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- Title
Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes.
- Authors
Ketel, Mirte H. M.; Klarenbeek, Bastiaan R.; Abma, Inger; Belgers, Eric H. J.; Coene, Peter-Paul L. O.; Dekker, Jan Willem T.; van Duijvendijk, Peter; Emous, Marloes; Gisbertz, Suzanne S.; Haveman, Jan Willem; Heisterkamp, Joos; Nieuwenhuijzen, Grard A. P.; Ruurda, Jelle P.; van Sandick, Johanna W.; van der Sluis, Pieter C.; van Det, Marc J.; van Esser, Stijn; Law, Simon; de Steur, Wobbe O.; Sosef, Meindert N.
- Abstract
Key Points: Question: What is the association between surgical performance of minimally invasive esophagectomy (MIE) and patient outcomes? Findings: In this cohort study, surgical performance across all 15 Dutch hospitals performing MIE was associated with intraoperative and severe postoperative complications; conversion occurred less frequently in the highest compared with the lowest performance hospital quartile, and better anastomosis creation performance resulted in decreased anastomotic leakage. Meaning: These findings suggest that better patient outcomes on a national level may be achievable by improving surgical performance of MIE, likely with MIE competency assessment tool implementation. This cohort study investigates the association between surgical performance and postoperative outcomes after minimally invasive esophagectomy in Dutch hospitals. Importance: Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes. Objective: To investigate associations between surgical performance and postoperative outcomes after MIE. Design, Setting, and Participants: In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes. Exposure: Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction. Main Outcome and Measure: The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes. Results: In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31). Conclusions and Relevance: These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.
- Subjects
NETHERLANDS; ESOPHAGEAL surgery; PEARSON correlation (Statistics); RESEARCH funding; MULTIPLE regression analysis; MINIMALLY invasive procedures; TREATMENT effectiveness; DESCRIPTIVE statistics; DIGESTIVE organ surgery; LONGITUDINAL method; SURGICAL complications; INTRACLASS correlation; NATIONAL competency-based educational tests; CONFIDENCE intervals; LENGTH of stay in hospitals; DATA analysis software; VIDEO recording
- Publication
JAMA Network Open, 2024, Vol 7, Issue 4, pe246556
- ISSN
2574-3805
- Publication type
Article
- DOI
10.1001/jamanetworkopen.2024.6556