O61: TEXTBOOK SURGICAL OUTCOMES IN OESOPHAGO-GASTRIC CANCER: THE INFLUENCE OF NATIONAL KEY PERFORMANCE INDICATORS

Introduction

High quality surgery remains the cornerstone of treating oesophago-gastric malignancy. Recent work from the Dutch Upper-gastrointestinal Cancer Audit (DUCA) have defined ten surgical and perioperative ‘textbook’ parameters that correlate with improved overall survival. The aim of this project was to examine the proportion of patients attaining ‘textbook’ outcomes for oesophagectomy and gastrectomy in our unit before and after the introduction of national key performance indicators (KPIs).

Method

A retrospective review of all oesophagectomies and gastrectomies from January 2010 until June 2019 was performed. Clinical, pathological, perioperative, morbidity and mortality outcomes were recorded. 10 ‘textbook’ parameters were studied pre- and post-KPI introduction.

Result

269 and 284 patients underwent oesophagectomy and gastrectomy respectively, 167 pre-KPI and 386 post-KPI. There were no significant differences in age (67.6 vs 66.4 years, p=0.6), gender (71% male, 29% female vs 68% male, 22% female, p=0.48), ASA grade (p=0.6) or tumour stage (p=0.37) pre- and post-KPI. In the pre-KPI era, 28/167 (17%) patients achieved all ten textbook parameters, compared with 157/386, (41%, p=0.001) post-KPI. This compares favourably to DUCA ‘textbook’ data. There was an improvement in adequate lymphadenectomy (56% vs 83%, p=0.002), a reduction in margin positivity (21% vs 7%, p= 0.001) and peri-operative mortality (6% vs 2%, p=0.03) post-KPI.

Conclusion

There has been a significant improvement in perioperative outcomes in esophagectomy following the introduction of national KPIs in our unit. The number of patients achieving ‘textbook’ outcomes is comparable with international standards. The identification of textbook parameters allows further focus for future quality improvement initiatives.

Take-home message

National KPIs improve peri-operative outcomes in oesophago-gastric cancer.

An emotion-focused approach to the overregulation of emotion and emotional pain

The importance of facilitating productive therapeutic processes to gain access to overregulated primary adaptive emotional experience is discussed. In addition to describing common two- and three-step emotion sequences involved in change, this article presents the more complex sequences involved in facing emotional pain. Key aspects of facing pain are allowing the experience of "brokenness," or a "shattering" of the self, feeling the associated painful emotions, and processing them to completion. This promotes a transformation in view of self, world, and other. A case example and some general principles of emotional change are given.

Late onset, symptomatic, demyelinating encephalomyelitis in mice infected with MHV-JHM in the presence of maternal antibody

The presence of maternal antibodies protected suckling C57BL/6 mice from the clinical manifestations of the acute encephalomyelitis caused by mouse hepatitis virus, strain JHM (MHV-JHM), a coronavirus, even though histological evidence of encephalomyelitis was found at early times after inoculation. 100% of infected suckling mice developed a fatal disease in the absence of maternal antibody. By 14 days after inoculation, the brains of all antibody-protected mice examined were nearly normal on histological examination. At 3-8 weeks post-inoculation, approximately 40% of the antibody-protected mice developed a neurological disease characterized by hindlimb paralysis and wasting. Evidence of inflammation and demyelination was apparent in the spinal cord and brainstem. The mice that remained asymptomatic at this time showed few signs of inflammation and none developed clinical disease over the following 9 months. Viral antigen could be detected in most of the mice examined at all times after inoculation, whether symptomatic or not, and was particularly evident in the animals with hindlimb paralysis. MHV-JHM could be consistently cultured from the mice with hindlimb paralysis. These results show that maternal immune factors can completely protect susceptible mice from the acute, fatal, clinical encephalomyelitis caused by MHV-JHM, but cannot prevent the establishment of a latent state and subsequent development of virus-induced, clinically evident, demyelinating disease. This model will be useful for studying the virus and host factors important for the development of MHV-JHM latency and subsequent virus-induced demyelination.

MHV nucleocapsid synthesis in the presence of cycloheximide and accumulation of negative strand MHV RNA

We have found that genomic RNA synthesis is inhibited by cycloheximide in cells infected with mouse hepatitis virus, strain A59 (MHV-A59), in agreement with previously published results (Sawicki, S.G. and Sawicki, D.L. (1986) J. Virol, 57, 328-334). In the present study, the fate of the residual genomic RNA synthesized in the presence of cycloheximide was determined. Nearly all of the genomic RNA synthesized in the presence of drug was incorporated into nucleocapsid structures, suggesting that even in the absence of protein synthesis, genomic RNA synthesis and encapsidation are coupled in MHV-infected cells. Sufficient free nucleocapsid N protein was available for this purpose, since the pool of soluble N protein was determined to decay with a half-life of approximately one hour. Negative strand RNA is the template for the synthesis of both genomic and subgenomic positive strand RNA, and would be predicted to accumulate primarily during the early phases of the lytic cycle. In agreement with this prediction, negative strand RNA accumulated during the first 5-6 h of infection, with little additional accumulation occurring over the next 2.5 h. In marked contrast, positive strand RNA increased 5-6-fold over the same 2.5 h period. These results, taken in conjunction with published data, suggest that negative strand RNA is synthesized during the early period of the infectious cycle and is stable in infected cells and also suggest that treatment with cycloheximide at late times does not inhibit positive strand RNA synthesis indirectly by blocking the formation of negative strand templates.

Local cerebral glucose utilization in the symptomatic thiamine-deficient rat: increases in fornix and pyramidal tract

Local cerebral glucose utilization (LCGU) was measured in asymptomatic rats on a thiamine (B1)-deficient diet for 70 days and in symptomatic rats on a B1-deficient diet for 98 days. LCGU increased in postcommissural fornix (F), pyramidal tracts (P), and inferior internal capsule (CAI) of symptomatic, compared with asymptomatic B1-deficient rats but decreased in thalamic nuclei, auditory structures, and lesioned vestibular nuclei. B1 administration to symptomatic rats improved symptoms; decreased LCGU in F. P, and CAI; increased LCGU in the lesioned vestibular nuclei; but decreased LCGU in mammillary nuclei, anteroventral nucleus of thalamus, and medial raphe. The results indicate that B1 deficiency symptoms correlate with LCGU changes in F and P and vestibular nuclei.

Thiamine deficiency limits glucose utilization and glial proliferation in brain lesions of symptomatic rats

The effects of thiamine (B1) deficiency on local CMRglu (LMCRglu) in the vestibular nuclei were studied with the 14C-2-deoxyglucose autoradiographic method in awake asymptomatic and symptomatic rats. Animals on the B1-deficient diet for 98 days developed symptoms of ataxia and opisthotonos. The results show that B1 deficiency produces: (1) bilateral vestibular nuclei lesions in symptomatic animals; (2) very low LCMRglu rates in these lesions; and (3) limitation of glial proliferation in the lesions. Giving B1 to B1-deficient symptomatic animals produced a cellular proliferation response consisting mostly of microglia in the lesioned areas of the vestibular nuclei and a high LCMRglu rate in the regions of microglial proliferation.