[Minimum case volume regulations in surgery from the perspective of the specialist society (DGCH) : Balancing act between science, politics, treatment reality and a range of other aspects]

Determination of Minimum Surgical Caseloads for Major Oncologic Resections Using a Population-Attributable Fraction Model of Observational Data in Germany

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.

Caseload per Year in Robotic-Assisted Minimally Invasive Esophagectomy: A Narrative Review

Esophageal surgery is deemed one of the most complex visceral operations. There is a well-documented correlation between higher caseload and better outcomes, with hospitals that perform more surgeries experiencing significantly lower mortality rates. The approach to caseload per year varies across different countries within Europe. Germany increased the minimum annual required caseload of complex esophageal surgeries from 10 to 26 starting in 2023. Furthermore, the new regulations present challenges for surgical training and staff recruitment, risking the further fragmentation of training programs. Enhanced regional cooperation is proposed as a solution to ensure comprehensive training. This review explores the benefits of robotic-assisted minimally invasive esophagectomy (RAMIE) in improving surgical precision and patient outcomes and aims to evaluate how the caseload per year influences the quality of patient care and the efficacy of surgical training, especially with the integration of advanced robotic techniques.

Western European Variation in the Organization of Esophageal Cancer Surgical Care

Reasons for structural and outcome differences in esophageal cancer surgery in Western Europe remain unclear. This questionnaire study aimed to identify differences in the organization of esophageal cancer surgical care in Western Europe. A cross-sectional international questionnaire study was conducted among upper gastrointestinal (GI) surgeons from Western Europe. One surgeon per country was selected based on scientific output and active membership in the European Society for Diseases of the Esophagus or (inter)national upper GI committee. The questionnaire consisted of 51 structured questions on the structural organization of esophageal cancer surgery, surgical training, and clinical audit processes. Between October 2021 and October 2022, 16 surgeons from 16 European countries participated in this study. In 5 countries (31%), a volume threshold was present ranging from 10 to 26 annual esophagectomies, in 7 (44%) care was centralized in designated centers, and in 4 (25%) no centralizing regulations were present. The number of centers performing esophageal cancer surgery per country differed from 4 to 400, representing 0.5-4.9 centers per million inhabitants. In 4 countries (25%), esophageal cancer surgery was part of general surgical training and 8 (50%) reported the availability of upper GI surgery fellowships. A national audit for upper GI surgery was present in 8 (50%) countries. If available, all countries use the audit to monitor the quality of care. Substantial differences exist in the organization and centralization of esophageal cancer surgical care in Western Europe. The exchange of experience in the organizational aspects of care could further improve the results of esophageal cancer surgical care in Europe.

[The new continuing education regulations-A challenge for visceral surgery : Results of a survey among DGAV members and solution strategies of the Young Surgeons]

BACKGROUND

The new competency-based further training regulations (nWBO) for surgical training have been adopted by all German state medical associations.

METHODS

From May to June 2023 the Young Surgeons' Working Group (CAJC) conducted an anonymous online survey among the 5896 members of the German Society for General and Visceral Surgery (DGAV).

OBJECTIVE

The survey aimed to assess expectations regarding the nWBO and to develop strategies for enhancing surgical training.

RESULTS

With 488 participants (response rate 8.3%) the study is representative. The respondents consisted of 107 continuing education assistants (WBA 21.9%), 69 specialist physicians, and 188 senior physicians (specialist physicians 14.1% and senior physicians 38.5%), as well as 107 chief physicians (21.9%). The majority worked in regular care providers (44%), followed by maximum care providers (26.8%) and university clinics (20.1%). Only 22% considered the required operative spectrum of the new medical specialist training regulations (nWBO) to be realistic. Half of the respondents believed that full training in their clinic according to the new catalog will no longer be possible and 54.6% considered achieving the target numbers in 6 years to be impossible or state that they can no longer train the same number of continuing education assistants (WBAs) in the same time frame. Endoscopy (17.1-18.8%), fundoplication (15.4-17.7%) and head and neck procedures (12.1-17.1%) were consistently mentioned as bottlenecks across all levels of care. Rotations for balance were reported to be already established or not necessary in 64.7%. In 48% it was stated that the department had established the partial steps concept. The importance of a structured training concept was considered important by 85% of WBAs, compared to 53.3% of chief physicians (CÄ). If a structured training concept was present in the department, the achievability of the target numbers was significantly assessed more positively in the univariate analysis. In the multivariate analysis, male gender and the status of "habilitated/professor" were independent factors for a more positive assessment of the nWBO. Objective certification of training was considered important by 51.5%.

CONCLUSION

Concerns surround the nWBO and the sentiment is pessimistic. Additional requirements and hospital reforms could exacerbate the situation. Collaboration and rotations are crucial but still insufficiently implemented. Quality-oriented certification could enhance the quality of training.

[Tailored surgery in the treatment of gastroesophageal cancer]

The surgical options and particularly perioperative treatment, have significantly advanced in the case of gastroesophageal cancer. This progress enables a 5-year survival rate of nearly 50% to be achieved through curative multimodal treatment concepts for locally advanced cancer. Therefore, in tumor boards and surgical case discussions the question increasingly arises regarding the type of treatment that provides optimal oncological and functional outcomes for individual patients with pre-existing diseases. It is therefore essential to carefully assess whether organ-preserving treatment might also be considered in the future or in what way minimally invasive or robotic surgery can offer advantages. Simultaneously, the boundaries of surgical and oncological treatment are currently being shifted in order to enable curative forms of treatment for patients with pre-existing conditions or those with oligometastatic diseases. With the integration of artificial intelligence into decision-making processes, new possibilities for information processing are increasingly becoming available to incorporate even more data into making decisions in the future.

[Effects of new minimum volume standards in visceral surgery on healthcare in Brandenburg, Germany, from the perspective of healthcare providers]

BACKGROUND

The legally prescribed minimum volume standards for complex esophageal and pancreatic surgery have been increased or will increase in 2023 and 2025, respectively. Hospitals not reaching the minimum volume standards are no longer allowed to perform these surgeries and are not entitled tor reimbursement.

OBJECTIVE

The study aims to explore which effects are expected by healthcare professionals and patient representatives and what possible solutions exist for Brandenburg, a rural federal state in northeast Germany.

MATERIAL AND METHODS

In this study 19 expert interviews were conducted with hospital employees (head/senior physicians, nursing director), resident physicians and patient representatives between July 2022 and January 2023. The data analysis was based on content analysis.

RESULTS

Healthcare professionals and patient representatives expect a redistribution into a few clinics for surgical care (specialized centres); conversely more clinics that do not (no longer) perform the defined surgeries but could function as gatekeeping hospitals for basic care, diagnostics and follow-up (regional centres). The redistribution could also impact forms of treatment that are not directly defined within the regulation for minimum volume standards. The increased thresholds could also affect medical training and staff recruitment. A solution could be collaborations between different hospitals, which would have to be structurally promoted.

CONCLUSION

The study showed that minimum volume standards not only influence the quality of outcomes and accessibility but also have a multitude of other effects. Particularly for rural regions, minimum volume standards are challenging for access to esophageal and pancreatic surgery as well as for communication between specialized and regional centres or resident providers.