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Uttinger K, Mansournia MA, Baum P, Diers J, Rust C, Wiegering A. Determination of Minimum Surgical Caseloads for Major Oncologic Resections Using a Population-Attributable Fraction Model of Observational Data in Germany. JCO Oncol Pract 2025:OP2401012. [PMID: 40300126 DOI: 10.1200/op-24-01012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2024] [Revised: 01/29/2025] [Accepted: 03/21/2025] [Indexed: 05/01/2025] Open
Abstract
PURPOSE There is a volume-outcome association in cancer surgery; fulfillment of minimum surgical caseloads (MSCs) is known to be associated with reduced in-hospital mortality. To our knowledge, to date, there is no evidence-based approach to determine MSC with regard to in-hospital mortality. METHODS Hospital billing data of pulmonary, esophageal, gastric, pancreatic, colon, and rectal cancer resections were analyzed. Nonfulfillment of annual caseloads of 5-100 procedures was defined as a risk factor of in-hospital mortality in a population-attributable fraction (PAF) model adjusting for age, sex, resection extent, and comorbidity. MSCs were obtained using a linear-trend approach. The primary end point was the fraction of attributable deaths due to nonfulfillment of MSCs. Driving distances to the treating hospital and closest MSC-fulfilling hospital were obtained using geocoding. RESULTS A total of 824,535 patient records were analyzed. Resulting MSCs were 50 in pulmonary, 31 in esophageal, 31 in gastric, 48 in pancreatic, 28 in colon, and 43 per year in rectal resections. The PAF of nonfulfillment of the MSC was lowest in colon resections (8.8%, 95% CI, 1.0% to 16.5%) and highest in pancreatic resections (30.6%, 95% CI, 22.8% to 38.5%). The median difference in the driving distance (to the treating hospital v to MSC-fulfilling hospital) ranged between -3.5 km (IQR, -16.2 km to +0.2 km) in colon resections and +39.1 km (IQR, +0.3 km to +89.5 km) in rectal resections. CONCLUSION A PAF model is feasible in determining MSCs in cancer surgery with regard to in-hospital mortality; differences in driving distances to MSC fulfilling hospitals can be assessed using geocoding.
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Affiliation(s)
- Konstantin Uttinger
- Department of General, Visceral, and Transplant Surgery at Frankfurt University Hospital, Frankfurt, Germany
- Frankfurt Cancer Institute, Georg-Speyer-Haus, Frankfurt, Germany
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Philip Baum
- Department of Thoracic Surgery, Thoraxklinik at Heidelberg University Hospital, Heidelberg, Germany
| | | | - Christoph Rust
- Department of Econometrics, University of Regensburg, Regensburg, Germany
- Department of Finance, Accounting and Statistics, Vienna University of Economics and Business, Vienna, Austria
| | - Armin Wiegering
- Department of General, Visceral, and Transplant Surgery at Frankfurt University Hospital, Frankfurt, Germany
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Moletta L, Pierobon ES, Capovilla G, Zuin IS, Carrillo Lizarazo JL, Nezi G, Lonardi S, Murgioni S, Galuppo S, Zanchettin G, Salvador R, Provenzano L, Valmasoni M. Short- and Long-Term Outcomes in Elderly Patients with Resectable Esophageal Cancer: Upfront Esophagectomy Compared to Surgery after Neoadjuvant Treatments. J Clin Med 2024; 13:4271. [PMID: 39064311 PMCID: PMC11277732 DOI: 10.3390/jcm13144271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/08/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Background/Objectives: Despite the increased incidence of esophageal cancer (EC) in elderly people, there are no clear guidelines for its treatment in these patients. The aim of this study was to compare the outcomes of patients ≥ 75 years with resectable EC, receiving either upfront esophagectomy or neoadjuvant treatment. Methods: We retrospectively identified 127 patients with resectable EC ≥ 75 years who underwent esophagectomy between January 2000 and December 2022 at our Clinic in the University Hospital of Padova. The included patients were stratified into two groups: patients undergoing upfront esophagectomy (SURG group) and patients receiving neoadjuvant treatment (NAT group). Results: There were no statistically significant differences in OS (p = 0.7708), DFS (p = 0.7827) and cancer-related survival (p = 0.0827) between the SURG and the NAT group, except for the OS of EAC with stage III-IV, where the NAT group experienced a significant benefit in OS (p = 0.0263). When comparing the two groups, patients receiving neoadjuvant treatment experienced a significantly higher rate of postoperative complications (p = 0.0266). At univariate analysis, neoadjuvant therapy was the only variable strongly associated with postoperative morbidity (p = 0.026). Conclusions: Considering the unique characteristics of elderly patients, the choice of a multimodal approach should be tailored to each case in a multidisciplinary setting and balanced with a potential higher risk of postoperative complications, as well as potential toxicity related to chemoradiation and reduced life expectancy.
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Affiliation(s)
- Lucia Moletta
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Elisa Sefora Pierobon
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Giovanni Capovilla
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Irene Sole Zuin
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Jose Luis Carrillo Lizarazo
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Giulia Nezi
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Sara Lonardi
- Department of Oncology, Veneto Institute of Oncology IOV—IRCCS, 35128 Padova, Italy
| | - Sabina Murgioni
- Department of Oncology, Veneto Institute of Oncology IOV—IRCCS, 35128 Padova, Italy
| | - Sara Galuppo
- Radiotherapy Unit, Veneto Institute of Oncology IOV—IRCCS, 35128 Padova, Italy
| | - Gianpietro Zanchettin
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Renato Salvador
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Luca Provenzano
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
| | - Michele Valmasoni
- 1st Surgical Clinic, Department of Surgery, Oncology and Gastroenterology, University of Padova, 35128 Padova, Italy
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Hoffmann J, Dresbach T, Hagenbeck C, Scholten N. Factors associated with the closure of obstetric units in German hospitals and its effects on accessibility. BMC Health Serv Res 2023; 23:342. [PMID: 37020222 PMCID: PMC10077609 DOI: 10.1186/s12913-023-09204-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 02/20/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND An increase in regionalization of obstetric services is being observed worldwide. This study investigated factors associated with the closure of obstetric units in hospitals in Germany and aimed to examine the effect of obstetric unit closure on accessibility of obstetric care. METHODS Secondary data of all German hospital sites with an obstetrics department were analyzed for 2014 and 2019. Backward stepwise regression was performed to identify factors associated with obstetrics department closure. Subsequently, the driving times to a hospital site with an obstetrics department were mapped, and different scenarios resulting from further regionalization were modelled. RESULTS Of 747 hospital sites with an obstetrics department in 2014, 85 obstetrics departments closed down by 2019. The annual number of live births in a hospital site (OR = 0.995; 95% CI = 0.993-0.996), the minimal travel time between two hospital sites with an obstetrics department (OR = 0.95; 95% CI = 0.915-0.985), the availability of a pediatrics department (OR = 0.357; 95% CI = 0.126-0.863), and population density (low vs. medium OR = 0.24; 95% CI = 0.09-0.648, low vs. high OR = 0.251; 95% CI = 0.077-0.822) were observed to be factors significantly associated with the closure of obstetrics departments. Areas in which driving times to the next hospital site with an obstetrics department exceeded the 30 and 40 min threshold slightly increased from 2014 to 2019. Scenarios in which only hospital sites with a pediatrics department or hospital sites with an annual birth volume of ≥ 600 were considered resulted in large areas in which the driving times would exceed the 30 and 40 min threshold. CONCLUSION Close distances between hospital sites and the absence of a pediatrics department at the hospital site associate with the closure of obstetrics departments. Despite the closures, good accessibility is maintained for most areas in Germany. Although regionalization may ensure high-quality care and efficiency, further regionalization in obstetrics will have an impact on accessibility.
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Affiliation(s)
- Jan Hoffmann
- Faculty of Medicine and University Hospital Cologne, Faculty of Human Sciences, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Eupener Str. 129, 50933, Cologne, Germany.
| | - Till Dresbach
- University Hospital Bonn, Department of Neonatology and Pediatric Intensive Care Medicine, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Carsten Hagenbeck
- Department of Obstetrics and Gynecology, University Hospital Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Nadine Scholten
- Faculty of Medicine and University Hospital Cologne, Faculty of Human Sciences, Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Eupener Str. 129, 50933, Cologne, Germany
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Okawa S, Tabuchi T, Morishima T, Nakata K, Koyama S, Odani S, Miyashiro I. Minimum surgical volume to ensure 5-year survival probability for six cancer sites in Japan. Cancer Med 2022; 12:1293-1304. [PMID: 35796145 PMCID: PMC9883575 DOI: 10.1002/cam4.4999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/15/2022] [Accepted: 06/23/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In Japan, the government designates hospitals specialized in cancer care, requiring them to perform 400 surgeries annually without requiring surgical volume per cancer site. This study aimed to estimate the site-specific minimum surgical volume per year based on its associations with 5-year survival probability. METHODS The data of 64,402 patients who had undergone surgery for six types of cancers (including esophageal, stomach, colorectal, pancreatic, lung, and breast cancers) at designated cancer care hospitals in Osaka between 2007 and 2011 were analyzed. The hospitals were categorized by the average annual surgical volume per cancer type (e.g., 0-4, 5-9, 10-14…). We estimated the adjusted 5-year survival probability per surgical volume category using multivariable Cox proportional hazard regression. Furthermore, we identified inflection points for the trend of adjusted survival probability per increase of five surgical volumes using the joinpoint regression model and considered them as the suggested minimum surgical volume. RESULTS The estimated minimum surgical volumes were 35-39, 20-25, 25-29, 10-14, 10-14, and 25-29 for esophageal, stomach, colorectal, pancreatic, lung, and breast cancers, respectively. The percentage change in the adjusted 5-year survival probability per increase of five surgical volumes before and after the suggested surgical volume were +2.23 and +0.39 for the esophagus, +9.68 and +0.34 for the stomach, +8.11 and +0.05 for the colorectum, +3.82 and +0.87 for the pancreas, +9.46 and +0.23 for the lung, and +1.27 and +0.03 for the breast. CONCLUSIONS The suggested surgical volume based on the association with survival probability varies with cancer sites, some of which are close to the existing surgical volume standards used in Japan. These evidence-based minimum surgical volumes may help improve the quality of cancer surgeries.
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Affiliation(s)
- Sumiyo Okawa
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan,Institute for Global Health Policy ResearchBureau of International Health Cooperation, National Center for Global Health and MedicineTokyoJapan
| | - Takahiro Tabuchi
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | | | - Kayo Nakata
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | - Shihoko Koyama
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | - Satomi Odani
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
| | - Isao Miyashiro
- Cancer Control CenterOsaka International Cancer InstituteOsakaJapan
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Holleran TJ, Napolitano MA, Sparks AD, Antevil JL, Brody FJ, Trachiotis GD. Hospital Operative Volume and Esophagectomy Outcomes in the Veterans Affairs System. J Surg Res 2022; 275:291-299. [DOI: 10.1016/j.jss.2022.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/08/2022] [Accepted: 02/10/2022] [Indexed: 11/26/2022]
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Okawa S, Tabuchi T, Nakata K, Morishima T, Koyama S, Odani S, Miyashiro I. Surgical volume threshold to improve 3-year survival in designated cancer care hospitals in 2004-2012 in Japan. Cancer Sci 2022; 113:1047-1056. [PMID: 34985172 PMCID: PMC8898718 DOI: 10.1111/cas.15264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 12/17/2021] [Accepted: 12/27/2021] [Indexed: 12/12/2022] Open
Abstract
In Japan, cancer care hospitals designated by the national government have a surgical volume requirement of 400 annually, which is not necessarily defined based on patient outcomes. This study aimed to estimate surgical volume thresholds that ensure optimal 3‐year survival for three periods. In total, 186 965 patients who had undergone surgery for solid cancers in 66 designated cancer care hospitals in Osaka between 2004 and 2012 were examined using data from a population‐based cancer registry. These hospitals were categorized by the annual surgical volume of each 50 surgeries (eg, 0‐49, 50‐99, and so on). Using multivariable Cox proportional hazard regression, we estimated the adjusted 3‐year survival probability per surgical volume category for 2004‐2006, 2007‐2009, and 2010‐2012. Using the joinpoint regression model that computes inflection points in a linear relationship, we estimated the points at which the trend of the association between surgical volume and survival probability changes, defining them as surgical volume thresholds. The adjusted 3‐year survival ranges were 71.7%‐90.0%, 68.2%‐90.0%, and 79.2%‐90.3% in 2004‐2006, 2007‐2009, and 2010‐2012, respectively. The surgical volume thresholds were identified at 100‐149 in 2004‐2006 and 2007‐2009 and 200‐249 in 2010‐2012. The extents of change in the adjusted 3‐year survival probability per increase of 50 surgical volumes were +4.00%, +6.88%, and +1.79% points until the threshold and +0.41%, +0.30%, and +0.11% points after the threshold in 2004‐2006, 2007‐2009, and 2010‐2012, respectively. The existing surgical volume requirements met our estimated thresholds. Surgical volume thresholds based on the association with patient survival may be used as a reference to validate the surgical volume requirement.
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Affiliation(s)
- Sumiyo Okawa
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan.,Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Takahiro Tabuchi
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Kayo Nakata
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | | | - Shihoko Koyama
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Satomi Odani
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Isao Miyashiro
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
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Overall Volume Trends in Esophageal Cancer Surgery Results From the Dutch Upper Gastrointestinal Cancer Audit. Ann Surg 2021; 274:449-458. [PMID: 34397452 DOI: 10.1097/sla.0000000000004985] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE In the pursuit of quality improvement, this study aimed to investigate volume-outcome trends in oncologic esophagectomy in the Netherlands. SUMMARY OF BACKGROUND DATA Concentration of Dutch esophageal cancer care was dictated by introducing an institutional minimum of 20 resections/yr. METHODS This nationwide cohort study included all esophagectomy patients registered in the Dutch Upper Gastrointestinal Cancer Audit in 2016-2019 from hospitals currently still performing esophagectomies. Annual esophagectomy hospital volume was assigned to each patient and categorized into quartiles. Multivariable logistic regression investigated short-term surgical outcomes. Restricted cubic splines investigated if volume-outcome relationships eventually plateaued. RESULTS In 16 hospitals, 3135 esophagectomies were performed. First volume quartile hospitals performed 24-39 resections/yr; second, third, and fourth quartile hospitals performed 40-53, 54-69, and 70-101, respectively. Compared to quartile 1, in quartiles 2 to 4, overall/severe/technical complication, anastomotic leakage, and prolonged hospital/intensive care unit stay rates were significantly lower and textbook outcome and lymph node yield were higher. When raising the cut-off from the first to second quartile, higher-volume centers had less technical complications [Adjusted odds ratio (aOR): 0.82, 95% confidence interval (CI): 0.70-0.96], less anastomotic leakage (aOR: 0.80, 95% CI: 0.66-0.97), more textbook outcome (aOR: 1.25, 95% CI: 1.07-1.46), shorter intensive care unit stay (aOR: 0.80, 95% CI: 0.69-0.93), and higher lymph node yield (aOR: 3.56, 95% CI: 2.68-4.77). For most outcomes the volume-outcome trend plateaued at 50-60 annual resections, but lymph node yield and anastomotic leakage continued to improve. CONCLUSION Although this study does not reflect on individual hospital quality, there appears to be a volume trend towards better outcomes in high-volume centers. Projects have been initiated to improve national quality of care by reducing hospital variation (irrespective of volume) in outcomes in The Netherlands.
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Song BG, Kim GH, Cho CJ, Kim HR, Min YW, Lee H, Min BH, Song HJ, Kim YH, Lee JH, Jung HY, Zo JI, Shim YM. Close Observation versus Additional Surgery after Noncurative Endoscopic Resection of Esophageal Squamous Cell Carcinoma. Dig Surg 2021; 38:247-254. [PMID: 33910202 DOI: 10.1159/000515717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 03/08/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION After noncurative endoscopic submucosal dissection (ESD) of superficial esophageal squamous cell carcinoma (SESCC), additional esophagectomy is generally recommended. However, considering its high mortality and morbidity, it is uncertain if additional surgery improves the clinical outcomes. This study aimed to compare the clinical outcomes between patients who were observed without additional treatment and those who underwent radical esophagectomy. METHODS A total of 52 patients with SESCC who underwent complete but noncurative ESD from January 2008 to December 2016 at the Samsung Medical Center and Asan Medical Center in Korea were retrospectively analyzed. Clinicopathologic characteristics and oncologic outcomes were compared between the observation group (n = 23) and the additional surgery group (n = 29). RESULTS During a mean follow-up of 34.4 and 41.7 months, respectively, the rates of death (observation vs. surgery, 17.4 vs. 10.3%; p = 0.686), recurrence (observation vs. surgery, 13 vs. 17.2%; p = 1.000), and disease-specific death (observation vs. surgery, 4.3 vs. 6.9%; p = 1.000) did not significantly differ between the 2 groups. The 3-year overall survival was 86.3 and 96.4%, respectively (p = 0.776). The 3-year recurrence-free survival (observation vs. surgery, 85.0 vs. 88.7%; p = 0.960) and disease-specific survival (observation vs. surgery, 95.2 vs. 96.4%; p = 0.564) also did not significantly differ. CONCLUSIONS The clinical outcomes of close observation of noncuratively resected SESCC are comparable to those of additional surgery, at least in the midterm. The wait-and-see strategy could be a feasible management option after noncurative ESD of SESCC in selected patients.
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Affiliation(s)
- Byeong Geun Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ga Hee Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Charles J Cho
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Won Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hyuk Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Byung-Hoon Min
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong-Hee Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun Haeng Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Ill Zo
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Young Mog Shim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
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Liesenfeld LF, Sauer P, Diener MK, Hinz U, Schmidt T, Müller-Stich BP, Hackert T, Büchler MW, Schaible A. Prognostic value of inflammatory markers for detecting anastomotic leakage after esophageal resection. BMC Surg 2020; 20:324. [PMID: 33298038 PMCID: PMC7726907 DOI: 10.1186/s12893-020-00995-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/01/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Early diagnosis of anastomotic leakage (AL) after esophageal resection is crucial for the successful management of this complication. Inflammatory serological markers are indicators of complications during the postoperative course. The aim of the present study was to evaluate the prognostic value of routine inflammatory markers to predict anastomotic leakage after transthoracic esophageal resection. METHODS Data from all consecutive patients undergoing transthoracic esophageal resection between January 2010 and December 2016 were analyzed from a prospective database. Besides clinicodemographic parameters, C-reactive protein, white blood cell count and albumin were analyzed and the Noble/Underwood (NUn) score was calculated to evaluate their predictive value for postoperative anastomotic leakage. Diagnostic accuracy was measured by sensitivity, specificity, and negative and positive predictive values using area under the receiver operator characteristics curve. RESULTS Overall, 233 patients with transthoracic esophageal resection were analyzed, 30-day mortality in this group was 3.4%. 57 patients (24.5%) suffered from AL, 176 patients were in the AL negative group. We found significant differences in WBCC, CRP and NUn scores between patients with and without AL, but the analyzed markers did not show an independent relevant prognostic value. For CRP levels below 155 mg/dl from POD3 to POD 7 the negative predictive value for absence of AI was > 80%. Highest diagnostic accuracy was detected for CRP levels on 4th POD with a cut-off value of 145 mg/l reaching negative predictive value of 87%. CONCLUSIONS In contrast to their prognostic value in other surgical procedures, CRP, WBCC and NUn score cannot be recommended as independent markers for the prediction of anastomotic leakage after transthoracic esophageal resection. CRP is an accurate negative predictive marker and discrimination of AL and no-AL may be helpful for postoperative clinical management. Trial registration The study was approved by the local ethical committee (S635-2013).
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Affiliation(s)
- Lukas F Liesenfeld
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
| | - Peter Sauer
- Department of Gastroenterology, Heidelberg University Hospital, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Markus K Diener
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Ulf Hinz
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Thilo Hackert
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Markus W Büchler
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Anja Schaible
- Department of Surgery, Heidelberg University Hospital, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
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Potential Impact of “Take the Volume Pledge” on Access and Outcomes for Gastrointestinal Cancer Surgery. Ann Surg 2019; 270:1079-1089. [DOI: 10.1097/sla.0000000000002796] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Meng R, Bright T, Woodman RJ, Watson DI. Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand. ANZ J Surg 2019; 89:683-688. [PMID: 30856682 DOI: 10.1111/ans.15058] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/03/2018] [Accepted: 12/10/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Volume-outcome relationships for mortality following oesophagectomy have been demonstrated in Europe and the USA, but not in Australia or New Zealand. We determined whether higher volume hospitals achieve better outcomes following oesophagectomy in Australia and New Zealand. METHODS Administrative data for hospitals contributing data to the Health Roundtable were analysed. Hospitals performing oesophagectomy for cancer from July 2008 to June 2015 were grouped according to mean annual caseload: low (1-5), medium (6-11) and high (12+) volume. Univariate and multivariable analyses determined the impact of volume on 30-day and in-hospital mortalities, length of hospital stay and mechanical ventilation following surgery. RESULTS A total of 2252 patients underwent oesophagectomy in 65 hospitals. Sixty-eight percent (n = 44) were low-, 26% (n = 17) were medium- and 6% (n = 4) were high-volume hospitals. Seven hundred and sixty-two (34%) procedures were performed in low-, 1042 (46%) in medium- and 448 (20%) in high-volume hospitals. Overall in-hospital mortality was 3.1% and 30-day mortality was 2.1%. In-hospital mortality was lowest in high-volume hospitals; 1.6% versus 2.6% and 4.1% for low- and medium-volume hospitals (P = 0.02). Surgery in high-volume hospitals was shorter (32 min, P = 0.001), and patients were less likely to require post-operative ventilation (16.7% versus 25.3% and 28.0%, P < 0.001), although patients requiring ventilation in high-volume hospitals were ventilated for longer. CONCLUSIONS A volume-outcome relationship was demonstrated, with overall better performance in higher volume hospitals. Colocation of oesophagectomies to hospitals that can demonstrate appropriate caseload should be considered.
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Affiliation(s)
- Rosie Meng
- Flinders University Discipline of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
- Flinders Centre for Innovation in Cancer, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Tim Bright
- Flinders Centre for Epidemiology and Biostatistics, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Richard J Woodman
- Flinders University Discipline of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
- Flinders Centre for Innovation in Cancer, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David I Watson
- Flinders University Discipline of Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
- Flinders Centre for Epidemiology and Biostatistics, Flinders Medical Centre, Adelaide, South Australia, Australia
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Omidele OO, Davoudzadeh N, Palese M. Fellowship and Subspecialization in Urology: An Analysis of Robotic-assisted Partial Nephrectomy. Urology 2019; 130:36-42. [PMID: 31034918 DOI: 10.1016/j.urology.2019.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 03/05/2019] [Accepted: 03/18/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the impact of a urologic fellowship on physician case-volume and immediate patient outcomes, and to assess predictors of undergoing a robotic-assisted partial nephrectomy by a fellowship-trained (FT) urologist. METHODS We retrospectively reviewed all robotic (ICD-9 17.4) partial nephrectomies (PN; ICD-9 55.4) reported in the Statewide Planning and Research Cooperative Systems (SPARCS) database of New York State (NYS) from 2009 to 2014. Perioperative outcomes assessed included length of stay, 30-day readmission rates, 90-day readmission rates, and complication rates. Pearson chi-square tests were used to compare categorical variables, and unpaired Student t tests were used to assess continuous variables. RESULTS FT urologists performed 2199 (56%) RAPN during the study period, and nonfellowship trained (NFT) urologists completed 1700 (44%) RAPN. FT urologists performed more RAPN in teaching hospitals than NFT urologists (23% vs 7%). The average surgical volume per year for a FT urologist conducting RAPN was 9.6 ± 2.2 cases/y. NFT urologists had an average surgical volume of 7.2 ± 1.5 cases/y (P = <.0001). No significant difference was found in length of stay, 30- or 90-day readmission rate, or complication rate between the groups. RAPN conducted at teaching hospitals were more likely to be conducted by FT urologists. Patients who were self-payers were less likely to have a RAPN by FT urologists. CONCLUSION There were no differences for RAPN perioperative outcomes between FT urologists and their NFT peers. FT urologists perform a higher case-volume of RAPN in NYS, and this trend is increasing.
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Affiliation(s)
- Olamide O Omidele
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Natan Davoudzadeh
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael Palese
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
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Zhang Y, Ding H, Chen T, Zhang X, Chen WF, Li Q, Yao L, Korrapati P, Jin XJ, Zhang YX, Xu MD, Zhou PH. Outcomes of Endoscopic Submucosal Dissection vs Esophagectomy for T1 Esophageal Squamous Cell Carcinoma in a Real-World Cohort. Clin Gastroenterol Hepatol 2019; 17:73-81.e3. [PMID: 29704682 DOI: 10.1016/j.cgh.2018.04.038] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 03/12/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy. METHODS We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period. RESULTS Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04). CONCLUSION In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.
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Affiliation(s)
- Yiun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Han Ding
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoen Zhang
- Department of Internal Medicine, Mount Sinai St. Luke's-West Hospital Center, New York, New York
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Quanin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Liing Yao
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Praneet Korrapati
- Department of Gastroenterology, Mount Sinai Beth Israel Hospital, New York, New York
| | - Xue-Juan Jin
- Center of Evidence-Based Medicine, Fudan University, Shanghai, China
| | - Yong-Xing Zhang
- Department of Thoracic Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China.
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Hesari A, Azizian M, Sheikhi A, Nesaei A, Sanaei S, Mahinparvar N, Derakhshani M, Hedayt P, Ghasemi F, Mirzaei H. Chemopreventive and therapeutic potential of curcumin in esophageal cancer: Current and future status. Int J Cancer 2018; 144:1215-1226. [PMID: 30362511 DOI: 10.1002/ijc.31947] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 09/15/2018] [Accepted: 10/10/2018] [Indexed: 12/15/2022]
Abstract
Esophageal cancer is a common malignant tumor with an increasing trend during the past three decades. Currently, esophagectomy, often in combination with neoadjuvant chemo- and radiotherapy, is the cornerstone of curative treatment for esophageal cancer. However, esophagostomy is related to significant risks of perioperative mortality and morbidity, as well as lengthy recovery. Moreover, the adjuvant therapies including chemotherapy and radiotherapy are associated with numerous side effects, limiting compliance and outcome. The dietary agent curcumin has been extensively studied over the past few decades and is known to have many biological activities especially in regard to the prevention and potential treatment of cancer. This review summarizes the chemo-preventive and chemotherapeutic potential of curcumin in esophageal cancer in both preclinical and clinical settings.
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Affiliation(s)
- AmirReza Hesari
- Molecular and Medicine Research Center, Department of Biotechnology, Faculty of Medicine, Arak University of Medical Sciences, Arak, Iran
| | - Mitra Azizian
- Department of Clinical Biochemistry, Faculty of Medicine, Shahid Beheshti University of Medical Science, Tehran, Iran
| | - Alireza Sheikhi
- Department of Medical Biochemistry, Faculty of Medicine, Iran University of Medical Science, Tehran, Iran
| | - Abolfazl Nesaei
- Department of Basic Sciences, Faculty of Medicine, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Shahin Sanaei
- General Practitioner, Medical Researcher, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Nazanin Mahinparvar
- General Practitioner, Medical Researcher, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | - Pegah Hedayt
- Department of Pathology, Medical University of Isfahan, Isfahan, Iran
| | - Faezeh Ghasemi
- Blood Transfusion Research Center, High Institute for Research and Education in Transfusion Medicine, Tehran, Iran
| | - Hamed Mirzaei
- Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran
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Grąt M, Lewandowski Z, Patkowski W, Grąt K, Wronka KM, Krasnodębski M, Wróblewski T, Nyckowski P, Krawczyk M. Individual Surgeon Experience Yields Bimodal Effects on Patient Outcomes After Deceased-Donor Liver Transplant: Results of a Quantile Regression for Survival Data. EXP CLIN TRANSPLANT 2018; 16:425-433. [PMID: 29108512 DOI: 10.6002/ect.2017.0027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Data on the relevance of surgeon experience in liver transplant procedures are scarce. In this study, we evaluated the effects of individual surgeon experience on survival outcomes after deceased-donor liver transplant. MATERIALS AND METHODS In this retrospective analysis of 1193 liver transplant procedures, quantile regression for survival data was performed to assess the effects of surgeon experience. Conditional quantiles of mortality and graft loss were set as primary and secondary outcome measures, respectively, which were categorized as early, midterm, and late. RESULTS Greater experience of a surgeon performing hepatectomy increased the risk of early mortality (P = .005) and graft loss (P = .025) when the recipient Model for End-Stage Liver Disease was ≤ 25 and the donor Model for End-Stage Liver Disease was ≤ 1600. In conventional transplant procedures, greater experience of surgeon performing hepatectomy additionally increased the risk of midterm mortality (P = .027) and graft loss (P = .046). Conversely, a graft implant procedure performed by a more experienced surgeon was associated with better early, midterm, and late outcomes after conventional transplants (all P < .037) and reduced the risk of early graft loss when the donor Model for End-Stage Liver Disease score was > 1600 (P = .027). CONCLUSIONS Unexpectedly, individual surgeon experience yields bimodal effects on posttransplant outcomes, dependent on the stage of operation, operative technique, severity of recipient status, and transplant risk profile.
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Affiliation(s)
- Michał Grąt
- From the Department of General, Transplant, and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
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Giwa F, Salami A, Abioye AI. Hospital esophagectomy volume and postoperative length of stay: A systematic review and meta-analysis. Am J Surg 2018; 215:155-162. [DOI: 10.1016/j.amjsurg.2017.03.022] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 03/05/2017] [Accepted: 03/16/2017] [Indexed: 12/22/2022]
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Billig JI, Lu Y, Momoh AO, Chung KC. A Nationwide Analysis of Cost Variation for Autologous Free Flap Breast Reconstruction. JAMA Surg 2017; 152:1039-1047. [PMID: 28724133 DOI: 10.1001/jamasurg.2017.2339] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Importance Cost variation among hospitals has been demonstrated for surgical procedures. Uncovering these differences has helped guide measures taken to reduce health care spending. To date, the fiscal consequence of hospital variation for autologous free flap breast reconstruction is unknown. Objective To investigate factors that influence cost variation for autologous free flap breast reconstruction. Design, Setting, and Participants A secondary cross-sectional analysis was performed using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 to 2010. The dates of analysis were September 2016 to February 2017. The setting was a stratified sample of all US community hospitals. Participants were female patients who were diagnosed as having breast cancer or were at high risk for breast cancer and underwent autologous free flap breast reconstruction. Main Outcomes and Measures Variables of interest included demographic data, hospital characteristics, length of stay, complications (surgical and systemic), and inpatient cost. The study used univariate and generalized linear mixed models to examine associations between patient and hospital characteristics and cost. Results A total of 3302 patients were included in the study, with a median age of 50 years (interquartile range, 44-57 years). The mean cost for autologous free flap breast reconstruction was $22 677 (interquartile range, $14 907-$33 391). Flap reconstructions performed at high-volume hospitals were significantly more costly than those performed at low-volume hospitals ($24 360 vs $18 918, P < .001). Logistic regression demonstrated that hospital volume correlated with increased cost (Exp[β], 1.06; 95% CI, 1.02-1.11; P = .003). Fewer surgical complications (16.4% [169 of 1029] vs 23.7% [278 of 1174], P < .001) and systemic complications (24.2% [249 of 1029] vs 31.2% [366 of 1174], P < .001) were experienced in high-volume hospitals compared with low-volume hospitals. Flap procedures performed in the West were the most expensive ($28 289), with a greater odds of increased expenditure (Exp[β], 1.53; 95% CI, 1.46-1.61; P < .001) compared with the Northeast. A significant difference in length of stay was found between the West and Northeast (odds ratio, 1.25; 95% CI, 1.17-1.33). Conclusions and Relevance There is significant cost variation among patients undergoing autologous free flap breast reconstruction. Experience, as measured by a hospital's volume, provides quality health care with fewer complications but is more costly. Longer length of stay contributed to regional cost variation and may be a target for decreasing expenditure, without compromising care. In the era of bundled health care payment, strategies should be implemented to eliminate cost variation to condense spending while still providing quality care.
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Affiliation(s)
- Jessica I Billig
- Section of Plastic Surgery, University of Michigan Health System, Ann Arbor
| | - Yiwen Lu
- Section of Plastic Surgery, University of Michigan Health System, Ann Arbor
| | - Adeyiza O Momoh
- Section of Plastic Surgery, University of Michigan Health System, Ann Arbor
| | - Kevin C Chung
- Section of Plastic Surgery, University of Michigan Health System, Ann Arbor
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Schaible A, Brenner T, Hinz U, Schmidt T, Weigand M, Sauer P, Büchler MW, Ulrich A. Significant decrease of mortality due to anastomotic leaks following esophageal resection: management makes the difference. Langenbecks Arch Surg 2017; 402:1167-1173. [PMID: 28975494 DOI: 10.1007/s00423-017-1626-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Accepted: 09/22/2017] [Indexed: 12/15/2022]
Abstract
PURPOSE Anastomotic leakage is the most frequent cause of postoperative mortality following esophageal surgery. However, no gold standard for diagnosing and managing leakage has been established. Continuous clinical judgment is extremely important; therefore, to optimize the management of leakage, we established a special group for decision-making in cases of suspected leakage in the early postoperative period. METHODS Between January 2010 and December 2016, 234 consecutive patients underwent elective esophageal resection with a thoracoabdominal incision. In 2014, we established a group consisting of a surgeon, surgical endoscopist, and anesthesiologist for decision-making in cases of suspected leakage. They discussed emerging problems and decided on further diagnostics or therapy. The data were documented prospectively and compared to the years prior to 2014. RESULTS Two hundred and thirty-four consecutive patients were enrolled in the study, 110 in the years 2010-2013 (group A), and 124 in the years 2014-2016 (group B). Neither patients' characteristics nor the rate of anastomotic leakage differed significantly between the two study groups. The hospital mortality rate was 10% (11 patients) in group A and 4.8% (six patients) in group B. Most interestingly, mortality due to anastomotic leakage was 35% in group A (9/26), whereas it decreased significantly to 6.5% (2/31 patients) (P < 0.001) in group B. CONCLUSIONS Our data clearly demonstrated that optimizing the management of anastomotic leakage by making team decisions can lead to a significant decrease in mortality.
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Affiliation(s)
- Anja Schaible
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany.
| | - Thorsten Brenner
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ulf Hinz
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Thomas Schmidt
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Markus Weigand
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Sauer
- Department of Internal Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus W Büchler
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
| | - Alexis Ulrich
- Department of General Surgery, Heidelberg University Hospital, INF 110, 69120, Heidelberg, Germany
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Fuchs HF, Harnsberger CR, Broderick RC, Chang DC, Sandler BJ, Jacobsen GR, Bouvet M, Horgan S. Simple preoperative risk scale accurately predicts perioperative mortality following esophagectomy for malignancy. Dis Esophagus 2017; 30:1-6. [PMID: 26727414 DOI: 10.1111/dote.12451] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Surgery remains one of the major treatment options available to patients with esophageal cancer, with high mortality in certain cohorts. The aim of this study was to develop a simple preoperative risk scale based on patient factors, hospital factors, and tumor pathology to predict the risk of perioperative mortality following esophagectomy for malignancy. The Nationwide Inpatient Sample database was used to create the risk scale. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using International Classification of Diseases, 9th edition codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regressions were used to define a predictive model of perioperative mortality and to create a simple risk scale. From 1998 to 2011, a total of 23 751 patients underwent esophagectomy. The observed overall perioperative mortality rate for this cohort was 7.7%. Minimally invasive techniques, and operations performed in higher volume centers were protective, whereas increasing age, comorbidities and diagnosis of squamous cell carcinoma were independent predictors of mortality. Based on this population, a risk scale from 0-16 was created. The calibration revealed a good agreement between the observed and risk scale-predicted probabilities. A set of sensitivity/specificity analyses was then performed to define normal (score 0-7) and high risk (score 8-16) patients for clinical practice. Mortality in patients with a score of 0-7 ranged from 1.3-7.6%, compared with 10.5-34.5% in patients with a score of 8-16. This simple preoperative risk scale may accurately predict the risk of perioperative mortality following esophagectomy for malignancy and can be used as a clinical tool for preoperative counseling.
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Affiliation(s)
- H F Fuchs
- Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, USA.,Department of General Surgery, University of Cologne, Cologne, Germany
| | - C R Harnsberger
- Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, USA
| | - R C Broderick
- Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, USA
| | - D C Chang
- Department of Surgery, University of California, San Diego, USA.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - B J Sandler
- Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, USA
| | - G R Jacobsen
- Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, USA
| | - M Bouvet
- Department of Surgery, Division of Surgical Oncology,, University of California , San Diego, California, USA
| | - S Horgan
- Department of Surgery, Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California, San Diego, USA
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Mortality after esophagectomy is heavily impacted by center volume: retrospective analysis of the Nationwide Inpatient Sample. Surg Endosc 2016; 31:2491-2497. [PMID: 27660245 DOI: 10.1007/s00464-016-5251-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 09/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The effects of hospital volume on in-hospital mortality after esophageal resection are disputed in the literature. We sought to analyze treatment effects in patient subpopulations that undergo esophagectomy for cancer based on hospital volume. METHODS We performed a retrospective analysis of the Nationwide Inpatient Sample from 1998 to 2011. Patients who underwent open or laparoscopic transhiatal and transthoracic esophageal resection were identified using ICD-9 codes. Patients <18 years and those with peritoneal disease were excluded. Multivariate logistic regression analyses were used with mortality as the independent variable to evaluate the effect of low (<6), intermediate (6-19), and high (≥20) hospital volume of esophagectomies. These analyses were repeated in different subsets of patients to determine whether hospital volume affected mortality depending on the subpopulation evaluated. Subgroups were created depending on age, race, gender, operative approach, comorbidities, and tumor pathology. RESULTS A total of 23,751 patients were included. The overall perioperative mortality rate was 7.7 % (low volume: 11.4 %; intermediate volume: 8.39 %, high volume: 4.01 %), and multivariate analysis revealed that high hospital volume had a protective effect (OR 0.54, 95 % CI 0.45-0.65). On subgroup analyses for low- and intermediate-volume hospitals, mortality was uniformly elevated for the subpopulations when comparing to high-volume hospitals (p < 0.05). There was no difference in mortality between low- and medium-volume hospitals and between subgroups. CONCLUSION No lower mortality risk subgroup could be identified in this nationwide collective. This analysis emphasizes that perioperative mortality after esophagectomy for cancer is lower in high-volume hospitals.
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Chen SY, Molena D, Stem M, Mungo B, Lidor AO. Post-discharge complications after esophagectomy account for high readmission rates. World J Gastroenterol 2016; 22:5246-5253. [PMID: 27298567 PMCID: PMC4893471 DOI: 10.3748/wjg.v22.i22.5246] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/05/2016] [Accepted: 04/15/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify rates of post-discharge complications (PDC), associated risk factors, and their influence on early hospital outcomes after esophagectomy.
METHODS: We used the 2005-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients ≥ 18 years of age who underwent an esophagectomy. These procedures were categorized into four operative approaches: transhiatal, Ivor-Lewis, 3-holes, and non-gastric conduit. We selected patient data based on clinical relevance to patients undergoing esophagectomy and compared demographic and clinical characteristics. The primary outcome was PDC, and secondary outcomes were hospital readmission and reoperation. The patients were then divided in 3 groups: no complication (Group 1), only pre-discharge complication (Group 2), and PDC patients (Group 3). A modified Poisson regression analysis was used to identify risk factors associated with developing post-discharge complication, and risk ratios were estimated.
RESULTS: 4483 total patients were identified, with 8.9% developing PDC within 30-d after esophagectomy. Patients who experienced complications post-discharge had a median initial hospital length of stay (LOS) of 9 d; however, PDC occurred on average 14 d following surgery. Patients with PDC had greater rates of wound infection (41.0% vs 19.3%, P < 0.001), venous thromboembolism (16.3% vs 8.9%, P < 0.001), and organ space surgical site infection (17.1% vs 11.0%, P = 0.001) than patients with pre-discharge complication. The readmission rate in our entire population was 12.8%. PDC patients were overwhelmingly more likely to have a reoperation (39.5% vs 22.4%, P < 0.001) and readmission (66.9% vs 6.6%, P < 0.001). BMI 25-29.9 and BMI ≥ 30 were associated with increased risk of PDC compared to normal BMI (18.5-25).
CONCLUSION: PDC after esophagectomy account for significant number of reoperations and readmissions. Efforts should be directed towards optimizing patient’s health pre-discharge, with possible prevention programs at discharge.
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Njei B, McCarty TR, Birk JW. Trends in esophageal cancer survival in United States adults from 1973 to 2009: A SEER database analysis. J Gastroenterol Hepatol 2016; 31:1141-6. [PMID: 26749521 PMCID: PMC4885788 DOI: 10.1111/jgh.13289] [Citation(s) in RCA: 255] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 12/07/2015] [Accepted: 12/21/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND AIM The rise in incidence of esophageal cancer (EC) in the USA over the last four decades has been well documented; however, data on trends in long-term survival and impact on modern therapies associated with survival are lacking. METHODS The Surveillance, Epidemiology, and End Results database was queried to identify patients with confirmed EC. Cox proportional hazard regression was used to determine independent mortality factors. RESULTS Of 93 167 patients diagnosed with EC between 1973 and 2009, 49% had a histologic diagnosis of esophageal adenocarcinoma (EAC). There was an increase (almost double) in the proportion of patients with adenocarcinoma from the 1970s to 2000s (n = 2,350; 35% to n = 32,212; 61%, P < 0.001). Surgery was performed for localized disease in a majority of EC regardless of type (n = 46 683; 89%). Use of surgical treatment increased significantly over the study period (49% to 64%, P < 0.001). There was also an increase in overall median survival (6 months versus 10 months, P < 0.001) and 5-year survival rate (9% to 22%, P < 0.001). Median survival increased consistently for EAC and squamous cell carcinoma (SCC) until the 1990s. After this period, median survival of EAC continued to increase more rapidly while SCC remained relatively stable. CONCLUSION A significant survival improvement in esophageal cancer was seen from 1973 to 2009, largely because of earlier detection at a curative stage and greater utilization of treatment modalities (especially surgery). Despite the rising prevalence, patients with EAC have better long-term survival outcomes than those SCC.
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Affiliation(s)
- Basile Njei
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA,Investigative Medicine Program, Yale Center of Clinical Investigation, New Haven, CT, USA
| | - Thomas R. McCarty
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA
| | - John W. Birk
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Connecticut, Farmington, CT, USA
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Parise P, Elmore U, Fumagalli U, De Manzoni G, Giacopuzzi S, Rosati R. Esophageal surgery in Italy. Criteria to identify the hospital units and the tertiary referral centers entitled to perform it. Updates Surg 2016; 68:129-33. [DOI: 10.1007/s13304-016-0374-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/18/2016] [Indexed: 12/20/2022]
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Samples JE, Snavely AC, Meyers MO. Postoperative Morbidity in Curative Resection of Gastroesophageal Carcinoma Does Not Impact Long-term Survival. Am Surg 2015; 81:1228-1231. [PMID: 26736158 DOI: 10.1177/000313481508101222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
Abstract
Significant morbidity and mortality have historically been reported for surgical resection of gastric and gastroesophageal junction tumors. We evaluated our experience to determine morbidity and mortality and evaluated demographic and pathologic risk factors associated with postoperative outcome and long-term survival. A retrospective, Institutional Review Board-approved, single-institution database identified 102 patients who underwent resection with curative intent for gastroesophageal junction or gastric carcinoma from 2004 to 2012. The method of Kaplan and Meier was used to describe overall survival and estimate median survival. Of 102 patients, 74 were male and 28 were female. Of these, 24 patients were > 70 years of age at surgery (median = 62.9). Forty esophagectomies, 25 total gastrectomies, and 37 subtotal gastrectomies were performed. Two patients died (one esophagectomy and one gastrectomy). Forty-one developed a complication: 17 minor and 35 major, including six anastomotic leaks. Patients with low preoperative albumin (P = 0.01) and increased age (P = 0.05) were associated with having a postoperative complication; extent of nodal dissection (P = 0.48), jejunostomy (0.24), performance status (P = 0.77), type of surgery (P = 0.74), and neoadjuvant therapy (P = 0.24) were not associated. More extensive nodal dissection was associated with a decreased risk of death (P = 0.007). Having any complication (P = 0.20), an anastomotic leak (P = 0.17), worse grade of complication (P = 0.15), presence of feeding jejunostomy tube (P = 0.17), and neoadjuvant therapy (P = 0.30) were not associated with changes in overall survival. Thorough lymph node dissection improves survival without increasing postoperative morbidity. The data advocate for increased lymph node yield and close attention to nutritional support in gastroesophageal carcinoma patients.
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Affiliation(s)
- Jennifer E Samples
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Johnston MJ, Singh P, Pucher PH, Fitzgerald JEF, Aggarwal R, Arora S, Darzi A. Systematic review with meta-analysis of the impact of surgical fellowship training on patient outcomes. Br J Surg 2015; 102:1156-66. [DOI: 10.1002/bjs.9860] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/12/2015] [Accepted: 04/20/2015] [Indexed: 12/11/2022]
Abstract
Abstract
Background
The number of surgeons entering fellowship training before independent practice is increasing. This may have a negative impact on surgeons in training. The impact of fellowship training on patient outcomes is not yet known. This review aimed to investigate the impact of fellowship training in surgery on patient outcomes.
Methods
A systematic review of the literature was conducted to identify studies exploring the structural and surgeon-specific characteristics of fellowship training on patient outcomes. Data from these studies were extracted, synthesized and reported qualitatively, or quantitatively through meta-analysis.
Results
Twenty-three studies were included. The mortality rate for patients in centres with an affiliated fellowship programme was lower than that for centres without (odds ratio 0·86, 95 per cent c.i. 0·84 to 0·88), as was the rate of complications (odds ratio 0·90, 0·78 to 1·02). Surgeons without fellowship training converted more laparoscopic operations to open surgery than those with fellowship training (risk ratio (RR) 1·04, 95 per cent c.i. 1·03 to 1·05). Comparison of outcomes for senior surgeons versus current fellows showed no differences in rates of mortality (RR 1·00, 1·00 to 1·01), complications (RR 1·03, 0·98 to 1·08) or conversion to open surgery (RR 1·01, 1·00 to 1·01).
Conclusion
Fellowship training appears to have a positive impact on patient outcomes.
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Affiliation(s)
- M J Johnston
- Patient Safety Translational Research Centre, Department of Surgery and Cancer, London, UK
| | - P Singh
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - P H Pucher
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - J E F Fitzgerald
- Department of General Surgery, Royal Free London, Barnet Hospital Campus, London, UK
| | - R Aggarwal
- Department of Surgery, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - S Arora
- Patient Safety Translational Research Centre, Department of Surgery and Cancer, London, UK
| | - A Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
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Arlow RL, Moore DF, Chen C, Langenfeld J, August DA. Outcome-volume relationships and transhiatal esophagectomy: minimizing "failure to rescue". ANNALS OF SURGICAL INNOVATION AND RESEARCH 2014; 8:9. [PMID: 25550708 PMCID: PMC4279687 DOI: 10.1186/s13022-014-0009-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 12/02/2014] [Indexed: 11/23/2022]
Abstract
Background The objective of this study is to describe the system and technical factors that enabled our moderate size transhiatal esophagectomy program to achieve low mortality rates. Methods A retrospective chart review was conducted on 200 consecutive patients who underwent transhiatal esophagectomy at Robert Wood Johnson University Hospital. Primary outcomes included operative times, estimated blood loss, frequency and nature of complications, and lengths of stay in the hospital and the intensive care unit. Results In general, surgical outcomes tended to improve over the course of this study. We identified decreased operative time, intra-operative blood loss, frequency of complications, and lengths of intensive care unit and hospital stay as the program matured. Through coordinated actions of the surgical and anesthesia teams, all intraoperative injuries were responded to in an effective, emergent fashion and all but one patient was saved. This resulted in an inhospital and 30-day mortality rate of only 0.5%. Conclusions Our study suggests that a dual attending approach, focus on avoiding “failure to rescue”, increased volume, and a surgeon driven commitment to quality improvement may lead to low mortality rates after transhiatal esophagectomy.
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Affiliation(s)
- Renee L Arlow
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, New Jersey 08903-2601 USA
| | - Dirk F Moore
- Department of Biostatistics, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, New Jersey 08903-2601 USA
| | - Chunxia Chen
- Department of Biostatistics, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, New Jersey 08903-2601 USA
| | - John Langenfeld
- Department of Surgery, Section of Thoracic Surgery, Rutgers Robert Wood Johnson Medical School and The Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, New Jersey 08903-2601 USA
| | - David A August
- Department of Surgery, Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, 195 Little Albany Street, New Brunswick, New Jersey 08903-2601 USA
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Fernandez FG, Khullar O, Force SD, Jiang R, Pickens A, Howard D, Ward K, Gillespie T. Hospital readmission is associated with poor survival after esophagectomy for esophageal cancer. Ann Thorac Surg 2014; 99:292-7. [PMID: 25442987 DOI: 10.1016/j.athoracsur.2014.07.052] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 07/16/2014] [Accepted: 07/21/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hospital readmissions are costly and associated with inferior patient outcomes. There is limited knowledge related to readmissions after esophagectomy for malignancy. Our aim was to determine the impact on survival of readmission after esophagectomy. METHODS This cohort study utilizes Surveillance, Epidemiology, and End Results-Medicare data (2002 to 2009). Survival, length of stay, 30-day readmissions, and discharge disposition were determined. Multivariate logistic regression models were created to examine risk factors associated with readmission. RESULTS In all, 1,744 patients with esophageal cancer underwent esophagectomy: 80% of patients (1,390) were male, and mean age was 73 years; 71.8% of tumors (1,251) were adenocarcinomas, and 72.5% (1,265) were distal esophageal tumors; 38% of patients (667) received induction therapy. Operative approach was transthoracic in 52.6% of patients (918) and transhiatal in 37.4% (653), and required complex reconstruction (intestinal interposition) in 9.9% (173). Stage distribution was as follows: stage I, 35.3% (616); stage II, 32.5% (566); stage III, 27.9% (487); and stage IV, 2.3% (40). Median length of stay was 13 days, hospital mortality was 9.3% (158 patients), and 30-day readmission rate was 18.6% (212 of 1,139 home discharges); 25.4% of patients (443) were discharged to institutional care facilities. Overall survival was significantly worse for patients who were readmitted (p < 0.0001, log rank test). Risk factors for readmission were comorbidity score of 3+, urgent admission, and urban residence. CONCLUSIONS Hospital readmissions after esophagectomy for cancer occur frequently and are associated with worse survival. Improved identification of patients at risk for readmission after esophagectomy can inform patient selection, discharge planning, and outpatient monitoring. Optimization of such practices may lead to improved outcomes at reduced cost.
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Affiliation(s)
- Felix G Fernandez
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
| | - Onkar Khullar
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Seth D Force
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Renjian Jiang
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Allan Pickens
- Section of General Thoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - David Howard
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Kevin Ward
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Theresa Gillespie
- Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
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Markar SR, Schmidt H, Kunz S, Bodnar A, Hubka M, Low DE. Evolution of standardized clinical pathways: refining multidisciplinary care and process to improve outcomes of the surgical treatment of esophageal cancer. J Gastrointest Surg 2014; 18:1238-46. [PMID: 24777435 DOI: 10.1007/s11605-014-2520-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Accepted: 03/31/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience. STUDY DESIGN All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991-1996, Gp2 1997-2002, Gp3 2003-2007, and Gp4 2008-2012). RESULTS Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5-50) to 8 (5-115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively. CONCLUSIONS The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.
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Affiliation(s)
- Sheraz R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, 1100 Ninth Ave, Seattle, WA, 98111, USA
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Benedix F, Dalicho S, Stübs P, Schubert D, Bruns C. Evidenzlage zur minimalinvasiven Chirurgie beim Ösophaguskarzinom. Chirurg 2014; 85:668-74. [DOI: 10.1007/s00104-014-2754-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Smith RC, Creighton N, Lord RV, Merrett ND, Keogh GW, Liauw WS, Currow DC. Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001-2008. Med J Aust 2014; 200:408-413. [PMID: 24794674 DOI: 10.5694/mja13.11182] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 02/24/2014] [Indexed: 09/18/2023]
Abstract
OBJECTIVES To examine the relationship between hospital volume and patient outcomes for New South Wales hospitals performing oesophagectomy and gastrectomy for oesophagogastric cancer. DESIGN, SETTING AND PATIENTS A retrospective, population-based cohort study of NSW residents diagnosed with a new case of invasive oesophageal or gastric cancer who underwent oesophagectomy or gastrectomy between 2001 and 2008 in NSW hospitals using linked de-identified data from the NSW Central Cancer Registry, the National Death Index and the NSW Admitted Patient Data Collection. A higher-volume hospital was defined as one performing > 6 relevant procedures per year. MAIN OUTCOME MEASURES Odds ratios for > 21-day length of stay, 28-day unplanned readmission, 30-day mortality and 90-day mortality, and hazard ratios (HRs) for 5-year absolute and conditional survival. RESULTS Oesophagectomy (908 patients) and gastrectomy (1621 patients) were undertaken in 42 and 84 hospitals, respectively, between 2001 and 2008. Median annual hospital volume ranged from 2 to 4 for oesophagectomies and ranged from 2 to 3 for gastrectomies. Controlling for known confounders, no associations between hospital volume and > 21-day length of stay and 28-day unplanned readmission were found. Overall 30-day mortality was 4.1% and 4.4% for oesophagectomy and gastrectomy, respectively. Five-year absolute survival was significantly better for patients who underwent oesophagectomy in higher-volume hospitals (adjusted HR for lower-volume hospitals, 1.28 [95% CI, 1.10-1.49]; P = 0.002) and for those with localised gastric cancer who underwent gastrectomy in higher-volume hospitals (adjusted HR for lower-volume hospitals, 1.83 [95% CI, 1.28-2.61]; P = 0.001). CONCLUSIONS These data support initial surgery for oesophagogastric cancer in higher-volume hospitals.
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Affiliation(s)
- Ross C Smith
- Northern Clinical School, University of Sydney, Sydney, NSW, Australia.
| | | | - Reginald V Lord
- School of Medicine, University of Notre Dame Australia, Sydney, NSW, Australia
| | - Neil D Merrett
- School of Medicine, University of Western Sydney, Sydney, NSW, Australia
| | | | - Winston S Liauw
- Cancer Care Centre, St George Hospital, Sydney, NSW, Australia
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Update on clinical impact, documentation, and management of complications associated with esophagectomy. Thorac Surg Clin 2013; 23:535-50. [PMID: 24199703 DOI: 10.1016/j.thorsurg.2013.07.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The assessment and monitoring of complications associated with esophageal resection suffers from the absence of an internationally recognized system for documenting the incidence and severity of complications. The impact of complications is significant, with direct effects being identified on mortality, length of stay, postoperative quality of life, and long-term survival. Newer systems of assessing surgical complication severity and the resources required to treat complications include the Accordion and Clavien grading systems. New endoscopic and interventional approaches to treating anastomotic leak and stricture and chyle leak can selectively decrease length of stay and costs of managing complications.
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Bronson NW, Luna RA, Hunter JG. Tailoring esophageal cancer surgery. Semin Thorac Cardiovasc Surg 2013; 24:275-87. [PMID: 23465676 DOI: 10.1053/j.semtcvs.2012.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2012] [Indexed: 12/15/2022]
Abstract
Esophageal cancer is a significant source of major mortality worldwide and is increasing dramatically in incidence. Without treatment this disease leads rapidly to death, but intervention also carries significant risk, so a carefully tailored approach must be used to maximize oncological efficacy while minimizing the negative consequences of intervention. Careful patient selection based on histologic and anatomic staging, consideration of each patient's clinical variables, appropriately timing chemo- and radiation therapy, and minimizing the morbidity of surgical intervention may significantly improve a patient's chances of surviving this disease, but each must be carefully orchestrated with a tailored approach to treatment. This review will serve as a guide to tailoring surgery for esophageal cancer.
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Affiliation(s)
- Nathan W Bronson
- Department of Surgery, Oregon Health & Science University, Portland, Oregon 97239, USA
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Dolan JP, Kaur T, Diggs BS, Luna RA, Schipper PH, Tieu BH, Sheppard BC, Hunter JG. Impact of comorbidity on outcomes and overall survival after open and minimally invasive esophagectomy for locally advanced esophageal cancer. Surg Endosc 2013; 27:4094-103. [PMID: 23846365 PMCID: PMC7102391 DOI: 10.1007/s00464-013-3066-5] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 06/06/2013] [Indexed: 01/10/2023]
Abstract
Background The aim of this study was to examine the impact of the Charlson Comorbidity Index-Grade (CCI-G) on predicting outcomes and overall survival after open and minimally invasive esophagectomy (MIE). Methods One hundred and forty-six patients who underwent esophagectomy between 1995 and 2011 for stage II and III cancer were selected and separated into open esophagectomy (Open) and MIE groups. Risk adjustment was performed using the CCI-G. The outcomes of interest were operative time, estimated blood loss (EBL), lymph node harvest, length of hospital stay (LOS), major complications, 30-day mortality, and overall survival. Results Sixty-four patients (44 %) underwent Open while 71 (49 %) had MIE. An additional (7 %) were converted and classified with MIE. There was no significant difference between MIE and Open in terms of operative time. MIE had less EBL (mean difference = 234 mL, p < 0.001), higher lymph node harvest (mean = 7.4 nodes, p < 0.001), and shorter LOS (median = 1.5 days, p = 0.02). Atrial arrhythmias were the most frequent complication, occurring in 33 % of patients in both the MIE and the Open group (p = 0.988). Thirty-day mortality was 2 % for MIE and 5 % for Open (p = 0.459). Five-year survival was 41 % for MIE and 33 % for Open (p = 0.513). Operative approach, age, gender, BMI, clinical stage, and neoadjuvant therapy did not have any significant effect on the outcomes or overall survival. CCI-G influenced outcomes with operative time, LOS, cardiovascular complication, and anastomotic leak rate, favoring CCI-G 0 compared to CCI-G 3. Overall survival was worse for CCI-G 1 in comparison with CCI-G 0 [hazard ratio (HR) 1.99, p = 0.027]. Conclusions MIE is a safe alternative to open esophagectomy for the treatment of locally advanced esophageal cancer. The presence of comorbidities increased operative time, length of hospital stay, and postoperative complications while worsening overall survival.
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Affiliation(s)
- James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, and the Digestive Health Center, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L223A, Portland, OR, 97239, USA,
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Abstract
Esophageal resection remains the primary treatment for local regional esophageal cancer, although its role in superficial (T1A) cancers and squamous cell cancer is in evolution. Mortality associated with esophagectomy has historically been high but is improving with the current expectation of in-hospital mortality rates of 2-4% in high-volume centers. Most patients with regional cancers (T2-4 N0-3) are recommended for neoadjuvant therapy, which most commonly involves radiochemotherapy. Some centers have proposed treating with definitive chemoradiation and reserving surgery for patients who have persistent or recurrent disease. 'Salvage resections' are possible but are associated with higher levels of perioperative morbidity and mortality, and treatment decisions should routinely be based on multidisciplinary discussion in the tumor board. Although open surgical resection (both transthoracic and transhiatal operations) remain the most common approach, minimally invasive or hybrid operations are being done in up to 30% of procedures internationally. There are some indications that minimally invasive esophagectomy may decrease the incidence of respiratory complications and decrease length of stay. At this point, oncologic outcomes appear equivalent between open and minimally invasive procedures. Recent reviews from high-volume esophagectomy centers demonstrate that elderly patients can selectively undergo esophagectomy with the expectation of increased complications but similar mortality and survival to younger patients. Multiple studies confirm that quality of life following esophagectomy can be equivalent to the general population when surgery is done in experienced centers. Patients requiring surgical treatment of esophageal cancer should be referred to high-volume centers, especially those with established care pathways or enhanced recovery programs to improve outcomes including morbidity, mortality, survival, and quality of life.
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Affiliation(s)
- Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA 98111, USA.
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Markar SR, Karthikesalingam A, Thrumurthy S, Ho A, Muallem G, Low DE. Systematic review and pooled analysis assessing the association between elderly age and outcome following surgical resection of esophageal malignancy. Dis Esophagus 2013; 26:250-62. [PMID: 22591068 DOI: 10.1111/j.1442-2050.2012.01353.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The incidence of esophageal malignancy continues to increase worldwide. At the same time, average life expectancy levels continue to climb, ensuring that more patients will present in their 70s, 80s, and 90s. The aim of this pooled analysis is to compare short- and long-term outcomes for elderly and younger patients undergoing esophagectomy for malignancy. Studies comparing the outcomes of esophagectomy for malignancy in elderly and young cohorts of patients were included. The minimum threshold age used to define the elderly cohort was 70 years. Primary outcomes were in-hospital mortality, overall and cancer-related 5-year survival. Secondary outcomes were the length of hospital stay, the incidence of anastomotic leak, conduit ischemia, cardiac and pulmonary complications, and the use of neoadjuvant therapy. Twenty-five publications comprising 9531 and 2573 operations on younger and elderly cohorts of patients respectively were analyzed. Elderly patients were less likely to receive neoadjuvant therapy (14.6% vs. 29.47%; pooled odds ratio [POR]= 0.48; 95% confidence interval [C.I.]= 0.35-0.65; P < 0.05). Esophagectomy in elderly patients was associated with increased in-hospital mortality (7.83% vs. 4.21%; POR = 1.87; 95% C.I. = 1.54-2.26; P < 0.05), as well as increased pulmonary (21.77% vs. 19.49%) and cardiac (18.7% vs. 13.17%) complications. Subset analysis of studies using an age threshold of 80 years showed an even more significant association between in-hospital mortality and elderly age (pooled odds ratio = 3.19; 95% C.I. = 1.6-6.35; P < 0.05). There were no significant differences between the groups in length of hospital stay, incidence of anastomotic leak, or conduit ischemia. The elderly group showed reduced overall 5-year survival (21.23% vs. 29.01%; pooled odds ratio = 0.73; 95% C.I. = 0.62-0.87; P < 0.05) and reduced cancer-free 5-year survival (34.4% vs. 41.8%; POR = 0.75; 95% C.I. = 0.64-0.89; P < 0.05). Elderly patients are at increased risk of pulmonary and cardiac complications, and perioperative mortality following esophagectomy, and show reduced cancer-related 5-year survival compared with younger patients. These patients represent a high-risk cohort, who requires thorough assessment of medical comorbidity, targeted counseling, and optimized treatment pathways.
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Affiliation(s)
- S R Markar
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, WA 98111, USA
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Abstract
This article reviews the current management of esophageal cancer, including staging and treatment options, as well as providing support for using multidisciplinary teams to better manage esophageal cancer patients.
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Abstract
Several well described and accepted traditional techniques exist for the performance of an open esophagectomy. The rationale for selecting one of these techniques is determined by the location and histology of the disease being treated and surgeon and institutional preferences. Large retrospective studies and a limited number of prospective studies have comparatively evaluated the operative and long-term oncologic outcomes of transthoracic versus transhiatal surgical approaches, which indicate trends toward higher perioperative complications but improved long-term outcomes among patients treated with a transthoracic approach. Other retrospective studies investigated the extent of a thoracic lympadenectomy that is necessary at the time of an esophagectomy to optimize survival.
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Affiliation(s)
- Brendon M Stiles
- Cardiothoracic Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY 10024, USA.
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40
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LaPar DJ, Stukenborg GJ, Lau CL, Jones DR, Kozower BD. Differences in reported esophageal cancer resection outcomes between national clinical and administrative databases. J Thorac Cardiovasc Surg 2012; 144:1152-7. [DOI: 10.1016/j.jtcvs.2012.08.010] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/24/2012] [Accepted: 08/01/2012] [Indexed: 12/22/2022]
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van der Leeuw RM, Lombarts KMJMH, Arah OA, Heineman MJ. A systematic review of the effects of residency training on patient outcomes. BMC Med 2012; 10:65. [PMID: 22742521 PMCID: PMC3391170 DOI: 10.1186/1741-7015-10-65] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 06/28/2012] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Residents are vital to the clinical workforce of today and tomorrow. Although in training to become specialists, they also provide much of the daily patient care. Residency training aims to prepare residents to provide a high quality of care. It is essential to assess the patient outcome aspects of residency training, to evaluate the effect or impact of global investments made in training programs. Therefore, we conducted a systematic review to evaluate the effects of relevant aspects of residency training on patient outcomes. METHODS The literature was searched from December 2004 to February 2011 using MEDLINE, Cochrane, Embase and the Education Resources Information Center databases with terms related to residency training and (post) graduate medical education and patient outcomes, including mortality, morbidity, complications, length of stay and patient satisfaction. Included studies evaluated the impact of residency training on patient outcomes. RESULTS Ninety-seven articles were included from 182 full-text articles of the initial 2,001 hits. All studies were of average or good quality and the majority had an observational study design. Ninety-six studies provided insight into the effect of 'the level of experience of residents' on patient outcomes during residency training. Within these studies, the start of the academic year was not without risk (five out of 19 studies), but individual progression of residents (seven studies) as well as progression through residency training (nine out of 10 studies) had a positive effect on patient outcomes. Compared with faculty, residents' care resulted mostly in similar patient outcomes when dedicated supervision and additional operation time were arranged for (34 out of 43 studies). After new, modified or improved training programs, patient outcomes remained unchanged or improved (16 out of 17 studies). Only one study focused on physicians' prior training site when assessing the quality of patient care. In this study, training programs were ranked by complication rates of their graduates, thus linking patient outcomes back to where physicians were trained. CONCLUSIONS The majority of studies included in this systematic review drew attention to the fact that patient care appears safe and of equal quality when delivered by residents. A minority of results pointed to some negative patient outcomes from the involvement of residents. Adequate supervision, room for extra operation time, and evaluation of and attention to the individual competence of residents throughout residency training could positively serve patient outcomes. Limited evidence is available on the effect of residency training on later practice. Both qualitative and quantitative research designs are needed to clarify which aspects of residency training best prepare doctors to deliver high quality care.
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Affiliation(s)
- Renée M van der Leeuw
- Professional Performance Research Group, Department of Quality Management and Process Innovation, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
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Early outcomes of surgery for oesophageal cancer in a thoracic regional unit. Can we maintain training without compromising results? Eur J Cardiothorac Surg 2012; 41:31-4; discussion 34-5. [PMID: 21622004 DOI: 10.1016/j.ejcts.2011.04.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Meaningful exposure to oesophageal cancer surgery during general thoracic surgical training is restricted to few centres in the United Kingdom. Our Regional Tertiary Unit remains a rare 'large-volume' oesophagectomy centre. We aimed to determine the proportion of patients operated by trainees and their perioperative outcomes. METHODS From January 2004 to September 2009, 323 patients (229 male and 94 female, median age of 69 (range 40-92) years) underwent oesophagectomy for carcinoma in our Thoracic Surgical Unit. Data were complete and obtained from a prospective departmental database. The preoperative characteristics, operative data and postoperative results were compared between the 120 patients (37%) operated by a trainee (group T) and the remainder 203 patients operated by a consultant (group C). RESULTS The overall incidence of mortality, anastomotic leak and chylothorax were 6.5%, 5.3% and 2.2%, respectively. There were no differences in terms of age, gender, tumour location, tumour staging, preoperative spirometry or use of neoadjuvant chemotherapy between the two groups. There was no significant difference between the consultant group and the trainee group in the following key outcome measures: postoperative mortality (8% vs 4%), incidence of respiratory complications (30% vs 25%), hospital stay (14 days vs 13 days) and number of lymph nodes excised (median of 16 vs 14). CONCLUSIONS Training in oesophageal cancer surgery can be provided in a large-volume thoracic surgical unit. It does not seem to compromise outcomes or use of resources.
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Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg 2012; 16:1055-63. [PMID: 22089950 DOI: 10.1007/s11605-011-1731-3] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2011] [Accepted: 10/05/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The aim of this study is to provide a contemporary quantitative analysis of the existing literature examining the relationship between surgical caseload and outcome following esophageal resection. METHODS Medline, Embase, trial registries, conference proceedings and reference lists were searched for trials comparing clinical outcome following esophagectomy from high- and low-volume hospitals since 2000. Primary outcomes were in-hospital and 30-day mortality. Secondary outcomes were length of hospital stay and post-operative complications. RESULTS Nine appropriate publications comprising 27,843 esophagectomy operations were included, 12,130 and 15,713 operations were performed in low- and high-volume surgical units, respectively. Esophagectomy at low-volume hospitals was associated with a significant increase in incidence of in-hospital (8.48% vs. 2.82%; pooled odds ratio (POR) = 0.29; P < 0.0001) and 30-day mortality (2.09% vs. 0.73%; POR = 0.31; P < 0.0001). There was insufficient data for conclusive statistical analysis of length of hospital stay or post-operative complications. CONCLUSIONS This meta-analysis does suggest a benefit in the centralization of esophageal cancer surgery to high-volume institutions with respect to mortality. The outcomes of this study are of interest to patients, healthcare providers and payers, particularly regarding service reconfiguration and more specifically centralization of services. Future studies that look at long-term survival will help improve understanding of any late consequences such as survival and quality of life following esophageal surgery at low- and high-volume hospitals.
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Affiliation(s)
- Sheraz R Markar
- Department of Thoraco-esophageal Surgery, Virginia Mason Medical Center, Seattle, WA, USA.
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Hospital Esophageal Cancer Resection Volume Does Not Predict Patient Mortality Risk. Ann Thorac Surg 2012; 93:1690-6; discussion 1696-8. [DOI: 10.1016/j.athoracsur.2012.01.111] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2011] [Revised: 01/23/2012] [Accepted: 01/31/2012] [Indexed: 01/08/2023]
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Semel ME, Lipsitz SR, Funk LM, Bader AM, Weiser TG, Gawande AA. Rates and patterns of death after surgery in the United States, 1996 and 2006. Surgery 2012; 151:171-82. [DOI: 10.1016/j.surg.2011.07.021] [Citation(s) in RCA: 113] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2010] [Accepted: 07/07/2011] [Indexed: 01/01/2023]
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Cen P, Banki F, Cheng L, Khalil K, Du XL, Fallon M, Amato RJ, Kaiser LR. Changes in age, stage distribution, and survival of patients with esophageal adenocarcinoma over three decades in the United States. Ann Surg Oncol 2011; 19:1685-91. [PMID: 22130619 DOI: 10.1245/s10434-011-2141-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Our aim was to evaluate the changes in age, stage distribution, and overall survival (OS) of patients with esophageal adenocarcinoma (EAC) over time. METHODS Patients from the Surveillance, Epidemiology, and End Results (SEER) database aged ≥ 20 with invasive EAC, diagnosed from 1973-2003 were reviewed. Survival follow-up ended in 2006. RESULTS There were 11,620 patients; 6580 (57%) aged ≥ 65. The stage distribution was 22%, 35%, and 43% for localized, regional, and distant metastasis for patients aged <65, and 33%, 33%, and 34% for patients aged ≥ 65. The number of patients ≥ 65 years with localized stage increased over time. Three-year OS for localized, regional, and distant disease increased from 19%, 10%, and 1% in 1973-1976, to 34%, 13%, and 2% in 1987-1991, and to 45%, 25%, and 4% in 2002-2003 (P < 0.001). A sub-analysis of 5475 patients from 1988-2002 showed better survival for patients with esophagectomy for all stages. Three-year OS for 2074 patients with esophagectomy improved every 5 years from 1988-2002 (39%, 43% to 54%, P < 0.001). Stratified by stage, year and esophagectomy status, patients aged <65 had better survival compared to patients aged ≥ 65 (P < 0.001). CONCLUSIONS There has been a substantial improvement in overall survival among patients with invasive EAC over the last 3 decades. Patients receiving esophagectomy had longer survival. Survival with esophagectomy improved in each time period. Although younger EAC patients were diagnosed at more advanced stages over time, they had better survival.
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Affiliation(s)
- Putao Cen
- Division of Oncology, Department of Internal Medicine, The University of Texas Medical School at Houston, Houston, TX, USA.
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Hanna EM, Norton HJ, Reames MK, Salo JC. Minimally invasive esophagectomy in the community hospital setting. Surg Oncol Clin N Am 2011; 20:521-30, ix. [PMID: 21640919 DOI: 10.1016/j.soc.2011.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We report our initial experience with minimally-invasive esophagectomy in 32 patients at Carolinas Medical Center, a community academic medical center. Indications for surgery were adenocarcinoma in 27, squamous cell carcinoma in 3, and benign stricture in 2. Transthoracic Ivor-Lewis esophagectomy with laparoscopy and thoracoscopy was performed in 28, a 3-stage esophagectomy in 3, and transhaital esophagectomy in 1. There was no operative mortality and median hospital stay was 10.5 days for patients treated with minimally invasive esophagectomy. This compares with an operative mortality of 8.9% and median hospital stay of 17 days for open esophagectomy in our institution.
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Affiliation(s)
- Erin M Hanna
- Department of General Surgery, Carolinas Medical Center, 1000 Blythe Boulevard, PO Box 32861, Charlotte, NC 28232-2861, USA
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Low DE. Open versus minimally invasive esophagectomy: what is the best approach? Frame the issue. J Gastrointest Surg 2011; 15:1497-9. [PMID: 21590458 DOI: 10.1007/s11605-011-1559-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Accepted: 05/02/2011] [Indexed: 01/31/2023]
Abstract
Surgical resection continues to be the gold standard treatment approach for early invasive and locoregional esophageal cancer. Esophagectomy has historically had a reputation as a complex operation with high mortality and morbidity. Increasingly, results from high-volume specialized centers have demonstrated that mortality rates of below 4% should be expected and that patients can potentially demonstrate excellent levels of quality of life following surgical resection. Up until recently, virtually all surgical resections were done utilizing an open approach utilizing either a transthoracic or a transhiatal operation. Over the past several years, however, a variety of fully minimally invasive or hybrid procedures have been advocated with a view of improving mortality and morbidity outcomes. In the absence of either randomized or controlled prospective comparisons, this series of papers will review current perceptions of the advantages of both minimally invasive and open surgery for the treatment of esophageal cancer.
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Affiliation(s)
- Donald E Low
- Department of Thoracic Surgery and Thoracic Oncology, Virginia Mason Medical Center, Seattle, WA 98101, USA.
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Abstract
"Open" esophagectomy has been the standard of care for treatment of esophageal carcinoma against which evolving minimally invasive surgical, endoscopic, and non-operative therapies must be compared. In experienced hands and with appropriate patient selection, "open" esophagectomy can achieve good rates of cure with low mortality, acceptable morbidity, and good long-term quality of life.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
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Ferguson MK, Celauro AD, Prachand V. Assessment of a scoring system for predicting complications after esophagectomy. Dis Esophagus 2011; 24:510-5. [PMID: 21418123 DOI: 10.1111/j.1442-2050.2011.01185.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Complications occur frequently after esophagectomy. Identifying the risk of complications preoperatively may help in patient selection and postoperative management. We performed a retrospective review of patients who underwent esophagectomy between 1980 and 2009. A previously reported scoring system was used to estimate risk, and its ability to predict complications was assessed. A total of 514 patients (382 men; 74%) with a mean age of 59.0 ± 12.5 years underwent esophagectomy for cancer (398; 77%) or benign disease. Minor complications occurred in 224 patients (44%) and severe complications occurred in 134 patients (26%). The calculated risk score was based on weighted values for age, coronary artery disease, cerebrovascular disease, type of operation, and forced expiratory volume in the first second expressed as a percent of predicted (FEV1%). Increasing risk score was associated with a linear increase in the incidence of complications (P < 0.001 for either severe complications or any complications). The scoring system predicted severe complications with an accuracy of 65.3% (P < 0.001). Score groups identified an incremental risk of severe complications (0 to 6 = 12%; 7 to 13 = 18%; 14 to 20 = 28%; 21 to 27 = 36%; >27 = 52%; P < 0.001). Complications are frequent after esophagectomy and can be predicted using a previously reported scoring system. This scoring system may assist in patient selection for esophagectomy and in providing appropriate resources for postoperative management of higher risk patients.
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Affiliation(s)
- M K Ferguson
- Department of Surgery, The University of Chicago, Chicago, Illinois 60637, USA.
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