University hospital status and prognosis following surgery for esophageal cancer

University hospital status and gastric cancer mortality: A population-based nationwide study in Finland

BACKGROUND

Gastric cancer remains a significant global health issue with increasing mortality, despite advancements in treatment. Previous studies have suggested that surgery performed at university hospitals may influence surgical outcomes and mortality rates, but evidence of its effect on gastric cancer remains limited. This study aimed to investigate whether gastrectomy performed at university hospitals reduces short-term and long-term mortality rates in Finland.

METHODS

This nationwide population-based retrospective cohort study analyzed patients with gastric cancer who underwent gastrectomy in Finland from 1987 to 2016, using data from the Finnish Cancer Registry, Finnish Patient Registry, and Finnish Death Registry. The study compared 5-year, 30-day, and 90-day all-cause mortality rates between patients treated at university hospitals and those treated at nonuniversity hospitals, with adjustments for confounders using multivariate Cox regression models.

RESULTS

Of 10,455 patients who underwent gastrectomy in Finland between 1987 and 2016, most were treated in nonuniversity hospitals. Patients who underwent gastrectomy at university hospitals were generally younger and had more comorbidities and more advanced cancer stages. Of note, 30-day, 90-day, and 5-year survival rates were higher in university hospitals than in nonuniversity hospitals, although the differences in 90-day and 5-year survival rates were not statistically significant in more recent years.

CONCLUSION

Our findings suggest that gastrectomy performed at university hospitals in Finland is associated with lower short-term and long-term mortality rates than gastrectomy performed at nonuniversity hospitals. In addition, our findings support the potential benefits of centralizing gastric cancer surgical procedures at university hospitals. However, further research is needed to explore the underlying reasons.

Refining the thoracic surgical oncology regionalization standards for esophageal surgery in Ontario, Canada: Moving from good to better

BACKGROUND

The consolidation of surgical practices has been suggested to improve patient outcomes for complex surgeries. In 2005, Ontario Health-Cancer Care Ontario released the Thoracic Surgical Oncology Standards to facilitate the regionalization process at thoracic centers in Ontario, Canada. This work describes the quality-improvement process involved in updating the minimum surgical volume and supporting requirement recommendations for thoracic centers to further optimize patient care for esophageal cancer.

METHODS

We conducted a literature review to identify and synthesize evidence informing the volume-outcome relationship related to esophagectomy. The results of this review and esophageal cancer surgery common indicators (reoperation rate, unplanned visit rate, 30-day and 90-day mortality) from Ontario's Surgical Quality Indicator Report were presented and reviewed by a Thoracic Esophageal Standards Expert Panel and Surgical Oncology Program Leads at Ontario Health-Cancer Care Ontario. Hospital outliers were identified, and a subgroup analysis was conducted to determine the most appropriate minimum surgical volume threshold based on 30- and 90-day mortality rates data from the last 3 fiscal years.

RESULTS

Based on the finding that a significant decrease in mortality occurred at 12 to 15 esophagectomies per year, the Thoracic Esophageal Standards Expert Panel reached a consensus that thoracic centers should perform a minimum of 15 esophagectomies per year. The panel also recommended that any center performing esophagectomies have at least 3 thoracic surgeons to ensure continuity in clinical care.

CONCLUSIONS

We have described the process involved in updating the provincial minimum volume threshold and the appropriate support services for esophageal cancer surgery in Ontario.

A study of the learning curve for robotic oesophagectomy for oesophageal cancer

OBJECTIVES

Robot-assisted minimally invasive oesophagectomy (RAMIE) enables radical, meticulous dissection of the oesophagus and lymph nodes. Our goal was to identify the effect of the learning curve for RAMIE when performing radical upper mediastinal dissection in patients with oesophageal cancer.

METHODS

We conducted a retrospective review of a prospectively maintained database of patients who underwent RAMIE for oesophageal cancer between May 2008 and July 2016. The gain in proficiency for each postoperative outcome measure was presented using observed-expected cumulative sum (O-E CUSUM) curves. The change points were defined at the maximal distance from the zero axis.

RESULTS

A total of 140 patients were included. Squamous cell carcinoma (n = 131, 93.6%) was the dominant type. Thirty-day and 90-day deaths occurred in 1 and 5 patients (0.7% and 3.6%, respectively). The change points of the risk-adjusted O-E CUSUM curves were similar to those of the unadjusted O-E CUSUM curves with the exception of those for thoracic procedure time and vocal cord palsy. The number of harvested lymph nodes increased from 25 to 45 before and after 30 cases. The vocal cord palsy rate decreased from 36% to 17% before and after 60 cases. The total operation time decreased from 496 min to 431 min; the length of the hospital stay decreased from 24 days to 14 days; and the anastomotic leakage rate decreased from 15% to 2% before and after 80 cases.

CONCLUSIONS

Our study demonstrated a temporal improvement in postoperative outcomes based on accumulated experience with RAMIE. The risk-adjusted O-E CUSUM curves were similar to the unadjusted O-E CUSUM curves, which represents the significant impact of the effect of a learning period on the postoperative outcomes of RAMIE in patients with oesophageal cancer.