Implementation of Minimally Invasive Esophagectomy From a Randomized Controlled Trial Setting to National Practice

Markar, Sheraz R.; Ni, Melody; Gisbertz, Suzanne S.; Werf, L. van der; Straatman, Jennifer; Peet, Donald L. van der; Cuesta, Miguel A.; Henegouwen, Mark I. van Berge

doi:10.1200/jco.19.02483

Cited by 67 publications

(52 citation statements)

References 31 publications

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“…There is conflicting evidence regarding the impact of minimally invasive oesophagectomy compared with open surgery on complication rates and other outcomes 27–30 . The TIME and MIRO trials, which demonstrated the superiority of minimally invasive techniques, have further driven rapid adoption 27 , 30 , 31 , although it should be recognized that transition to a new operative technique can be associated with increased complications that are likely to influence outcomes outside a trial setting 32 , 33 . The DUCA involved significantly more minimally invasive surgery than the OGAA and ECCG studies, yet had similar levels of complications.…”

Section: Discussionmentioning

confidence: 99%

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

Kamarajah¹,

Nepogodiev²,

Bundred³

et al. 2021

BJS Open

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Background The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA). Methods The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up. Results The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien–Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013). Conclusion Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

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Section: Discussionmentioning

confidence: 99%

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

Kamarajah¹,

Nepogodiev²,

Bundred³

et al. 2021

BJS Open

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“…The phase of the minimally invasive learning curve of each individual hospital might also partially explain the hospital variation. Introduction of MIE in a non-expert center leads to higher complication rates [26]. Even though the underlying reasons remain speculative, the presence of hospital variation indicates that…”

Section: Discussionmentioning

confidence: 99%

Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit

Voeten

Werf

Gisbertz

et al. 2021

European Journal of Surgical Oncology

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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: 0e4]. 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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“…A recent study from Markar et al [69] investigated outcomes in minimally invasive esophagectomies separating cohort from the TIME trial with 115 patients treated in highly specialized centers and under very selective study environments and the national database with 4,605 patients. Only the study population achieved lower complications and better outcomes in the minimally invasive group, whereas the database population fell short and suffered from higher complication rates in minimally invasive esophagectomies [69]. While this study did not focus on BMI or obesity, it shows the relevance of experience and skill in highly ambitious surgical approaches, which underlines the need of specialization and centralization of centers performing complex surgeries.…”

Section: Confounding Factors Affecting Postoperative Outcomementioning

confidence: 99%

Impact of Excess Body Weight on Postsurgical Complications

Plassmeier

Hankir

Seyfried³

2021

Visc Med

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Background: Obesity is considered a risk factor for postoperative complications as it can limit exposure to the operation field, thereby significantly prolonging surgery time. Obesity-associated comorbidities, such as low-grade systemic inflammation, impaired functional status, and type 2 diabetes, are independent risk factors for impaired anastomotic wound healing and nonsurgical site infections. If obesity itself is an independent risk factor for surgical complications remains controversial, but the reason for this is largely unexplored. Summary: A MEDLINE literature search was performed using the terms: “obesity,” “excess body weight,” and “surgical complications.” Out of 65,493 articles 432 meta-analyses were screened, of which 25 meta-analyses were on the subject. The vast majority of complex oncologic procedures in the field of visceral surgery have shown higher complication rates in obese patients. Meta-analyses from the last 10 to 15 years with high numbers of patients enrolled consistently have shown longer operation times, higher blood loss, longer hospital stay for colorectal procedures, oncologic upper gastrointestinal (GI) procedures, and pancreatic surgery. Interestingly, these negative effects seem not to affect the overall survival in oncologic patients, especially in esophageal resections. A selection bias in oncologic upper GI patients may have influenced the results with higher BMI in upper GI cancer to be a predictor for better nutritional and performance status. Key Messages: Contrary to bariatric surgery, only limited evidence indicated that site and type of surgery, the approach to the abdominal cavity (laparoscopic vs. open), institutional factors, and the type of perioperative care such as ERAS protocols may play a role in determining postsurgical complications in obese patients. The initial question remains therefore partially unanswered. Large nationwide register-based studies are necessary to better understand which aspects of obesity and its related comorbidities define it as a risk factor for surgical complications.

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Implementation of Minimally Invasive Esophagectomy From a Randomized Controlled Trial Setting to National Practice

Cited by 67 publications

References 31 publications

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

Postoperative intensive care unit stay after minimally invasive esophagectomy shows large hospital variation. Results from the Dutch Upper Gastrointestinal Cancer Audit

Impact of Excess Body Weight on Postsurgical Complications

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