Evaluation of oesophageal and gastric resection outcomes in a small-volume unit

Abstract

Introduction Oesophagogastric resections continue to be a major surgical challenge with high morbidity, this has led to a worldwide trend for centralisation of these complex surgeries. However, there is no clear agreement on what constitutes a high-volume centre, leading to worldwide disparity. We evaluate our experience of oesophagogastric resection in a small volume unit to seek other factors that influence patient outcome. Methods We analysed 173 consecutive oesophagogastric resection from 2010 to 2020. The primary outcome was 30-day mortality and secondary outcome included peri-operative morbidity, length of stay, lymph node harvest, R0 resection. Collected continuous data were compared using the Mann-Whitney test and categorical data using the chi-squared test and expressed as p value. Results Of the 173 patients, 94 (54%) underwent hybrid minimal invasive esophagectomy (HIMO) and 79 (46%) underwent gastrectomy. 135 (78%) patients received Neoadjuvant therapy. The site of tumour was GOJ in 29%, distal stomach in 26% and distal oesophagus in 20%. Perioperative morbidity was observed in 18 (19%) after esophagectomy and 9 (11.4%) after gastrectomy. The median lymph node harvest was 18 (range 5–42) and 168 patients (97%) had longitudinal R0 resection. The most common complication was neurological seen in 3.6% followed by pulmonary complication and anastomotic leak seen in 5 patients (3%) each. The median in hospital stay was 6 days and the 30 day mortality was 2.9% with one year survival of 87%. Conclusion Small volume centres can produce comparable results. The outcomes depend on multifold parameters which include surgeon's experience in the field, ability to adhere to protocols and procedures and strong interpersonal relationship with individual patients.

Quality performance indicators for the surgical treatment of gastric adenocarcinoma: a systematic review

“…Factors for this include differences in tumour biology and presentation, limitation in training opportunities and volume. 2 Vlayen et al highlighted the proportion of patients who were diagnosed with T1a GC who underwent endoscopic mucosal resection as a QPI. 3 The role of ESD as a QPI should be further investigated and developed as a QPI once expert consensus is reached.…”

“…Nevertheless, its adoption in the West is relatively limited. Factors for this include differences in tumour biology and presentation, limitation in training opportunities and volume 2 . Vlayen et al .…”

“…Historically, emphasis on quality of care in GC has been placed on the technical elements of resectional surgery including obtaining acceptable resection margins, undertaking an appropriately aggressive regional lymphadenectomy and precise surgical anastomotic technique. Most frequently, institutional surgical volume has been used as a proxy measure for quality of care 2–4 . However, while a volume‐outcome relationship has been established for oesophagectomy, 5 it has not been convincingly established for gastrectomy 6 and many smaller volume institutions report good results following surgical treatment of GC, 2,3 although the successful performance of gastric resections does require a suitably trained and resourced surgical team 3,4 .…”

“…Most frequently, institutional surgical volume has been used as a proxy measure for quality of care 2–4 . However, while a volume‐outcome relationship has been established for oesophagectomy, 5 it has not been convincingly established for gastrectomy 6 and many smaller volume institutions report good results following surgical treatment of GC, 2,3 although the successful performance of gastric resections does require a suitably trained and resourced surgical team 3,4 . Consequently, developing effective QPIs for the treatment of patients with GC is important and they must reflect both the complexities of modern GC management, and the multidisciplinary contribution of the many services involved in patient care.…”