1
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Visser MR, Voeten DM, Gisbertz SS, Ruurda JP, Achiam MP, Nilsson M, Markar SR, Pera M, Rosati R, Piessen G, Nafteux P, Gutschow CA, Grimminger PP, Räsänen JV, Reynolds JV, Johannessen HO, Vieira P, Weitzendorfer M, Kechagias A, van Berge Henegouwen MI, van Hillegersberg R. Western European Variation in the Organization of Esophageal Cancer Surgical Care. Dis Esophagus 2024:doae033. [PMID: 38670807 DOI: 10.1093/dote/doae033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 03/21/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024]
Abstract
Reasons for structural and outcome differences in esophageal cancer surgery in Western Europe remain unclear. This questionnaire study aimed to identify differences in the organization of esophageal cancer surgical care in Western Europe. A cross-sectional international questionnaire study was conducted among upper gastrointestinal (GI) surgeons from Western Europe. One surgeon per country was selected based on scientific output and active membership in the European Society for Diseases of the Esophagus or (inter)national upper GI committee. The questionnaire consisted of 51 structured questions on the structural organization of esophageal cancer surgery, surgical training, and clinical audit processes. Between October 2021 and October 2022, 16 surgeons from 16 European countries participated in this study. In 5 countries (31%), a volume threshold was present ranging from 10 to 26 annual esophagectomies, in 7 (44%) care was centralized in designated centers, and in 4 (25%) no centralizing regulations were present. The number of centers performing esophageal cancer surgery per country differed from 4 to 400, representing 0.5-4.9 centers per million inhabitants. In 4 countries (25%), esophageal cancer surgery was part of general surgical training and 8 (50%) reported the availability of upper GI surgery fellowships. A national audit for upper GI surgery was present in 8 (50%) countries. If available, all countries use the audit to monitor the quality of care. Substantial differences exist in the organization and centralization of esophageal cancer surgical care in Western Europe. The exchange of experience in the organizational aspects of care could further improve the results of esophageal cancer surgical care in Europe.
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Affiliation(s)
- Maurits R Visser
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Daan M Voeten
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Michael P Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Magnus Nilsson
- Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Department of Clinical Science Technology and Interventions, Stockholm, Sweden
| | - Sheraz R Markar
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Manuel Pera
- Section of Gastrointestinal Surgery, Hospital del Mar, Department of Surgery, Universitat Autònoma de Barcelona, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Riccardo Rosati
- Department of Gastrointestinal Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Philippe Nafteux
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Christian A Gutschow
- Department of Surgery and Transplantation, University Hospital Zurich, Zurich, Switzerland
| | - Peter P Grimminger
- Department of General, Visceral and Transplant Surgery, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Jari V Räsänen
- Department of General Thoracic and Esophageal Surgery, Heart and Lung Centre, Helsinki University Hospital, Helsinki, Finland
| | - John V Reynolds
- Trinity St. James's Cancer Institute, St. James's Hospital, Dublin, Ireland
| | | | - Pedro Vieira
- Digestive Cancer Unit, Champalimaud Clinical Centre - Champalimaud Foundation, Lisbon, Portugal
| | | | | | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, the Netherlands
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2
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Henckens SPG, Liu D, Gisbertz SS, Kalff MC, Anderegg MCJ, Crull D, Daams F, van Dalsen AD, Dekker JWT, van Det MJ, van Duijvendijk P, Eshuis WJ, Groenendijk RPR, Haveman JW, van Hillegersberg R, Luyer MDP, Olthof PB, Pierie JPEN, Plat VD, Rosman C, Ruurda JP, van Sandick JW, Sosef MN, Voeten DM, Vijgen GHEJ, Bijlsma MF, Meijer SL, Hulshof MCCM, Oyarce C, Lagarde SM, van Laarhoven HWM, van Berge Henegouwen MI. Prognostic value of Mandard score and nodal status for recurrence patterns and survival after multimodal treatment of oesophageal adenocarcinoma. Br J Surg 2024; 111:znae034. [PMID: 38387083 PMCID: PMC10883709 DOI: 10.1093/bjs/znae034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/30/2024] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND This study evaluated the association of pathological tumour response (tumour regression grade, TRG) and a novel scoring system, combining both TRG and nodal status (TRG-ypN score; TRG1-ypN0, TRG>1-ypN0, TRG1-ypN+ and TRG>1-ypN+), with recurrence patterns and survival after multimodal treatment of oesophageal adenocarcinoma. METHODS This Dutch nationwide cohort study included patients treated with neoadjuvant chemoradiotherapy followed by oesophagectomy for distal oesophageal or gastro-oesophageal junctional adenocarcinoma between 2007 and 2016. The primary endpoint was the association of Mandard score and TRG-ypN score with recurrence patterns (rate, location, and time to recurrence). The secondary endpoint was overall survival. RESULTS Among 2746 inclusions, recurrence rates increased with higher Mandard scores (TRG1 30.6%, TRG2 44.9%, TRG3 52.9%, TRG4 61.4%, TRG5 58.2%; P < 0.001). Among patients with recurrent disease, the distribution (locoregional versus distant) was the same for the different TRG groups. Patients with TRG1 developed more brain recurrences (17.7 versus 9.8%; P = 0.001) and had a longer mean overall survival (44 versus 35 months; P < 0.001) than those with TRG>1. The TRG>1-ypN+ group had the highest recurrence rate (64.9%) and worst overall survival (mean 27 months). Compared with the TRG>1-ypN0 group, patients with TRG1-ypN+ had a higher risk of recurrence (51.9 versus 39.6%; P < 0.001) and worse mean overall survival (33 versus 41 months; P < 0.001). CONCLUSION Improved tumour response to neoadjuvant therapy was associated with lower recurrence rates and higher overall survival rates. Among patients with recurrent disease, TRG1 was associated with a higher incidence of brain recurrence than TRG>1. Residual nodal disease influenced prognosis more negatively than residual disease at the primary tumour site.
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Affiliation(s)
- Sofie P G Henckens
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Dajia Liu
- Department of Medical Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Centre for Experimental and Molecular Medicine, Laboratory for Experimental Oncology and Radiobiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Marianne C Kalff
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Maarten C J Anderegg
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - David Crull
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | | | | | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | | | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | | | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Pim B Olthof
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | | | - Victor D Plat
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | | | - Daan M Voeten
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
| | - Guy H E J Vijgen
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Maarten F Bijlsma
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Centre for Experimental and Molecular Medicine, Laboratory for Experimental Oncology and Radiobiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Oncode Institute, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Pathology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten C C M Hulshof
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Radiotherapy, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Cesar Oyarce
- Centre for Experimental and Molecular Medicine, Laboratory for Experimental Oncology and Radiobiology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Oncode Institute, Amsterdam, the Netherlands
| | - Sjoerd M Lagarde
- Department of Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Hanneke W M van Laarhoven
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands
- Cancer Centre Amsterdam, Cancer Treatment and Quality of Life, Amsterdam, the Netherlands
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Location University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, the Netherlands
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3
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van Doesburg JR, Kalff MC, Voeten DM, Engelsman AF, Jol S, van Berge Henegouwen MI, Daams F, Gisbertz SS. Thyroid Incidentalomas: Incidence and Oncological Implication in Patients with Esophageal Cancer. Dig Surg 2023; 40:216-224. [PMID: 37678197 DOI: 10.1159/000534027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Thyroid incidentalomas are often encountered during imaging performed for the workup of esophageal cancer. Their oncological significance is unknown. This study aimed to establish incidence and etiology of thyroid incidentalomas found during the diagnostic workup of esophageal cancer. METHODS All esophageal cancer patients referred to or diagnosed at the Amsterdam UMC between January 2012 and December 2016 were included. Radiology and multidisciplinary team meeting reports were reviewed for presence of thyroid incidentalomas. When present, the fluorodeoxyglucose-positron emission tomography/computed tomography (18FDG-PET/CT) or CT was reassessed by a radiologist. Primary outcome was the incidence and etiology of thyroid incidentalomas. RESULTS In total, 1,110 esophageal cancer patients were included. Median age was 66 years, most were male (77.2%) and had an adenocarcinoma (69.4%). For 115 patients (10.4%), a thyroid incidentaloma was reported. Two thyroidal lesions proved malignant. One was an esophageal cancer metastasis (0.9%) and one was a primary thyroid carcinoma (0.9%). Only the primary thyroid carcinoma resulted in treatment alteration. The other malignant thyroid incidentaloma was in the context of disseminated esophageal disease and ineligible for curative treatment. CONCLUSION In this study, thyroid incidentalomas were only very rarely oncologically significant. Further etiological examination should only be considered in accordance with the TI-RADS classification system and when clinical consequences are to be expected.
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Affiliation(s)
- Jasmijn R van Doesburg
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Marianne C Kalff
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Daan M Voeten
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Anton F Engelsman
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Saskia Jol
- Department of Radiology, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Freek Daams
- Department of Surgery, Amsterdam UMC, Location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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4
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van Doesburg JR, Voeten DM, Kalff MC, van Berge Henegouwen MI, Jol S, van den Bergh JE, Engelsman AF, Gisbertz SS, Daams F. Incidence and oncological implication of adrenal incidentalomas in esophageal cancer patients. Dis Esophagus 2023; 36:doad003. [PMID: 36722353 PMCID: PMC10473449 DOI: 10.1093/dote/doad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 12/15/2022] [Accepted: 01/01/2023] [Indexed: 02/02/2023]
Abstract
Adrenal incidentalomas are regularly encountered during imaging for esophageal cancer patients, but their oncological significance remains unknown. This study aimed to describe the incidence and etiology of adrenal incidentalomas observed throughout the diagnostic workup. This retrospective cohort study included all esophageal cancer patients referred to or diagnosed in the Amsterdam UMC between January 2012 and December 2016. Radiology and multidisciplinary team meeting reports were reviewed for adrenal incidentalomas. In case of adrenal incidentaloma, the 18FDG-PET/CT was reassessed by a radiologist blinded for the original report. In case of a metachronous incidentaloma during follow-up, visibility on previous imaging was reassessed. Primary outcome was the incidence, etiology and oncological consequence of synchronous adrenal incidentalomas. This study included 1,164 esophageal cancer patients, with a median age of 66 years. Patients were predominantly male (76.1%) and the majority had an adenocarcinoma (69.0%). Adrenal incidentalomas were documented in 138 patients (11.9%) during the diagnostic workup. At primary esophageal cancer workup, 22 incidentalomas proved malignant. However, follow-up showed that four incidentalomas were inaccurately diagnosed as benign and three malignant incidentalomas were visible on staging imaging but initially missed. Stage migration occurred in 15 of 22 (68.2%), but this would have been higher if none were missed or inaccurately diagnosed. The oncological impact of adrenal incidentalomas in patients with esophageal cancer is significant as a considerable part of incidentalomas changed treatment intent from curative to palliative. As stage migration is likely, pathological examination of a synchronous adrenal incidentaloma should be weighted in mind.
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Affiliation(s)
- J R van Doesburg
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - D M Voeten
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - M C Kalff
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S Jol
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - J E van den Bergh
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
- Department of Radiology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - A F Engelsman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - S S Gisbertz
- Department of Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - F Daams
- Department of Surgery, Amsterdam UMC location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Treatment and Quality of Life, Cancer Center Amsterdam, Amsterdam, The Netherlands
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5
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Kalff MC, van Berge Henegouwen MI, Baas PC, Bahadoer RR, Belt EJT, Brattinga B, Claassen L, Ćosović A, Crull D, Daams F, van Dalsen AD, Dekker JWT, van Det MJ, Drost M, van Duijvendijk P, Eshuis WJ, van Esser S, Gaspersz MP, Görgec B, Groenendijk RPR, Hartgrink HH, van der Harst E, Haveman JW, Heisterkamp J, van Hillegersberg R, Kelder W, Kingma BF, Koemans WJ, Kouwenhoven EA, Lagarde SM, Lecot F, van der Linden PP, Luyer MDP, Nieuwenhuijzen GAP, Olthof PB, van der Peet DL, Pierie JPEN, Pierik EGJMR, Plat VD, Polat F, Rosman C, Ruurda JP, van Sandick JW, Scheer R, Slootmans CAM, Sosef MN, Sosef OV, de Steur WO, Stockmann HBAC, Stoop FJ, Voeten DM, Vugts G, Vijgen GHEJ, Weeda VB, Wiezer MJ, van Oijen MGH, Gisbertz SS. Trends in Distal Esophageal and Gastroesophageal Junction Cancer Care: The Dutch Nationwide Ivory Study. Ann Surg 2023; 277:619-628. [PMID: 35129488 DOI: 10.1097/sla.0000000000005292] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer. SUMMARY OF BACKGROUND DATA The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer. METHODS Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods. RESULTS Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% ( P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P <0.001), median lymph node harvest increased from 15 to 19 ( P <0.001), and median survival increased from 35 to 41 months ( P = 0.027). CONCLUSION In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.
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Affiliation(s)
- Marianne C Kalff
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Peter C Baas
- Department of Surgery, Martini Ziekenhuis, Groningen, the Netherlands
| | - Renu R Bahadoer
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Eric J T Belt
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Baukje Brattinga
- Department of Surgery, MC Leeuwarden, Leeuwarden, the Netherlands
| | - Linda Claassen
- Department of Surgery, Gelre Ziekenhuis, Apeldoorn, the Netherlands
| | - Admira Ćosović
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - David Crull
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Freek Daams
- Department of Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | | | | | - Marc J van Det
- Department of Surgery, Ziekenhuisgroep Twente, Almelo, the Netherlands
| | - Manon Drost
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | | | - Wietse J Eshuis
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Stijn van Esser
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | | | - Burak Görgec
- Department of Surgery, Maasstad Ziekenhuis, Rotterdam, the Netherlands
| | | | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jan Willem Haveman
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Joos Heisterkamp
- Department of Surgery, Elisabeth-TweeSteden Ziekenhuis, Tilburg, the Netherlands
| | | | - Wendy Kelder
- Department of Surgery, Martini Ziekenhuis, Groningen, the Netherlands
| | - B Feike Kingma
- Department of Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Willem J Koemans
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | | | | | - Frederik Lecot
- Department of Surgery, Zuyderland, Heerlen, the Netherlands
| | | | - Misha D P Luyer
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | | | - Pim B Olthof
- Department of Surgery, Reinier de Graaf Groep, Delft, the Netherlands
| | | | | | | | - Victor D Plat
- Department of Surgery, VU University Medical Center, Amsterdam, the Netherlands
| | - Fatih Polat
- Department of Surgery, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, UMC Utrecht, Utrecht, the Netherlands
| | - Johanna W van Sandick
- Department of Surgery, Antoni van Leeuwenhoek Ziekenhuis, Amsterdam, the Netherlands
| | - Rene Scheer
- Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | | | - Odin V Sosef
- Department of Surgery, Zuyderland, Heerlen, the Netherlands
| | - Wobbe O de Steur
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Fanny J Stoop
- Department of Surgery, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands
| | - Daan M Voeten
- Department of Surgery, Spaarne Gasthuis, Haarlem, the Netherlands
| | - Guusje Vugts
- Department of Surgery, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | | | - Víola B Weeda
- Department of Surgery, Albert Schweitzer Ziekenhuis, Dordrecht, the Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St Antonius Ziekenhuis, Nieuwegein, the Netherlands
| | - Martijn G H van Oijen
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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6
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Visser M, Straatman J, Voeten DM, Gisbertz SS, Ruurda JP, van der Peet DL, van Berge Henegouwen MI, van Hillegersberg R. Hospital variation in feeding jejunostomy policy for minimally invasive esophagectomy; population-based results from the Dutch Upper gastrointestinal Cancer Audit (DUCA). European Journal of Surgical Oncology 2023. [DOI: 10.1016/j.ejso.2022.11.630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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de Graaff MR, Hogenbirk RNM, Janssen YF, Elfrink AKE, Liem RSL, Nienhuijs SW, de Vries JPPM, Elshof JW, Verdaasdonk E, Melenhorst J, van Westreenen HL, Besselink MGH, Ruurda JP, van Berge Henegouwen MI, Klaase JM, den Dulk M, van Heijl M, Hegeman JH, Braun J, Voeten DM, Würdemann FS, Warps ALK, Alberga AJ, Suurmeijer JA, Akpinar EO, Wolfhagen N, van den Boom AL, Bolster-van Eenennaam MJ, van Duijvendijk P, Heineman DJ, Wouters MWJM, Kruijff S, Koningswoud-Terhoeve CL, Belt E, van der Hoeven JAB, Marres GMH, Tozzi F, von Meyenfeldt EM, Coebergh RRJ, van den Braak, Huisman S, Rijken AM, Balm R, Daams F, Dickhoff C, Eshuis WJ, Gisbertz SS, Zandbergen HR, Hartemink KJ, Keessen SA, Kok NFM, Kuhlmann KFD, van Sandick JW, Veenhof AA, Wals A, van Diepen MS, Schoonderwoerd L, Stevens CT, Susa D, Bendermacher BLW, Olofsen N, van Himbeeck M, de Hingh IHJT, Janssen HJB, Luyer MDP, Nieuwenhuijzen GAP, Ramaekers M, Stacie R, Talsma AK, Tissink MW, Dolmans D, Berendsen R, Heisterkamp J, Jansen WA, de Kort-van Oudheusden M, Matthijsen RM, Grünhagen DJ, Lagarde SM, Maat APWM, van der Sluis PC, Waalboer RB, Brehm V, van Brussel JP, Morak M, Ponfoort ED, Sybrandy JEM, Klemm PL, Lastdrager W, Palamba HW, van Aalten SM, Tseng LNL, van der Bogt KEA, de Jong WJ, Oosterhuis JWA, Tummers Q, van der Wilden GM, Ooms S, Pasveer EH, Veger HTC, Molegraafb MJ, Nieuwenhuijs VB, Patijn GA, van der Veldt MEV, Boersma D, van Haelst STW, van Koeverden ID, Rots ML, Bonsing BA, Michiels N, Bijlstra OD, Braun J, Broekhuis D, Brummelaar HW, Hartgrink HH, Metselaar A, Mieog JSD, Schipper IB, de Steur WO, Fioole B, Terlouw EC, Biesmans C, Bosmans JWAM, Bouwense SAW, Clermonts SHEM, Coolsen MME, Mees BME, Schurink GWH, Duijff JW, van Gent T, de Nes LCF, Toonen D, Beverwijk MJ, van den Hoed E, Keizers B, Kelder W, Keller BPJA, Pultrum BB, van Rosum E, Wijma AG, van den Broek F, Leclercq WKG, Loos MJA, Sijmons JML, Vaes RHD, Vancoillie PJ, Consten ECJ, Jongen JMJ, Verheijen PM, van Weel V, Arts CHP, Jonker J, Murrmann-Boonstra G, Pierie JPEN, Swart J, van Duyn EB, Geelkerken RH, de Groot R, Moekotte NL, Stam A, Voshaar A, van Acker GJD, Bulder RMA, Swank DJ, Pereboom ITA, Hoffmann WH, Orsini M, Blok JJ, Lardenoije JHP, Reijne MMPJ, van Schaik P, Smeets L, van Sterkenburg SMM, Harlaar NJ, Mekke S, Verhaakt T, Cancrinus E, van Lammeren GW, Molenaar IQ, van Santvoort HC, Vos AWF, Schouten- van der Velden AP, Woensdregt K, Mooy-Vermaat SP, Scharn DM, Marsman HA, Rassam F, Halfwerk FR, Andela AJ, Buis CI, van Dam GM, ten Duis K, van Etten B, Lases L, Meerdink M, de Meijer VE, Pranger B, Ruiter S, Rurenga M, Wiersma A, Wijsmuller AR, Albers KI, van den Boezem PB, Klarenbeek B, van der Kolk BM, van Laarhoven CJHM, Matthée E, Peters N, Rosman C, Schroen AMA, Stommel MWJ, Verhagen AFTM, van der Vijver R, Warlé MC, de Wilt JHW, van den Berg JW, Bloemert T, de Borst GJ, van Hattum EH, Hazenberg CEVB, van Herwaarden JA, van Hillegerberg R, Kroese TE, Petri BJ, Toorop RJ, Aarts F, Janssen RJL, Janssen-Maessen SHP, Kool M, Verberght H, Moes DE, Smit JW, Wiersema AM, Vierhout BP, de Vos B, den Boer FC, Dekker NAM, Botman JMJ, van Det MJ, Folbert EC, de Jong E, Koenen JC, Kouwenhoven EA, Masselink I, Navis LH, Belgers HJ, Sosef MN, Stoot JHMB. Impact of the COVID-19 pandemic on surgical care in the Netherlands. Br J Surg 2022; 109:1282-1292. [PMID: 36811624 PMCID: PMC10364688 DOI: 10.1093/bjs/znac301] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 05/14/2022] [Accepted: 07/31/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. METHODS A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018-2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. RESULTS Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018-2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). CONCLUSION The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.
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Affiliation(s)
- Michelle R de Graaff
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands.,Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands.,Department of Surgery, Gelre Ziekenhuizen, Apeldoorn, the Netherlands
| | - Rianne N M Hogenbirk
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Yester F Janssen
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Arthur K E Elfrink
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Ronald S L Liem
- Department of Surgery, Dutch Obesity Clinic, Gouda, the Netherlands.,Department of Surgery, Groene Hart Hospital, Gouda, the Netherlands
| | - Simon W Nienhuijs
- Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands
| | | | - Jan-Willem Elshof
- Department of Surgery, VieCuri Medical Centre, Venlo, the Netherlands
| | - Emiel Verdaasdonk
- Department of Surgery, Jeroen Bosch Hospital, 's Hertogenbosch, the Netherlands
| | - Jarno Melenhorst
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Marc G H Besselink
- Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Joost M Klaase
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
| | - Marcel den Dulk
- Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Mark van Heijl
- Department of Surgery, Diakonessenhuis, Utrecht, the Netherlands
| | - Johannes H Hegeman
- Department of Surgery, Ziekenhuisgroep Twente Almelo-Hengelo, Almelo, Hengelo, the Netherlands
| | - Jerry Braun
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Daan M Voeten
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Franka S Würdemann
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anne-Loes K Warps
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands
| | - Anna J Alberga
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Vascular Surgery, Erasmus MC, Rotterdam, the Netherlands
| | - J Annelie Suurmeijer
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, the Netherlands.,Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Erman O Akpinar
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Nienke Wolfhagen
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Surgery, Radboud University Medical Centre, Nijmegen, the Netherlands
| | | | | | | | - David J Heineman
- Department of Surgery, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Michel W J M Wouters
- Dutch Institute for Clinical Auditing, Scientific Bureau, Leiden, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Centre Groningen, Groningen, the Netherlands
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8
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Voeten DM, Vissers PAJ, Verhoeven RHA, van Hillegersberg R, van Berge Henegouwen MI. Association between Surgical Patient Selection and Hospital Variation in Failure to Cure in Esophageal Cancer Surgery: A Nationwide Cohort Study. Dig Surg 2022; 39:183-190. [PMID: 35545020 DOI: 10.1159/000524999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/08/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Failure to cure describes: (1) nonresectional ("open-close") surgery, (2) non-radical surgery (R1-R2), and/or (3) postoperative mortality. This study aimed to investigate whether hospitals offering surgery to a large proportion of patients have higher failure-to-cure rates than hospitals operating fewer patients. METHODS From the Netherlands Cancer Registry, all cT1-cT4a/cTx-any cN-cM0 esophageal cancer patients diagnosed in 2015-2018 were included. For each center, the expected (E) proportion of patients undergoing surgery was established and divided by the observed (O) proportion. Hospitals were categorized into three groups: (1) hospitals treating relatively many patients with surgery, (2) average hospitals, and (3) hospitals treating relatively few patients with surgery. Multilevel multivariable regression investigated the association between these hospital groups and failure to cure. RESULTS Some 3,437 (53.2%) of 6,457 patients underwent surgery, ranging from 45 to 64% among 16 hospitals. The failure-to-cure rate was 15.0% (hospital variation [4.6-23.7%]). After categorizing, 1,003 patients underwent surgery in hospitals with low surgery rates (O/E ratio <0.94/corrected percentage <50%), 1,297 patients in average hospitals, and 1,137 patients in hospitals treating many patients surgically (O/E ratio >1.01/corrected percentage >54%). Failure-to-cure rates were 16.8%, 12.2%, and 14.0%, respectively. This was nonsignificant in multilevel analyses (aOR: 0.63, 95% CI: 0.38-1.05; aOR: 0.76, 95% CI: 0.46-1.24). DISCUSSION/CONCLUSION Failure-to-cure rates were similar in hospitals with a high surgery rate and hospitals with a low rate. Increasing the proportion of patients undergoing a resection may offer more patients, a chance for cure.
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Affiliation(s)
- Daan M Voeten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Pauline A J Vissers
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands.,Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob H A Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands.,Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
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9
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Voeten DM, Busweiler LAD, van der Werf LR, Wijnhoven BPL, Verhoeven RHA, van Sandick JW, van Hillegersberg R, van Berge Henegouwen MI. Outcomes of Esophagogastric Cancer Surgery During Eight Years of Surgical Auditing by the Dutch Upper Gastrointestinal Cancer Audit (DUCA). Ann Surg 2021; 274:866-873. [PMID: 34334633 DOI: 10.1097/sla.0000000000005116] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate changes in treatment and outcomes of esophagogastric cancer surgery after introduction of the DUCA. In addition, the presence of risk-averse behavior was assessed. SUMMARY OF BACKGROUND DATA Clinical auditing is seen as an important quality improvement tool; however, its long-term efficacy remains largely unknown. In addition, critics claim that enhancements result from risk-averse behavior rather than positive effects of auditing. METHODS DUCA data were used from registration start (1-1-2011) until 31-12-2018. Trends in patient, tumor, hospital and treatment characteristics were univariably assessed. Trends in short-term outcomes were investigated using multilevel multivariable logistic regression. Presence of risk aversion was described by the corrected proportion of patients undergoing surgery, using data from the Netherlands Cancer Registry. To evaluate the impact of centralization on time trends identified, the association between hospital volume and outcomes was investigated. RESULTS This study included 6172 patients with esophageal and 3,690 with gastric cancer who underwent surgery. Pathological outcomes (lymph node yield, radicality) improved and futile surgery decreased over the years. In-hospital/30-day mortality decreased for esophagectomy (4.2% to 2.5%) and for gastrectomy (7.1% to 4.3%). Reinterventions, (minor) complications and readmissions increased. Risk aversion appeared absent. Between 2011-2018, annual median hospital volumes increased from 38 to 53 for esophagectomy and from 14 to 29 for gastrectomy. Higher hospital volumes were associated with several improved outcomes measures. CONCLUSIONS During 8 years of auditing, outcomes improved, with no signs of risk-averse behavior. These improvements occurred in parallel with centralization. Feedback on postoperative complications remains the focus of the DUCA.
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Affiliation(s)
- Daan M Voeten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands
| | - Linde A D Busweiler
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Leonie R van der Werf
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
- Department of Surgery, Gelre Hospital, Apeldoorn, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rob H A Verhoeven
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
- Department of Medical Oncology, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | | | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Centre Amsterdam, Amsterdam, the Netherlands
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10
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van Kooten RT, Voeten DM, Steyerberg EW, Hartgrink HH, van Berge Henegouwen MI, van Hillegersberg R, Tollenaar RAEM, Wouters MWJM. ASO Visual Abstract: Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses. Ann Surg Oncol 2021. [PMID: 34570332 DOI: 10.1245/s10434-021-10785-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Robert T van Kooten
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Daan M Voeten
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Michel W J M Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.,Department of Surgery, Dutch Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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11
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van Kooten RT, Voeten DM, Steyerberg EW, Hartgrink HH, van Berge Henegouwen MI, van Hillegersberg R, Tollenaar RAEM, Wouters MWJM. Patient-Related Prognostic Factors for Anastomotic Leakage, Major Complications, and Short-Term Mortality Following Esophagectomy for Cancer: A Systematic Review and Meta-Analyses. Ann Surg Oncol 2021; 29:1358-1373. [PMID: 34482453 PMCID: PMC8724192 DOI: 10.1245/s10434-021-10734-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/09/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this study is to identify preoperative patient-related prognostic factors for anastomotic leakage, mortality, and major complications in patients undergoing oncological esophagectomy. BACKGROUND Esophagectomy is a high-risk procedure with an incidence of major complications around 25% and short-term mortality around 4%. METHODS We systematically searched the Medline and Embase databases for studies investigating the associations between patient-related prognostic factors and anastomotic leakage, major postoperative complications (Clavien-Dindo ≥ IIIa), and/or 30-day/in-hospital mortality after esophagectomy for cancer. RESULTS Thirty-nine eligible studies identifying 37 prognostic factors were included. Cardiac comorbidity was associated with anastomotic leakage, major complications, and mortality. Male sex and diabetes were prognostic factors for anastomotic leakage and major complications. Additionally, American Society of Anesthesiologists (ASA) score > III and renal disease were associated with anastomotic leakage and mortality. Pulmonary comorbidity, vascular comorbidity, hypertension, and adenocarcinoma tumor histology were identified as prognostic factors for anastomotic leakage. Age > 70 years, habitual alcohol usage, and body mass index (BMI) 18.5-25 kg/m2 were associated with increased risk for mortality. CONCLUSIONS Various patient-related prognostic factors are associated with anastomotic leakage, major postoperative complications, and postoperative mortality following oncological esophagectomy. This knowledge may define case-mix adjustment models used in benchmarking or auditing and may assist in selection of patients eligible for surgery or tailored perioperative care.
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Affiliation(s)
- Robert T van Kooten
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands.
| | - Daan M Voeten
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Rob A E M Tollenaar
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel W J M Wouters
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.,Department of Surgery, Dutch Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
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12
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Plat VD, Voeten DM, Daams F, van der Peet DL, Straatman J. C-reactive protein after major abdominal surgery in daily practice. Surgery 2021; 170:1131-1139. [PMID: 34024474 DOI: 10.1016/j.surg.2021.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 03/24/2021] [Accepted: 04/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Infectious complications are frequently encountered after abdominal surgery. Early recognition, diagnosis, and subsequent timely treatment is the single most important denominator of postoperative outcome. This study prospectively addressed the predictive value of routine assessment of C-reactive protein levels as an early marker for infectious complications after major abdominal surgery. METHODS Consecutive patients undergoing major abdominal surgery between November 2015 and November 2019 were prospectively enrolled. Routine C-reactive protein measurements were implemented on postoperative days 3, 4, and 5, and additional computed tomography examinations were performed on demand. The primary endpoint was the occurrence of Clavien-Dindo grade III or higher infectious complications. RESULTS Of 350 patients, 71 (20.3%) experienced a major infectious complication, and median time to diagnosis was 7 days. C-reactive protein levels were significantly higher in patients with major infectious complications compared to minor or no infectious complications. The optimal cut-off was calculated for each postoperative day, being 175 mg/L on day 3, 130 mg/L on day 4, and 144 mg/L on day 5, and corresponding sensitivities, specificities, and positive and negative predictive values were over 80%, 65%, 40%, and 92% respectively. Alternative safe discharge cut-offs were calculated at 105 mg/L, 71 mg/L and 63 mg/L on days 3, 4, and 5, respectively, each having a negative predictive value of over 97%. CONCLUSION The C-reactive protein cut-offs provided in this study can be used as a discharge criterion or to select patients that might require an invasive intervention due to infectious complications. These diagnostic criteria can easily be implemented in daily surgical practice.
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Affiliation(s)
- Victor D Plat
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands.
| | - Daan M Voeten
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Freek Daams
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
| | - Jennifer Straatman
- Department of Gastrointestinal surgery, Amsterdam UMC, VU University Medical Center, The Netherlands
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13
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Voeten DM, van Berge Henegouwen MI. ASO Author Reflections: Failure to Cure in Patients Undergoing Surgery for Gastric Cancer: A Nationwide Cohort Study. Ann Surg Oncol 2021; 28:4497-4498. [PMID: 33506307 PMCID: PMC8253704 DOI: 10.1245/s10434-020-09539-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 12/17/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Daan M Voeten
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands. .,Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands.
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, Cancer Center Amsterdam, University of Amsterdam, Amsterdam, the Netherlands
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14
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Voeten DM, van der Werf LR, Wilschut JA, Busweiler LAD, van Sandick JW, van Hillegersberg R, van Berge Henegouwen MI. Failure to Cure in Patients Undergoing Surgery for Gastric Cancer: A Nationwide Cohort Study. Ann Surg Oncol 2021; 28:4484-4496. [PMID: 33486644 PMCID: PMC8253712 DOI: 10.1245/s10434-020-09510-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/03/2020] [Indexed: 12/13/2022]
Abstract
Background This study aimed to describe the incidence of failure to cure (a composite outcome measure defined as surgery not meeting its initial aim), and the impact of hospital variation in the administration of neoadjuvant therapy on this outcome measure. Methods All patients in the Dutch Upper Gastrointestinal Cancer Audit undergoing curatively intended gastric cancer surgery in 2011–2019 were included. Failure to cure was defined as (1) ‘open-close’ surgery; (2) irradical surgery (R1/R2); or (3) 30-day/in-hospital mortality. Case-mix-corrected funnel plots, based on multivariable logistic regression analyses, investigated hospital variation. The impact of a hospital’s tendency to administer neoadjuvant chemotherapy on the heterogeneity in failure to cure between hospitals was assessed based on median odds ratios and multilevel logistic regression analyses. Results Some 3862 patients from 28 hospitals were included. Failure to cure was noted in 22.3% (hospital variation: 14.5–34.8%). After case-mix correction, two hospitals had significantly higher-than-expected failure to cure rates, and one hospital had a lower-than-expected rate. The failure to cure rate was significantly higher in hospitals with a low tendency to administer neoadjuvant chemotherapy. Approximately 29% of hospital variation in failure to cure could be attributed to different hospital policies regarding neoadjuvant therapy. Conclusions Failure to cure has an incidence of 22% in patients undergoing gastric cancer surgery. Higher failure to cure rates were seen in centers administering less neoadjuvant chemotherapy, which confirms the Dutch guideline recommendation on the administration of neoadjuvant chemotherapy. Failure to cure provides short loop feedback and can be used as a quality indicator in surgical audits. Supplementary Information The online version contains supplementary material available at 10.1245/s10434-020-09510-6.
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Affiliation(s)
- Daan M Voeten
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands. .,Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - Leonie R van der Werf
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Janneke A Wilschut
- Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, The Netherlands
| | - Linde A D Busweiler
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Surgery, Gelre Hospital, Apeldoorn, The Netherlands
| | - Johanna W van Sandick
- Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Mark I van Berge Henegouwen
- Department of Surgery, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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Voeten DM, van der Werf LR, Gisbertz SS, Ruurda JP, van Berge Henegouwen MI, van Hillegersberg R. Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit. Eur J Surg Oncol 2021; 47:1961-1968. [PMID: 33485673 DOI: 10.1016/j.ejso.2021.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/01/2020] [Accepted: 01/06/2021] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes. MATERIALS AND METHODS Patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses. RESULTS Between 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0-4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay. CONCLUSION This study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction.
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Affiliation(s)
- Daan M Voeten
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands; Scientific Bureau, Dutch Institute for Clinical Auditing, Leiden, the Netherlands.
| | - Leonie R van der Werf
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Jelle P Ruurda
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mark I van Berge Henegouwen
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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Voeten DM, Hillegersberg RV, Henegouwen MIVB, Gisbertz SS. Adenocarcinoma of the gastro-esophageal junction: is centralization policy always a good idea? ACTA ACUST UNITED AC 2020. [DOI: 10.21037/aoe-2020-geja-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Voeten DM, den Bakker CM, Goedegebuure RSA, Heineman DJ, Daams F, van der Peet DL. [Non-metastatic oesophageal cancer: diagnosis and treatment]. Ned Tijdschr Geneeskd 2019; 163:D3718. [PMID: 31556490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The incidence of oesophageal cancer is on the rise, particularly due to an increase in the number of adenocarcinomas of the distal oesophagus. Adenomas and squamous cell carcinomas are the most common histological subtypes; each should be considered as a different entity. The diagnosis 'oesophageal cancer' is confirmed on the basis of histopathological investigation of biopsies, whereas tumour staging is conducted through transoesophageal endoscopic ultrasound and FDG-PET/CT diagnostics. There are various options to treat patients with oesophageal cancer, such as endoscopic resection, multimodal therapy or definitive chemoradiotherapy. Since 2012, neoadjuvant chemoradiotherapy followed by surgery is the standard treatment for oesophageal cancer, except with regard to patients with a T1 or M1 tumour. In the Netherlands, most surgical procedures are now minimally invasive procedures. Despite improved treatment options, mortality rates associated with oesophageal cancer remain high.
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Affiliation(s)
- Daan M Voeten
- Amsterdam UMC, afd. Heelkunde, Amsterdam
- Contact: D.M. Voeten
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Voeten DM, den Bakker CM, Heineman DJ, Ket JCF, Daams F, van der Peet DL. Definitive Chemoradiotherapy Versus Trimodality Therapy for Resectable Oesophageal Carcinoma: Meta-analyses and Systematic Review of Literature. World J Surg 2019; 43:1271-1285. [PMID: 30607604 DOI: 10.1007/s00268-018-04901-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Standard therapy for loco-regionally advanced, resectable oesophageal carcinoma is trimodality therapy (TMT) consisting of neoadjuvant chemoradiotherapy and oesophagectomy. Evidence of survival advantage of TMT over organ-preserving definitive chemoradiotherapy (dCRT) is inconclusive. The aim of this study is to compare survival between TMT and dCRT. METHODS A systematic review and meta-analyses were conducted. Randomised controlled trials and observational studies on resectable, curatively treated, oesophageal carcinoma patients above 18 years were included. Three online databases were searched for studies comparing TMT with dCRT. Primary outcomes were 1-, 2-, 3- and 5-year overall survival rates. Risk of bias was assessed using the Cochrane risk of bias tools for RCTs and cohort studies. Quality of evidence was evaluated according to Grading of Recommendation Assessment, Development and Evaluation. RESULTS Thirty-two studies described in 35 articles were included in this systematic review, and 33 were included in the meta-analyses. Two-, three- and five-year overall survival was significantly lower in dCRT compared to TMT, with relative risks (RRs) of 0.69 (95% CI 0.57-0.83), 0.76 (95% CI 0.63-0.92) and 0.57 (95% CI 0.47-0.71), respectively. When only analysing studies with equal patient groups at baseline, no significant differences for 2-, 3- and 5-year overall survival were found with RRs of 0.83 (95% CI 0.62-1.10), 0.81 (95% CI 0.57-1.14) and 0.63 (95% CI 0.36-1.12). CONCLUSION These meta-analyses do not show clear survival advantage for TMT over dCRT. Only a non-significant trend towards better survival was seen, assuming comparable patient groups at baseline. Non-operative management of oesophageal carcinoma patients might be part of a personalised and tailored treatment approach in future. However, to date hard evidence proving its non-inferiority compared to operative management is lacking.
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Affiliation(s)
- Daan M Voeten
- Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands.
| | - Chantal M den Bakker
- Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands
| | - David J Heineman
- Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands
| | | | - Freek Daams
- Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands
| | - Donald L van der Peet
- Department of Gastrointestinal Surgery, VU University Medical Center, De Boelelaan 1117, 7F020, 1081 HV, Amsterdam, The Netherlands
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Abstract
Quality indicators are used to measure quality of care and enable benchmarking. An overview of all existing hip fracture quality indicators is lacking. The primary aim was to identify quality indicators for hip fracture care reported in literature, hip fracture audits, and guidelines. The secondary aim was to compose a set of methodologically sound quality indicators for the evaluation of hip fracture care in clinical practice. A literature search according to the PRISMA guidelines and an internet search were performed to identify hip fracture quality indicators. The indicators were subdivided into process, structure, and outcome indicators. The methodological quality of the indicators was judged using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument. For structure and process indicators, the construct validity was assessed. Sixteen publications, nine audits and five guidelines were included. In total, 97 unique quality indicators were found: 9 structure, 63 process, and 25 outcome indicators. Since detailed methodological information about the indicators was lacking, the AIRE instrument could not be applied. Seven indicators correlated with an outcome measure. A set of nine quality indicators was extracted from the literature, audits, and guidelines. Many quality indicators are described and used. Not all of them correlate with outcomes of care and have been assessed methodologically. As methodological evidence is lacking, we recommend the extracted set of nine indicators to be used as the starting point for further clinical research. Future research should focus on assessing the clinimetric properties of the existing quality indicators.
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Affiliation(s)
- S C Voeten
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333ZA, The Netherlands.
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands.
| | - P Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333ZA, The Netherlands
| | - D M Voeten
- Department of Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - J H Hegeman
- Department of Trauma Surgery, Ziekenhuisgroep Twente, Almelo/Hengelo, The Netherlands
| | - M W J M Wouters
- Dutch Institute for Clinical Auditing, Leiden, The Netherlands
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - I B Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Albinusdreef 2, Leiden, 2333ZA, The Netherlands
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