'Connell DL, Mala T, Elwood M, Zalcberg J, Huws DW, Ransom D, Bray F, Soerjomataram I. International variation in oesophageal and gastric cancer survival 2012-2014: differences by histological subtype and stage at diagnosis (an ICBP SURVMARK-2 population-based study). Gut 2022; 71:1532-1543. [PMID: 34824149 DOI: 10.1136/gutjnl-2021-325266] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/04/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To provide the first international comparison of oesophageal and gastric cancer survival by stage at diagnosis and histological subtype across high-income countries with similar access to healthcare. METHODS As part of the ICBP SURVMARK-2 project, data from 28 923 patients with oesophageal cancer and 25 946 patients with gastric cancer diagnosed during 2012-2014 from 14 cancer registries in seven countries (Australia, Canada, Denmark, Ireland, New Zealand, Norway and the UK) were included. 1-year and 3-year age-standardised net survival were estimated by stage at diagnosis, histological subtype (oesophageal adenocarcinoma (OAC) and oesophageal squamous cell carcinoma (OSCC)) and country. RESULTS Oesophageal cancer survival was highest in Ireland and lowest in Canada at 1 (50.3% vs 41.3%, respectively) and 3 years (27.0% vs 19.2%) postdiagnosis. Survival from gastric cancer was highest in Australia and lowest in the UK, for both 1-year (55.2% vs 44.8%, respectively) and 3-year survival (33.7% vs 22.3%). Most patients with oesophageal and gastric cancer had regional or distant disease, with proportions ranging between 56% and 90% across countries. Stage-specific analyses showed that variation between countries was greatest for localised disease, where survival ranged between 66.6% in Australia and 83.2% in the UK for oesophageal cancer and between 75.5% in Australia and 94.3% in New Zealand for gastric cancer at 1-year postdiagnosis. While survival for OAC was generally higher than that for OSCC, disparities across countries were similar for both histological subtypes. CONCLUSION Survival from oesophageal and gastric cancer varies across high-income countries including within stage groups, particularly for localised disease. Disparities can partly be explained by earlier diagnosis resulting in more favourable stage distributions, and distributions of histological subtypes of oesophageal cancer across countries. Yet, differences in treatment, and also in cancer registration practice and the use of different staging methods and systems, across countries may have impacted the comparisons. While primary prevention remains key, advancements in early detection research are promising and will likely allow for additional risk stratification and survival improvements in the future.
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Affiliation(s)
- Melina Arnold
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Eileen Morgan
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Aude Bardot
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Mark J Rutherford
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jacques Ferlay
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
| | - Alana Little
- Cancer Institute New South Wales, Alexandria, New South Wales, Australia
| | | | | | - Prithwish De
- Surveillance and Cancer Registry, Cancer Care Ontario, Toronto, Ontario, Canada
| | | | - Nathalie Saint-Jacques
- Registry & Analytics, Nova Scotia Health Authority Cancer Care Program, Halifax, Nova Scotia, Canada
| | - Anna T Gavin
- Northern Ireland Cancer Registry, Queen's University Belfast, Belfast, UK
| | - Gerda Engholm
- Cancer Prevention & Documentation, Danish Cancer Society, Copenhagen, Denmark
| | - Michael P Achiam
- Danish EsophagoGastric Cancer group, Department of Surgical Gastroenterology, Rigshospitalet, Copenhagen, Denmark
| | - Geoff Porter
- Canadian Partnership Against Cancer, Toronto, Ontario, Canada
| | | | | | - Serena Kozie
- Saskatchewan Cancer Agency, Regina, Saskatchewan, Canada
| | | | - Charlotte Lynch
- International Cancer Benchmarking Partnership (ICBP), Policy & Information, Cancer Research UK, London, UK
| | - Samantha Harrison
- International Cancer Benchmarking Partnership (ICBP), Policy & Information, Cancer Research UK, London, UK
| | - Neil Merrett
- Department of Upper Gastrointestinal Surgery, Bankstown-Lidcombe Hospital and School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Dianne L O'Connell
- The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, New South Wales, Australia
| | - Tom Mala
- Department of Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway
| | - Mark Elwood
- School of Population Health, The University of Auckland, Auckland, New Zealand
| | - John Zalcberg
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dyfed W Huws
- Swansea University, Swansea, Wales, UK
- Welsh Cancer Intelligence and Surveillance Unit, Public Health Wales, Cardiff, Wales, UK
| | - David Ransom
- WA Cancer and Palliative Care Network Policy Unit, Health Networks Branch, Department of Health, Perth, WA, Australia
| | - Freddie Bray
- Cancer Surveillance Branch, International Agency for Research on Cancer, Lyon, France
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19
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Yu Y, Li M, Kang R, Liu X, Wang N, Zhu Q, Cao J, Cong M. The effectiveness of telephone and Internet-based supportive care for patients with esophageal cancer on enhanced recovery after surgery in China: A randomized controlled trial. Asia Pac J Oncol Nurs 2022; 9:217-228. [PMID: 35571631 PMCID: PMC9096733 DOI: 10.1016/j.apjon.2022.02.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 02/23/2022] [Indexed: 12/24/2022] Open
Abstract
Objective The aim of this study was to establish a nurse-led supportive care program based on telephone and Internet support and evaluate its efficacy in comparison with conventional care on enhanced recovery after surgery. Methods The study was designed as an open-label, randomized controlled trial to value the efficacy of a nurse-led supportive care program in comparison with conventional care. A convenience sampling method was employed to recruit patients with esophageal cancer in a tertiary Grade A cancer center in Beijing from November 2018 to January 2019. Patients were assigned randomly (1:1) to one of the two groups (intervention group vs control group) via a web randomization system. The control group received conventional care. Patients from the intervention group received conventional care and one-on-one phone calls from nurses following their discharge assessments and education about nutrition and symptoms. Nurses also set up a WeChat group, which they invited patients to join in before discharge for better communication during follow-up. Statistical testing, including nutritional status, quality of life, the helpfulness of the follow-up service, and the patients’ satisfaction with their care, was conducted 6 months after discharge to assess for differences between the two groups. The independent sample t, chi-squared, and Mann–Whitney tests were used to compare between the experiences of the intervention and control groups. The Spearman correlation analysis was used for the analysis of correlation of the nutritional index and quality of life. Results Finally, 168 patients were included in the study, with 86 patients in the intervention group and 82 in the control group. Significant differences between the intervention and control groups were found in the nutrition risk screening 2002 and simple diet self-assessment tool scores. The changes in blood albumin, prealbumin, and transferrin were also statistically significant. All (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire) QLQ-C30 results of the intervention group were better than those of the control group. A significant positive correlation of the simple diet self-assessment tool (the higher, the better) and the scores for total health/quality of life were detected (r = 0.214, P = 0.005). A significant negative correlation of the nutrition risk screening 2002 (the lower, the better) and the scores of total health/quality of life was detected (r = −0.446, P = 0.000). The patients’ scores on the helpfulness of the follow-up service and their satisfaction with it were both significantly higher in the intervention group than in the control group. Conclusions This study highlighted the important role of nurse-led supportive care based on telephone and Internet-based support for patients after enhanced recovery after surgery. The supportive care improved patients’ nutritional status, elevated their quality of life, and improved their satisfaction with the care provided to them.
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Affiliation(s)
- Yuan Yu
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Corresponding author.
| | - Min Li
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ran Kang
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinzhe Liu
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Nuoxiaoxuan Wang
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qingmiao Zhu
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Cao
- Thoracic Surgery Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minghua Cong
- Comprehensive Oncology Department of National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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The impact of performing gastric cancer surgery during holiday periods. A population-based study using Dutch upper gastrointestinal cancer audit (DUCA) data. Curr Probl Cancer 2022; 46:100850. [DOI: 10.1016/j.currproblcancer.2022.100850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 12/12/2022]
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21
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Wirth K, Näpflin M, Graber SM, Blozik E. Does hospital volume affect outcomes after abdominal cancer surgery: an analysis of Swiss health insurance claims data. BMC Health Serv Res 2022; 22:262. [PMID: 35219332 PMCID: PMC8881861 DOI: 10.1186/s12913-022-07513-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/13/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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22
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Chiang CL, Hsieh WT, Tang CH, Sheu ML, Chen YM. Treatment patterns and survival in patients with small cell lung cancer in Taiwan. J Chin Med Assoc 2021; 84:772-777. [PMID: 34183592 DOI: 10.1097/jcma.0000000000000576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Small cell lung cancer (SCLC) is the most aggressive form of lung cancer. The chemotherapy regimens and their efficacy in practice are seldom reported. We aimed to investigate treatment patterns and survival outcomes of patients with SCLC in Taiwan. METHODS Patients newly diagnosed with SCLC from 2011 to 2015 were identified from the Cancer Registry database. Their clinical characteristics, treatment regimens, and survival status were obtained from National Health Insurance Research database. The Kaplan-Meier method and Cox-proportional hazard model were used to analyze the survival outcomes. RESULTS Among a total of 2707 patients enrolled, 439 were in the limited stage (LS, 16.22%) and 2268 were in the extensive stage of the disease (ES, 83.78%). The median age was 66 and the majority were male (90.36%). The first-line regimen used for the patients was etoposide/cisplatin-based treatment, followed by etoposide/carboplatin-based regimen, and etoposide only. The median overall survival (OS) was 16.92 months (95% confidence interval [CI] 15.31-18.92) and 8.71 months (95% CI 8.38-9.07) in LS and ES patients, respectively. Chemotherapy regimen, Eastern Cooperative Oncology Group performance status, and history of radiotherapy were significant factors associated with OS. On the other hand, the major second-line treatment was a topotecan-based regimen (68.3%). However, this showed inferior survival outcome compared to etoposide-based regimen (5.09 months [95% CI 4.76-5.62] versus 8.77 months [95% CI 6.31-11.89], p < 0.001). CONCLUSION Etoposide is the preferred and superior first-line chemotherapy regimen in combination with platinum, and an alternative choice of second-line regimen for Taiwanese patients with SCLC.
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Affiliation(s)
- Chi-Lu Chiang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Wen-Ting Hsieh
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan, ROC
| | - Chao-Hsiun Tang
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan, ROC
| | - Mei-Ling Sheu
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan, ROC
| | - Yuh-Min Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
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Hospital volume following major surgery for gastric cancer determines in-hospital mortality rate and failure to rescue: a nation-wide study based on German billing data (2009-2017). Gastric Cancer 2021; 24:959-969. [PMID: 33576929 DOI: 10.1007/s10120-021-01167-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Accepted: 01/31/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND For many cancer resections, a hospital volume-outcome relationship exists. The data regarding gastric cancer resection-especially in the western hemisphere-are ambiguous. This study analyzes the impact of gastric cancer surgery caseload per hospital on postoperative mortality and failure to rescue in Germany. METHODS All patients diagnosed with gastric cancer from 2009 to 2017 who underwent gastric resection were identified from nation-wide administrative data. Hospitals were grouped into five equal caseload quintiles (I-V in ascending caseload order). Postoperative deaths and failure to rescue were determined. RESULTS Forty-six thousand one hundred eighty-seven patients were identified. There was a significant shift from partial resections in low-volume hospitals to more extended resections in high-volume centers. The overall in-house mortality rate was 6.2%. The crude in-hospital mortality rate ranged from 7.9% in quintile I to 4.4% in quintile V, with a significant trend between volume categories (p < 0.001). In the multivariable logistic regression analysis, quintile V hospitals (average of 29 interventions/year) had a risk-adjusted odds ratio of 0.50 (95% CI 0.39-0.65), compared to the baseline in-house mortality rate in quintile I (on average 1.5 interventions/year) (p < 0.001). In an analysis only evaluating hospitals with more than 30 resections per year mortality dropped below 4%. The overall postoperative complication rate was comparable between different volume quintiles, but failure to rescue (FtR) decreased significantly with increasing caseload. CONCLUSION Patients who had gastric cancer surgery in hospitals with higher volume had better outcomes and a reduced failure to rescue rates for severe complications.
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Huang RJ, Barakat MT, Park W, Banerjee S. Quality metrics in the performance of EUS: a population-based observational cohort of the United States. Gastrointest Endosc 2021; 94:68-74.e3. [PMID: 33476611 DOI: 10.1016/j.gie.2020.12.055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/31/2020] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Robert J Huang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Walter Park
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California, USA
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25
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Patel DC, Jeffrey Yang CF, He H, Liou DZ, Backhus LM, Lui NS, Shrager JB, Berry MF. Influence of facility volume on long-term survival of patients undergoing esophagectomy for esophageal cancer. J Thorac Cardiovasc Surg 2021; 163:1536-1546.e3. [PMID: 34247867 DOI: 10.1016/j.jtcvs.2021.05.048] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 04/03/2021] [Accepted: 05/25/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE This study investigated the influence of facility volume on long-term survival in patients with esophageal cancer treated with esophagectomy. METHODS Patients treated with esophagectomy for cT1 3N0 3M0 adenocarcinoma or squamous cell carcinoma of the mid-distal esophagus in the National Cancer Database between 2006 and 2013 were stratified by annual facility esophagectomy volume dichotomized as more/less than both 6 and 20. Patient characteristics associated with facility volume were evaluated using logistic regression, and the influence of facility volume on survival was evaluated with Kaplan-Meier curves, Cox proportional hazards methods, and propensity matched analysis. RESULTS Of 11,739 patients who had esophagectomy at 1018 facilities where annual volume ranged from 1 to 47.6 cases, 4262 (36.3%) were treated at 44 facilities with annual esophagectomy volume > 6 and 1515 (12.9%) were treated at 7 facilities with annual volume > 20. Higher volume was associated with significantly better 5-year survival for both annual volume > 6 (47.6% vs 40.2%; P < .001) and annual volume > 20 (47.2% vs 42.3%; P < .001), which persisted in propensity matched analyses as well as Cox multivariable analysis (hazard ratio, 0.81; 95% confidence interval, 0.74-0.89; P < .001 for facility volume > 6 and hazard ratio, 0.78; 95% confidence interval, 0.65-0.95; P = .01 for facility volume > 20). In Cox multivariable analysis that considered facility volume as a continuous variable, higher volume continued to be associated with better survival (hazard ratio, 0.93 per 5 cases; 95% CI, 0.91-0.96; P < .001). CONCLUSIONS Esophageal cancer patients treated with esophagectomy at higher volume facilities have significantly better long-term survival than patients treated at lower volume facilities.
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Affiliation(s)
- Deven C Patel
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Chi-Fu Jeffrey Yang
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Hao He
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Douglas Z Liou
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Leah M Backhus
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif
| | - Natalie S Lui
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif
| | - Joseph B Shrager
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif
| | - Mark F Berry
- Department of Cardiothoracic Surgery, Falk Cardiovascular Research Institute, Stanford University Medical Center, Stanford, Calif; VA Palo Alto Health Care System, Palo Alto, Calif.
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Moya-Herraiz AA, Dorcaratto D, Martin-Perez E, Escrig-Sos J, Poves-Prim I, Fabregat-Prous J, Larrea Y Olea J, Sanchez-Bueno F, Botello-Martinez F, Sabater L. Non-arbitrary minimum threshold of yearly performed pancreatoduodenectomies: National multicentric study. Surgery 2021; 170:910-916. [PMID: 33875253 DOI: 10.1016/j.surg.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/11/2021] [Accepted: 03/06/2021] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Angel Antonio Moya-Herraiz
- Department of Surgery, HPB unit, Hospital General Universitario de Castelló, Castelló de la Plana, Castellón, Spain
| | - Dimitri Dorcaratto
- Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain.
| | | | - Javier Escrig-Sos
- Department of Surgery, Hospital General Universitario de Castelló, Castelló de la Plana, Castellón, Spain
| | | | - Joan Fabregat-Prous
- Department of Surgery, Hospital Universitari Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Larrea Y Olea
- Department of Surgery, Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Las Palmas, Spain
| | | | | | - Luis Sabater
- Department of Surgery, Liver, Biliary and Pancreatic Unit, Hospital Clínico, University of Valencia, Biomedical Research Institute (INCLIVA), Valencia, Spain
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Long-term Outcomes of Gastric Cancer in a Small Institute: a Single Surgeon Experience. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02659-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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Surgeon Quality Control and Standardization of D2 Lymphadenectomy for Gastric Cancer: A Prospective Multicenter Observational Study (KLASS-02-QC). Ann Surg 2021; 273:315-324. [PMID: 33064386 DOI: 10.1097/sla.0000000000003883] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
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.
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Markar S, Santoni G, Maret-Ouda J, Lagergren J. Hospital volume of esophageal cancer surgery in relation to outcomes from primary anti-reflux surgery. Dis Esophagus 2021; 34:5874719. [PMID: 32696953 DOI: 10.1093/dote/doaa075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/01/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022]
Abstract
No previous study has sought to identify the effect of hospital volume of esophagectomy on anti-reflux surgery outcomes. The hypothesis under investigation was hospitals performing esophagectomies, particularly those of higher annual volume, have better outcomes from primary anti-reflux surgery. This population-based cohort study included adult individuals (≥18 years) in Sweden receiving primary anti-reflux surgery for a recorded gastro-esophageal reflux disease in 1997-2010, with follow-up until 2013 The 'exposure' was hospital volume of esophagectomy, with hospitals conducting esophagectomies divided into 0, >0-1, >1-3 and ≥ 4 based on annual volume, and hospitals not conducting esophagectomies were the reference category. The outcomes were 30-day re-intervention and surgical re-intervention during the entire follow-up after anti-reflux surgery. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for age, sex, comorbidity, type of anti-reflux surgery, and year of anti-reflux surgery. Among 10,959 participants having undergone primary anti-reflux surgery, the 30-day re-intervention rate was 1.1%, and the rate of surgical re-intervention during the entire follow-up was 6.8%. Compared with hospitals not performing esophagectomy, hospitals in the highest volume group of esophagectomy showed no decreased risks of 30-day re-intervention (HR = 1.46, 95% CI 0.89-2.39) or surgical re-intervention (HR = 1.21, 95%CI 0.91-1.60) during follow-up. Similarly, the intermediate hospital volume categories of esophageal cancer surgery had no decreased risk of surgical re-interventions after anti-reflux surgery. This study provides no evidence for centralization of primary anti-reflux surgery to centers for esophageal cancer surgery.
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Affiliation(s)
- Sheraz Markar
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden and.,Department Surgery & Cancer, Imperial College London, London, UK
| | - Giola Santoni
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden and
| | - John Maret-Ouda
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden and
| | - Jesper Lagergren
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden and.,School of Cancer and Pharmaceutical Sciences, King's College London, London, UK
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Failure to Cure in Patients Undergoing Surgery for Esophageal Carcinoma: Hospital of Surgery Influences Prospects for Cure: A Nation-wide Cohort Study. Ann Surg 2020; 272:744-750. [PMID: 32657922 DOI: 10.1097/sla.0000000000004178] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aimed to describe failure to cure in terms of incidence, hospital variation, and as an outcome parameter for salvage esophagectomy. SUMMARY BACKGROUND DATA Failure to cure is a composite outcome measure that could be used for hospital comparison in esophageal carcinoma care. METHODS All patients registered in the Dutch Upper GI Cancer Audit who underwent potentially curative esophageal carcinoma surgery in 2011 to 2018, were included in this nationwide cohort study. Failure to cure was defined as: 1) no surgical resection due to intraoperative metastasis or locally irresectable tumor, 2) macroscopically or microscopically incomplete resection, or 3) 30-day/in-hospital mortality. Association of baseline characteristics with failure to cure was analyzed using multivariable logistic regression in the total population and in salvage patients. RESULTS Some 5894 patients from 22 hospitals were included, of whom 630 (10.7%) had failure to cure (hospital variation [5.5%-19.1%]). Higher age, preoperative weight loss, higher ASA-score, higher N-stage, neoadjuvant chemotherapy, or no neoadjuvant therapy (compared with neoadjuvant chemoradiotherapy), open surgery, and resection before 2014 were associated with failure to cure. After case-mix correction, 2 hospitals had statistically significant higher failure to cure percentages, whereas 2 had lower percentages. Of 151 salvage esophagectomy patients, 32.5% had failure to cure. The failure to cure rate after salvage surgery was 27.6% in high-volume hospitals and 47.6% in medium-volume hospitals. CONCLUSIONS The incidence of failure to cure was 10.7%. Given the significant hospital variation in the percentage of failure to cure, improvement is needed. Since salvage procedures are more often successful in high-volume hospitals, further centralization of this procedure is warranted.
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Mazza E, Strignano P, Fop F, Patrono D, Catalano G, Salizzoni M, Romagnoli R. Semimechanical anastomosis during oesophagectomy reduces leaks and stenosis: a propensity score matched analysis. Interact Cardiovasc Thorac Surg 2020; 31:182-190. [PMID: 32530036 DOI: 10.1093/icvts/ivaa065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/04/2020] [Accepted: 03/12/2020] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES Several techniques for oesophageal anastomosis during oesophagectomy have been described, all of which are associated with variable leakage and stricture rates. Given the notable morbidity of oesophageal fistula, reducing its incidence is of paramount importance. We report our single-centre experience with the semimechanical (SM) technique as compared to a totally manual (TM) technique. METHODS Three hundred and twelve partial and subtotal oesophagectomies performed between January 1998 and April 2018 were analysed. The series was split into a training period (January 1998-September 2015), when both TM and SM techniques were used, and a validation period (October 2015-April 2018), during which SM technique became standard practice. Propensity score matching was used to reduce confounding. RESULTS The training period included 212 oesophagectomies (90 TM, 122 SM); SM technique was initially used in the neck and afterwards also in the thorax, mainly with gastric conduits (92%), whereas the TM group contained a prevalence of jejunal loops (48%). SM anastomosis was associated with a significant reduction in both leak (0.8% vs 12%; P < 0.001) and stricture rate (0% vs 7%; P = 0.005). After propensity score matching, the difference in leak (0% vs 14%; P = 0.013) and stricture rate (0% vs 10%; P = 0.022) was confirmed. During the validation period, which included 100 oesophagectomies performed with SM anastomosis, 1 leak (1%) and 1 stricture (1%) were observed. CONCLUSIONS SM technique for oesophageal anastomosis outperforms TM technique and allows achieving very low complication rates.
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Affiliation(s)
- Elena Mazza
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Paolo Strignano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Fabrizio Fop
- Renal Transplant Unit, Nephrology, Dialysis and Renal Transplant Division, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Damiano Patrono
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Giorgia Catalano
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Mauro Salizzoni
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Renato Romagnoli
- General Surgery 2U-Liver Transplant Unit, A.O.U. Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
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Gupta V, Levy J, Allen-Ayodabo C, Amirazodi E, Davis L, Li Q, Mahar A, Coburn NG. Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO): protocol for a multicentre clinical and pathological database including 25 000 patients. BMJ Open 2020; 10:e032729. [PMID: 32474423 PMCID: PMC7264637 DOI: 10.1136/bmjopen-2019-032729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 02/06/2020] [Accepted: 04/09/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Oesophagogastric cancers carry a high mortality, economic burden and rising incidence. There is a need to monitor and improve care for this disease. Pathologic information is a cornerstone of cancer diagnosis, treatment and prognosis. Few population-based studies combine pathology information and clinical outcomes. The objective of this study is to develop a clinical and pathological database of oesophagogastric cancers to study practice patterns, resource utilisation and clinical outcomes. METHODS AND ANALYSIS The Population Registry of Esophageal and Stomach Tumours in Ontario (PRESTO) will include all patients with oesophagogastric cancer diagnosed from 2002 onwards within the province of Ontario. We estimate that the sample over the first 14 years of the study will include 26 000 patients. Pathologic information from diagnostic procedures, endomucosal resection specimens and surgical resection specimens is being abstracted into a purpose-built database. Pathology information will be linked to administrative data, which capture baseline demographics, patient-reported symptoms, physician billings, hospital visits, hospital characteristics, geography and vital statistics. The registry will be updated prospectively. ETHICS AND DISSEMINATION Ethics approval for this study was obtained from the Sunnybrook Health Sciences Centre Research Ethics Board. The PRESTO database will enable the study of oesophagogastric cancer in Ontario under six themes of inquiry: treatment, surgical outcomes, pathology, survival, health system and resource utilisation and cost. This information will be a valuable addition to the global efforts to understand ways to optimise care for these diseases.
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Affiliation(s)
- Vaibhav Gupta
- Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jordan Levy
- Department of Surgery and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Elmira Amirazodi
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Laura Davis
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Qing Li
- Analysis, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Alyson Mahar
- Community Health Sciences, University of Manitoba College of Medicine, Winnipeg, Ontario, Canada
| | - Natalie G Coburn
- Division of General Surgery, Department of Surgery and Institute of Health Policy, Management, and Evaluation, Odette Cancer Centre, Toronto, Ontario, Canada
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Exarchakou A, Papacleovoulou G, Rous B, Magadi W, Rachet B, Neoptolemos JP, Coleman MP. Pancreatic cancer incidence and survival and the role of specialist centres in resection rates in England, 2000 to 2014: A population-based study. Pancreatology 2020; 20:454-461. [PMID: 32014435 DOI: 10.1016/j.pan.2020.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 01/09/2020] [Accepted: 01/18/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim was to compare population-based survival for exocrine pancreatic cancer in England in the 23 regions covered by specialist centres. The centres were initiated in 2001, covering populations of 2-4 million. METHODS We examined incidence for adults diagnosed with a pancreatic exocrine cancer during 1995-2014 and age-standardised net survival up to five years after diagnosis for patients diagnosed during 2000-2013. We examined variation in regional resection rates and survival for patients diagnosed during 2010-2013. The data were extracted from the National Cancer Registration and Analysis Service. RESULTS Age-standardised annual incidence rates of exocrine pancreatic cancer increased from 17.1 per 100,000 during 1995-1999 to 18.7 during 2010-2014. Age-standardised one-year and five-year net survival increased from 17.9% and 3.6%, respectively, for 2000-2009, to 21.6% and 4.2% during 2010-2013. There were 2086 (8.9%) resections among 23,415 patients diagnosed with an exocrine tumour in 2010-2013. The proportion ranged from 5.1% to 19.6% between centres. Among resected patients, survival was 73.0% at one year and 20.2% at five years. Of the total 2118 resected patients, 18 (0.9%) were at stage 1; 34 (1.6%) at stage 2; 791 (37.3%) at stage 3 and 140 (6.6%) at stage 4, although 53.6% of stage information was missing. Five-year survival was 2.1% for those who were not resected. The number of resections performed in each centre was not correlated with one-year survival. CONCLUSIONS Despite improvements in the management of pancreatic cancer in England with the introduction of specialist centres, resection rates remain relatively low, and survival remains lower than in comparably wealthy countries.
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Affiliation(s)
- Aimilia Exarchakou
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | | | - Brian Rous
- National Cancer Registration and Analysis Service, Public Health England, Wellington House, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Winnie Magadi
- UK Renal Registry, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Bernard Rachet
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - John P Neoptolemos
- Department of General Surgery, University of Heidelberg, Im Neuenheimer Feld 110, Heidelberg, 69120, Germany
| | - Michel P Coleman
- Cancer Survival Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Borggreve AS, Kingma BF, Ruurda JP, van Hillegersberg R. Safety and feasibility of minimally invasive surgical interventions for esophageal and gastric cancer in the acute setting: a nationwide cohort study. Surg Endosc 2020; 35:1219-1229. [PMID: 32215746 PMCID: PMC7886730 DOI: 10.1007/s00464-020-07491-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/02/2020] [Indexed: 12/23/2022]
Abstract
Background Minimally invasive esophagectomy and gastrectomy are increasingly performed and might be superior to their open equivalents in an elective setting. The aim of this study was to evaluate whether minimally invasive approaches can be safely applied in the acute setting as well. Methods All patients who underwent an acute surgical intervention for primary esophageal or gastric cancer between 2011 and 2017 were identified from the nationwide database of the Dutch Upper GI Cancer Audit (DUCA). Conversion rates, postoperative complications, re-interventions, postoperative mortality, hospital stay and oncological outcomes (radical resection rates and median lymph node yield) were evaluated. Results Between 2011 and 2017, surgery for esophagogastric cancer was performed in an acute setting in 2% (190/8861) in The Netherlands. A total of 14 acute resections for esophageal cancer were performed, which included 7 minimally invasive esophagectomies and 7 open esophagectomies. As these numbers were very low, no comparison between minimally invasive and open esophagectomies was made. A total of 122 acute resections for gastric cancer were performed, which included 39 minimally invasive gastrectomies and 83 open gastrectomies. Conversion occurred in 9 patients (23%). Minimally invasive gastrectomy was at least comparable to open gastrectomy regarding postoperative complications (36% versus 51%), median hospital stay (9 days [IQR: 7–16 days] versus 11 days [IQR: 7–17 days]), readmissions (8% versus 11%) and oncological outcomes (radical resection rate: 87% versus 66%, median lymph node yield: 21 [IQR: 15–32 days] versus 16 [IQR: 11–24 days]). Conclusions Minimally invasive surgery for gastric cancer is safe and feasible in the acute setting, with at least comparable postoperative clinical and short-term oncological outcomes compared to open surgery but a relatively high conversion rate.
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Affiliation(s)
- Alicia S Borggreve
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - B Feike Kingma
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
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Effect of Hospital Volume With Respect to Performing Gastric Cancer Resection on Recurrence and Survival: Results From the CRITICS Trial. Ann Surg 2020; 270:1096-1102. [PMID: 29995679 DOI: 10.1097/sla.0000000000002940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE We examined the association between surgical hospital volume and both overall survival (OS) and disease-free survival (DFS) using data obtained from the international CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. SUMMARY BACKGROUND DATA In the CRITICS trial, patients with resectable gastric cancer were randomized to receive preoperative chemotherapy followed by adequate gastrectomy and either chemotherapy or chemoradiotherapy. METHODS Patients in the CRITICS trial who underwent a gastrectomy with curative intent in a Dutch hospital were included in the analysis. The annual number of gastric cancer surgeries performed at the participating hospitals was obtained from the Netherlands Cancer Registry; the hospitals were then classified as low-volume (1-20 surgeries/year) or high-volume (≥21 surgeries/year) and matched with the CRITICS trial data. Univariate and multivariate analyses were then performed to evaluate the hazard ratio (HR) between hospital volume and both OS and DFS. RESULTS From 2007 through 2015, 788 patients were included in the CRITICS trial. Among these 788 patients, 494 were eligible for our study; the median follow-up was 5.0 years. Five-year OS was 59.2% and 46.1% in the high-volume and low-volume hospitals, respectively. Multivariate analysis revealed that undergoing surgery in a high-volume hospital was associated with higher OS [HR = 0.69, 95% confidence interval (CI) = 0.50-0.94, P = 0.020] and DFS (HR = 0.73, 95% CI: 0.54-0.99, P = 0.040). CONCLUSIONS In the CRITICS trial, hospitals with a high annual volume of gastric cancer surgery were associated with higher overall and DFS. These findings emphasize the value of centralizing gastric cancer surgeries in the Western world.
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Response to Comment on "Can Minimally Invasive Esophagectomy Replace Open Esophagectomy for Esophageal Cancer? Latest Analysis of 24,233 Esophagectomies From the Japanese National Clinical Database". Ann Surg 2020; 270:e110-e111. [PMID: 31726636 DOI: 10.1097/sla.0000000000003337] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kamarajah SK, Navidi M, Wahed S, Immanuel A, Hayes N, Griffin SM, Phillips AW. Anastomotic Leak Does Not Impact on Long-Term Outcomes in Esophageal Cancer Patients. Ann Surg Oncol 2020; 27:2414-2424. [PMID: 31974709 PMCID: PMC7311371 DOI: 10.1245/s10434-020-08199-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Indexed: 12/18/2022]
Abstract
Background Esophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence. Objective The aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer. Methods Consecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single high-volume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien–Dindo grade III/IV complications. Results This study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days; p < 0.001) and prolonged hospital stay (median 43 vs. 27 vs. 15 days; p < 0.001) compared with NSL or no AL. There were no significant differences in number of lymph nodes harvested and rates of R1 resection between groups. OS and RFS were not affected by either NSL or SEAL, and Cox multivariate regression showed NSL and SEAL were not independently associated with OS and RFS. Sensitivity analysis in patients receiving neoadjuvant therapy followed by esophagectomy demonstrated similar findings. Conclusion These results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact.
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Affiliation(s)
- S K Kamarajah
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - M Navidi
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - N Hayes
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK
| | - A W Phillips
- Northern Oesophagogastric Unit, Royal Victoria Infirmary, Newcastle University Trust Hospitals, Newcastle upon Tyne, UK. .,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK.
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Hospital Volume of Antireflux Surgery in Relation to Endoscopic and Surgical Re-interventions. Ann Surg 2020; 274:e1138-e1143. [DOI: 10.1097/sla.0000000000003776] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Back-to-Back Surgeries in AIS Patients Can be Performed Safely Without Compromising Radiographic or Perioperative Outcomes: A 10-year Review. Spine (Phila Pa 1976) 2020; 45:26-31. [PMID: 31361724 DOI: 10.1097/brs.0000000000003172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective chart review of prospectively collected data. OBJECTIVE The aim of this study was to determine whether back-to-back scoliosis surgeries can be performed safely without compromising outcomes and the reproducibility of the practice between institutions. SUMMARY OF BACKGROUND DATA During the summer, spinal surgeons will often book multiple cases in one day. The complexity and demands of spinal fusion surgery call into question the safety. Change of operating room staff including anesthesiologists, nurses, and neurologists may introduce new risks. METHODS From 2009 to 2018, index AIS surgeries were included. In Groups 1, 2, and 3, surgeries were performed by a single surgeon. In Group 4, they were performed by other institutional surgeons. Group 1: first surgery of the day, Group 2: second surgery of the day, Group 3: only surgery of the day, Group 4: only surgery of the day by different institutional surgeon. Additional analysis was done to determine reproducibility after a surgeon was moved from Institution 1 to Institution 2. RESULTS Five hundred sixty-seven AIS patients were analyzed. Group 1 patients had similar radiographic outcomes compared with Group 2 (P > 0.05). Surgical time was similar (P = 0.51), but significantly more levels fused (P = 0.01). Compared with Group 3, Group 2 had a smaller preoperative Cobb (P = 0.02), shorter surgeries (P < 0.001), and length of stay (P = 0.04) but similar complication rate (P = 1). Compared with Group 4, Group 2 had smaller preoperative Cobb (P < 0.001), shorter surgery, and lower complication rate (P = 0.03). When determining reproducibility, institution 2 patients had significantly less blood loss, shorter surgeries, and shorter lengths of stay (P < 0.05). CONCLUSION Although long and involved, back-to-back AIS surgeries do not compromise radiographic or perioperative outcomes. Changes in operating team do not appear to impact safety, efficiency, or outcomes. This study also found that the practice is reproducible between institutions. LEVEL OF EVIDENCE 3.
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Hellstadius Y, Malmström M, Lagergren P, Sundbom M, Wikman A. Reflecting a crisis reaction: Narratives from patients with oesophageal cancer about the first 6 months after diagnosis and surgery. Nurs Open 2019; 6:1471-1480. [PMID: 31660175 PMCID: PMC6805708 DOI: 10.1002/nop2.348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/04/2019] [Accepted: 07/05/2019] [Indexed: 12/16/2022] Open
Abstract
AIM The aim of the study was to describe patients' experiences of emotional adaption following treatment for oesophageal cancer from diagnosis to 6 months after surgery. DESIGN A qualitative interview study using an inductive approach was carried out. METHODS Participants were recruited from two university hospitals in Sweden. Ten patients who had been operated for oesophageal cancer with curative intent 6 months earlier and consented to participate in the study were included. Patients who had a disease recurrence were not eligible for inclusion. Participants were interviewed with a semi-structured interview approach. Data were analysed using qualitative content analysis. RESULTS One overarching theme was identified; Experiencing a crisis reaction, which comprised three key categories; (a) From emotionally numb to feeling quite alright; (b) From a focus on cure to reflections about a whole new life; and (c) From a severe treatment to suffering an emaciated, non-compliant body, derived from 14 distinct sub-categories. CONCLUSION This study highlights the process of emotional adaptation following oesophageal cancer surgery that patients describe when reflecting back on the first 6 months postoperatively pointing to a crisis reaction in this early postoperative period.
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Affiliation(s)
| | - Marlene Malmström
- Department of Clinical SciencesSkåne University Hospital, Lund UniversityLundSweden
| | - Pernilla Lagergren
- Department of Molecular Medicine and SurgeryKarolinska InstituteStockholmSweden
| | - Magnus Sundbom
- Department of Surgical SciencesUppsala UniversityUppsalaSweden
| | - Anna Wikman
- Department of Women's and Children's HealthUppsala UniversityUppsalaSweden
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Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación. Cir Esp 2019; 97:470-476. [DOI: 10.1016/j.ciresp.2019.03.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 03/18/2019] [Indexed: 01/26/2023]
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Schurink B, Mazza E, Ruurda JP, Roeling TA, Steenhagen E, Bleys RL, van Hillegersberg R. Low-Fat Tube Feeding After Esophagectomy Is Associated With a Lower Incidence of Chylothorax. Ann Thorac Surg 2019; 108:184-189. [DOI: 10.1016/j.athoracsur.2019.02.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/30/2019] [Accepted: 02/20/2019] [Indexed: 12/22/2022]
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van der Werf LR, Cords C, Arntz I, Belt EJT, Cherepanin IM, Coene PPLO, van der Harst E, Heisterkamp J, Langenhoff BS, Lamme B, van Berge Henegouwen MI, Lagarde SM, Wijnhoven BPL. Population-Based Study on Risk Factors for Tumor-Positive Resection Margins in Patients with Gastric Cancer. Ann Surg Oncol 2019; 26:2222-2233. [PMID: 31011900 PMCID: PMC6545177 DOI: 10.1245/s10434-019-07381-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Indexed: 12/16/2022]
Abstract
Background Radical gastrectomy is the cornerstone of the treatment of locally advanced gastric cancer. This study was designed to evaluate factors associated with a tumor-positive resection margin after gastrectomy and to evaluate the influence of hospital volume. Methods In this Dutch cohort study, patients with junctional or gastric cancer who underwent curative gastrectomy between 2011 and 2017 were included. The primary outcome was incomplete tumor removal after the operation defined as the microscopic presence of tumor cells at the resection margin. The association of patient and disease characteristics with incomplete tumor removal was tested with multivariable regression analysis. The association of annual hospital volume with incomplete tumor removal was tested and adjusted for the patient- and disease characteristics. Results In total, 2799 patients were included. Incomplete tumor removal was seen in 265 (9.5%) patients. Factors associated with incomplete tumor removal were: tumor located in the entire stomach (odds ratio (OR) [95% confidence interval (CI): 3.38 [1.91–5.96] reference: gastroesophageal junction), cT3, cT4, cTx (1.75 [1.20–2.56], 2.63 [1.47–4.70], 1.60 [1.03–2.48], reference: cT0-2), pN+ (2.73 [1.96–3.80], reference: pN−), and diffuse and unknown histological subtype (3.15 [2.14–4.46] and 2.05 [1.34–3.13], reference: intestinal). Unknown differentiation grade was associated with complete tumor removal (0.50 [0.30–0.83], reference: poor/undifferentiated). Compared with a hospital volume of < 20 resections/year, 20–39, and > 39 resections were associated with lower probability for incomplete tumor removal (OR 0.56 [0.42–0.76] and 0.34 [0.18–0.64]). Conclusions Tumor location, cT, pN, histological subtype, and tumor differentiation are associated with incomplete tumor removal. The association of incomplete tumor removal with an annual hospital volume of < 20 resections may underline the need for further centralization of gastric cancer care in the Netherlands. Electronic supplementary material The online version of this article (10.1245/s10434-019-07381-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leonie R van der Werf
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Charlotte Cords
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ivo Arntz
- Department of Surgery, Bravis Hospital, Roosendaal, The Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | | | | | - Joos Heisterkamp
- Department of Surgery, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | | | - Bas Lamme
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Borggreve AS, van Rossum PSN, Mook S, Haj Mohammad N, van Hillegersberg R, Ruurda JP. Frequency of surgical resection after starting neoadjuvant chemoradiotherapy in patients with esophageal cancer: A population-based cohort study. Eur J Surg Oncol 2019; 45:1919-1925. [PMID: 30975447 DOI: 10.1016/j.ejso.2019.03.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/11/2019] [Accepted: 03/24/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) for resectable esophageal cancer is accompanied by the risk of treatment-related toxicity. The aim of this population-based cohort study was to provide insight in patients who do not proceed to surgical resection after starting nCRT. METHODS Patients who started nCRT for primary esophageal cancer diagnosed in 2015 and 2016 were selected from the nationwide population-based cancer registry. Outcome measurements included omission from surgical resection, reasons for omission of surgical resection, mortality during nCRT (≤90 days after ending nCRT) and 1-year overall survival. Multivariable logistic regression analyses were performed to identify predictive factors for omission of surgical resection. RESULTS A total of 1521 patients were included, of whom 215 (14.1%) did not undergo surgical resection after starting nCRT. Age (OR:1.04, 95%CI:1.01-1.06), BMI (OR:0.95, 95%CI:0.90-0.99), WHO performance status (WHO 1: OR:1.62, 95%CI:1.16-2.62 and WHO 2: OR:3.53, 95%CI:1.68-7.41) and clinical N status (cN2: OR:1.57, 95% CI:1.04-2.37 and cN3: OR:2.52, 95%CI:1.14-5.55) were significantly associated with omission from surgery. The most frequently reported reasons for omission from surgery were disease progression (44.3%) and physical functioning (22.8%). During nCRT or within the subsequent waiting period to surgery, 38 patients (2.5%) deceased. One year overall survival of the patients who underwent nCRT followed by surgical resection was 94.9%, and 73.5% in the patients who did not undergo surgical resection following nCRT. CONCLUSIONS One in 7 patients who started nCRT for esophageal cancer do not proceed to surgical resection and have a decreased one year overall survival compared to patients who do proceed to surgical resection. Mortality during nCRT is considerable.
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Affiliation(s)
- Alicia S Borggreve
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Peter S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Stella Mook
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Nadia Haj Mohammad
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Richard van Hillegersberg
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.
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45
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Wang BY, Hung WH, Wu SC, Chen HC, Huang CL, Lin CH, Chen HS. Comparison Between Esophagectomy and Definitive Chemoradiotherapy in Patients With Esophageal Cancer. Ann Thorac Surg 2019; 107:1060-1067. [DOI: 10.1016/j.athoracsur.2018.11.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Revised: 11/05/2018] [Accepted: 11/17/2018] [Indexed: 11/29/2022]
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46
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Can Minimally Invasive Esophagectomy Replace Open Esophagectomy for Esophageal Cancer? Latest Analysis of 24,233 Esophagectomies From the Japanese National Clinical Database. Ann Surg 2019; 272:118-124. [DOI: 10.1097/sla.0000000000003222] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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47
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Claassen YHM, van Sandick JW, Hartgrink HH, Dikken JL, De Steur WO, van Grieken NCT, Boot H, Cats A, Trip AK, Jansen EPM, Meershoek-Klein Kranenbarg WM, Braak JPBM, Putter H, van Berge Henegouwen MI, Verheij M, van de Velde CJH. Association between hospital volume and quality of gastric cancer surgery in the CRITICS trial. Br J Surg 2019; 105:728-735. [PMID: 29652082 DOI: 10.1002/bjs.10773] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND Studies investigating the association between hospital volume and quality of gastric cancer surgery are lacking. In the present study, the effect of hospital volume on quality of gastric cancer surgery was evaluated by analysing data from the CRITICS (ChemoRadiotherapy after Induction chemotherapy In Cancer of the Stomach) trial. METHODS Patients who underwent gastrectomy with curative intent in the Netherlands were selected from the CRITICS trial database. Annual hospital volume of participating centres was derived from the Netherlands Cancer Registry. Hospital volume was categorized into very low (1-10 gastrectomies per year per institution), low (11-20), medium (21-30) and high (31 or more), and linked to the CRITICS database. Quality of surgery was analysed by surgicopathological compliance (removal of at least 15 lymph nodes), surgical compliance (removal of indicated lymph node stations) and the Maruyama Index. Postoperative morbidity and mortality were also compared between hospital categories. RESULTS Between 2007 and 2015, 788 patients were included in the CRITICS study, of whom 494 were analysed. Surgicopathological compliance was higher (86·7 versus 50·4 per cent; P < 0·001), surgical compliance was greater (52·9 versus 19·8 per cent; P < 0·001) and median Maruyama Index was lower (0 versus 6; P = 0·006) in high-volume hospitals compared with very low-volume hospitals. There was no statistically significant difference in postoperative complications or mortality between the hospital volume categories. CONCLUSION Surgery performed in high-volume hospitals was associated with better surgical quality than surgery carried out in lower-volume hospitals.
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Affiliation(s)
- Y H M Claassen
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - H H Hartgrink
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - J L Dikken
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - W O De Steur
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - N C T van Grieken
- Department of Pathology, VU University Medical Centre, Amsterdam, The Netherlands
| | - H Boot
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A Cats
- Department of Gastrointestinal Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - A K Trip
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E P M Jansen
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - J P B M Braak
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
| | - H Putter
- Department of Medical Statistics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - M Verheij
- Department of Radiation Oncology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - C J H van de Velde
- Department of Surgical Oncology, Leiden University Medical Centre, Leiden, The Netherlands
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Effect of hospital and surgeon volume on postoperative outcomes after distal gastrectomy for gastric cancer based on data from 145,523 Japanese patients collected from a nationwide web-based data entry system. Gastric Cancer 2019; 22:190-201. [PMID: 30302654 DOI: 10.1007/s10120-018-0883-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 09/29/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite interest in surgeon and hospital volume effects on distal gastrectomy, clinical significance has not been confirmed in a large-scale population. We studied to clarify the effects of surgeon and hospital volume on postoperative mortality after distal gastrectomy for gastric cancer among Japanese patients in a nationwide web-based data entry system. METHODS We extracted data on distal gastrectomy for gastric cancer from the National Clinical Database between 2011 and 2015. The primary outcome was operative mortality. Hospital volume was divided into 3 tertiles: low (1-22 cases per year), medium (23-51) and high (52-404). Surgeon volume was divided into the 5 groups: 0-3, 4-10, 11-20, 21-50, 51 + cases per year. We calculated the 95% confidence interval (CI) for the mortality rate based on odds ratios (ORs) estimated from a hierarchical logistic regression model. RESULTS We analyzed 145,523 patients at 2182 institutions. Operative mortality was 1.9% in low-, 1.0% in medium- and 0.5% in high-volume hospitals. The operative mortality rate decreased definitively with surgeon volume, 1.6% in the 0-3 group and 0.3% in the 51 + group. After risk adjustment for surgeon and hospital volume and patient characteristics, hospital volume was significantly associated with operative morality (medium: OR 0.64, 95% CI 0.56-0.73, P < 0.001; high: OR 0.42, 95% CI 0.35-0.51, P < 0.001). CONCLUSIONS We demonstrate that hospital volume can have a crucial impact on postoperative mortality after distal gastrectomy compared with surgeon volume in a nationwide population study. These findings suggest that centralization may improve outcomes after distal gastrectomy.
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Huang RJ, Barakat MT, Girotra M, Lee JS, Banerjee S. Unplanned Hospital Encounters After Endoscopic Retrograde Cholangiopancreatography in 3 Large North American States. Gastroenterology 2019; 156:119-129.e3. [PMID: 30243620 PMCID: PMC6309462 DOI: 10.1053/j.gastro.2018.09.037] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 09/07/2018] [Accepted: 09/14/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS We have few population-level data on the performance of endoscopic retrograde cholangiopancreatography (ERCP) in the United States. We investigated the numbers of unplanned hospital encounters (UHEs), patient and facility factors associated with UHEs, and variation in quality and outcomes in the performance of ERCP in 3 large American states. METHODS We collected data on 68,642 ERCPs, performed at 635 facilities in California, Florida, and New York from 2009 through 2014. The primary endpoint was number of UHEs with an ERCP-related event within 7 days of ERCP; secondary endpoints included number of UHEs within 30 days and mortality within 30 days. Each facility was assigned a risk-standardized cohort, and variations in number of UHEs were analyzed with multivariable analysis. RESULTS Among all ERCPs, 5.8% resulted in a UHE within 7 days and 10.2% within 30 days. Performance of sphincterotomy was significantly associated with a higher risk of UHE at 7 and 30 days (P < .001). Younger age, female sex, and more advanced comorbidity were associated with UHE. There was substantial heterogeneity in rates of UHE among facilities: 4.2% at facilities in the 5th percentile and 25.2% at facilities in the 95th percentile. Increasing facility volume and ability to perform endoscopic ultrasonography were associated inversely with risk. The median number of ERCPs performed each year was 68.7, but 69% of facilities performed 100 or fewer ERCPs per year. Risk for UHE after sphincterotomy decreased with increasing facility volume until an inflection point of 157 ERCPs per year was reached. CONCLUSIONS In an analysis of outcomes of 68,642 ERCPs performed in 3 states, we found a higher-than-expected number of UHEs. There is substantial unexplained variation in risk for adverse events after ERCPs among facilities, and volume is the strongest predictor of risk. Annual facility volumes above approximately 150 ERCPs per year may protect against UHE.
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Affiliation(s)
- Robert J. Huang
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA,Department of Health Research and Policy, Stanford University, Stanford, CA
| | - Monique T. Barakat
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Mohit Girotra
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA
| | - Jennifer S. Lee
- Department of Health Research and Policy, Stanford University, Stanford, CA,Department of Medicine, Stanford University, Stanford, CA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University, Stanford, California.
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50
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Shridhar R, Takahashi C, Huston J, Doepker MP, Meredith KL. Anastomotic leak and neoadjuvant chemoradiotherapy in esophageal cancer. J Gastrointest Oncol 2018; 9:894-902. [PMID: 30505592 DOI: 10.21037/jgo.2018.04.09] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background Anastomotic leaks (AL) cause significant morbidity after esophagectomy. Most patients receive neoadjuvant chemoradiation (NCR) prior to esophagectomy which has been associated with increase perioperative complications and mortality. We report on a comparison of AL rates in upfront surgical (UFS) and NCR patients. Methods An esophagectomy database was queried for UFS and NCR patients treated between 1996 and 2015. Predictors of AL rate were identified using univariate and multivariate (MVA) analysis and propensity score matching (PSM). Results We identified 820 patients (UFS, 288; NCR, 532). Overall AL rate was 5.4%. Decreased AL rate was observed in NCR patients on MVA (8.0% vs. 4.1%; P=0.02) but no difference was seen after PSM (7.7% vs. 4.2%; P=0.14). MVA of factors associated with decreased AL in UFS patients included distal esophageal tumors and body mass index (BMI) >25. Age, gender, year of surgery, histology, anastomotic location, and diabetes were not prognostic. Before PSM, MVA of NCR patients of factors associated with decreased AL revealed that only thoracic anastomosis was prognostic. However, this was not observed after PSM. MVA of factors associated with decreased AL in all patients revealed thoracic anastomosis, NCR, and BMI 25-30. After PSM, only distal esophageal tumors and thoracic anastomosis were prognostic for decreased AL. Conclusions There is no difference in the AL rate between UFS and NCR patients. Decreased AL rate was observed in patients with distal esophageal tumors and thoracic anastomosis.
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Affiliation(s)
- Ravi Shridhar
- Department of Radiation Oncology, Florida Hospital Orlando, Orlando, FL, USA
| | | | - Jamie Huston
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Matthew P Doepker
- Department of Surgery, University of South Carolina, Columbia, SC, USA
| | - Kenneth L Meredith
- Division of Surgical Oncology, Sarasota Memorial Hospital, Sarasota, FL, USA
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