Fit-for-Discharge Criteria after Esophagectomy: An International Expert Delphi Consensus

Development and Validation of a Machine Learning Prediction Model for Textbook Outcome in Liver Surgery: Results From a Multicenter, International Cohort

Objective

This study aimed to (1) develop a machine learning (ML) model that predicts the textbook outcome in liver surgery (TOLS) using preoperative variables and (2) validate the TOLS criteria by determining whether TOLS is associated with long-term survival after hepatectomy.

Background

Textbook outcome is a composite measure that combines several favorable outcomes into a single metric and represents the optimal postoperative course. Recently, an expert panel of surgeons proposed a Delphi consensus-based definition of TOLS.

Methods

Adult patients who underwent hepatectomies were identified from a multicenter, international cohort (2010-2022). After data preprocessing and train-test splitting (80:20), 4 models for predicting TOLS were trained and tested. Following model optimization, the performance of the models was evaluated using receiver operating characteristic curves, and a web-based calculator was developed. In addition, a multivariable Cox proportional hazards analysis was conducted to determine the association between TOLS and overall survival (OS).

Results

A total of 2059 patients were included, with 62.8% meeting the criteria for TOLS. The XGBoost model, which had the best performance with an area under the curve of 0.73, was chosen for the web-based calculator. The most predictive variables for having TOLS were a minimally invasive approach, fewer lesions, lower Charlson Comorbidity Index, lower preoperative creatinine levels, and smaller lesions. In the multivariable analysis, having TOLS was associated with improved OS (hazard ratio = 0.82, P = 0.015).

Conclusions

Our ML model can predict TOLS with acceptable discrimination. We validated the TOLS criteria by demonstrating a significant association with improved OS, thus supporting their use in informing patient care.

Recommendations for the implementation and conduct of multidisciplinary team meetings for those providing endometriosis and adenomyosis care - a Delphi consensus of the European Endometriosis League (EEL)

Background

The treatment of endometriosis and adenomyosis requires a complex, multidisciplinary approach. Some centres have established multidisciplinary teams (MDT) and regular meetings. There are currently no international data or recommendations.

Objectives

To examine existing MDT meetings and define consensus recommendations to support implementation and conduct.

Materials and Methods

Online questionnaires were sent through the European Endometriosis League (EEL) based on a Delphi protocol. After a literature review and assessment of existing MDT meetings, essential aspects for consensus statements were identified. The consensus statements were evaluated using a 5-point Likert scale with the possibility to modify them. Results were analysed between rounds and reported to the respondents. Consensus, defined as ≥70% agreement, concluded the Delphi process when achieved in the majority of statements.

Main outcome measures

Prevalence and type of existing MDT meetings and recommendations.

Results

In round 1, 69 respondents participated, with 49.3% (34) having an MDT meeting at their institutions, of which 97% are multidisciplinary. 50 % meet once a month and 64.7% indicated that less than 25% of their patients are discussed. Throughout the three rounds, 47 respondents from 21 countries participated. During the process, 82 statements were defined, with an agreement of 92.7% on the statements.

Conclusions

This study assessed existing MDT meetings for endometriosis and adenomyosis and developed recommendations for their implementation and conduct. The consensus group supports the strengths of MDT meetings, highlighting their role in offering guideline-based, multidisciplinary, and personalised care.

What is new?

This study presents the first international data and recommendations on MDT meetings for endometriosis and adenomyosis.

Robot-assisted pelvic floor reconstructive surgery: an international Delphi study of expert users

BACKGROUND

Robotic surgery has gained popularity for the reconstruction of pelvic floor defects. Nonetheless, there is no evidence that robot-assisted reconstructive surgery is either appropriate or superior to standard laparoscopy for the performance of pelvic floor reconstructive procedures or that it is sustainable. The aim of this project was to address the proper role of robotic pelvic floor reconstructive procedures using expert opinion.

METHODS

We set up an international, multidisciplinary group of 26 experts to participate in a Delphi process on robotics as applied to pelvic floor reconstructive surgery. The group comprised urogynecologists, urologists, and colorectal surgeons with long-term experience in the performance of pelvic floor reconstructive procedures and with the use of the robot, who were identified primarily based on peer-reviewed publications. Two rounds of the Delphi process were conducted. The first included 63 statements pertaining to surgeons' characteristics, general questions, indications, surgical technique, and future-oriented questions. A second round including 20 statements was used to reassess those statements where borderline agreement was obtained during the first round. The final step consisted of a face-to-face meeting with all participants to present and discuss the results of the analysis.

RESULTS

The 26 experts agreed that robotics is a suitable indication for pelvic floor reconstructive surgery because of the significant technical advantages that it confers relative to standard laparoscopy. Experts considered these advantages particularly important for the execution of complex reconstructive procedures, although the benefits can be found also during less challenging cases. The experts considered the robot safe and effective for pelvic floor reconstruction and generally thought that the additional costs are offset by the increased surgical efficacy.

CONCLUSION

Robotics is a suitable choice for pelvic reconstruction, but this Delphi initiative calls for more research to objectively assess the specific settings where robotic surgery would provide the most benefit.

Profiling symptom burden and its influencing factors at discharge for patients undergoing lung cancer surgery: a cross-sectional analysis

Background

Following lung cancer surgery, patients often experience severe symptoms which are not properly assessed at discharge. The aim of this study was to identify the clinical presentation at discharge and the influencing factors of postoperative symptoms in patients who have undergone lung cancer surgery.

Methods

This cross-sectional study analysed data from patients who participated in a prospective cohort study that enrolled patients who underwent lung cancer surgery at six tertiary hospitals in the People’s Republic of China, from November 2017 to January 2020. Patient symptoms at discharge were measured using the MD Anderson Symptom Inventory Lung Cancer module. The five core symptoms were defined according to ratings of moderate to severe symptoms (≥ 4 on a 0–10 scale). A multivariate linear regression model was used to identify the influencing factors of each symptom at discharge.

Results

Among the 366 participants, 51.9% were male and the mean (SD) age was 55.81 (10.43) years. At discharge, the core symptoms were cough (36.4%), pain (28.2%), disturbed sleep (26.3%), shortness of breath (25.8%), and fatigue (24.3%), and more than half of the participants (54.6%) had one to five of the core symptoms, with moderate to severe severity. A low annual income and the use of two chest tubes were significantly associated (P = 0.030 and 0.014, respectively) with higher mean scores of the core symptoms.

Conclusion

Though clinically eligible for discharge, more than half of the participants had severe symptoms at discharge after lung cancer surgery. Special attention should be given to patients who have two chest tubes after surgery and those who have a low annual income.

Early versus the traditional start of oral intake following esophagectomy for esophageal cancer: a systematic review and meta-analysis

BACKGROUND

Nil by mouth is considered the standard of care during the first days following esophagectomy. However, with the routine implementation of enhanced recovery after surgery, early oral intake is more likely to be the preferred mode of nutrition following esophagectomy. The present study aims to evaluate the safety and effectiveness of early oral intake following esophagectomy for esophageal cancer.

METHODS

Comprehensive literature searches were conducted using PubMed, Web of Science, Embase, and Cochrane Library. Weighted mean differences (WMD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated as the effect sizes for continuous and dichotomous variables, respectively.

RESULTS

Fourteen studies with a total of 1947 patients were included. Length of hospital stay (WMD =  - 3.94, CI: - 4.98 to - 2.90; P < 0.001), the time to first flatus (WMD =  - 1.13, CI: - 1.25 to - 1.01; P < 0.001) and defecation (WMD =  - 1.26, CI: - 1.82 to - 0.71; P < 0.001) favored the early oral intake group. There was no statistically significant difference in mortality (OR = 1.23, CI: 0.45 to 3.36; P = 0.69). Early oral intake also did not increase the risk of pneumonia and overall postoperative complications.

CONCLUSIONS

Current evidence indicates early oral intake following esophagectomy seems to be safe and effective. It may be the preferred mode of nutrition following esophagectomy. However, more high-quality studies are still needed to further validate this conclusion.

[Fast-track Rehabilitation after Oesophagectomy]

The multimodal and interprofessional concept of fast-track rehabilitation ("enhanced recovery after surgery", ERAS) is generally applicable to transthoracic oesophagectomy, but is associated with two special features as compared to other oncological procedures. Due to the high comorbidity of oesophageal cancer patients, fast-track pathways have to be considered as one component of perioperative management and cannot be separated from prehabilitation with preoperative conditioning of single organ dysfunctions. Since gastric reconstruction causes a high prevalence of delayed gastric conduit emptying (DGCE), early and sufficient postoperative oral feeding is not easily feasible. There is currently no generally accepted algorithm for the postoperative nutritional management as well as for the prophylaxis/treatment of DGCE. Fast-track prehabilitation does not influence the mortality rate in specialised centres. At present, it is not clear whether a fast-track pathway helps to reduce postoperative morbidity. After modified fast-track rehabilitation, hospital discharge is possible from the 8th postoperative day.

Pre-Emptive Endoluminal Negative Pressure Therapy at the Anastomotic Site in Minimally Invasive Transthoracic Esophagectomy (the preSPONGE Trial): Study Protocol for a Multicenter Randomized Controlled Trial

Introduction:

Anastomotic leakage (AL) accounts for a significant proportion of morbidity following oesophagectomy. Endoluminal negative pressure (ENP) therapy via a specifically designed polyurethane foam (EsoSponge^®, B.Braun Medical, Melsungen, Germany) has become the standard of care for AL in many specialized centres. The prophylactic (pENP) application of this technique aims to reduce postoperative morbidity and is a novel approach which has not yet been investigated in a prospective study. The aim of this study is therefore to assess the effect of pENP at the anastomotic site in high-risk patients undergoing minimally invasive transthoracic Ivor Lewis oesophagectomy.

Methods and analysis:

The study design is a prospective, multi-centre, two-arm, parallel-group, randomised controlled trial and will be conducted in two phases. Phase one is a randomised feasibility and safety pilot trial involving 40 consecutive patients. After definitive sample size calculation, additional patients will be included accordingly during phase two. The primary outcome of the study will be the postoperative length of hospitalization until reaching previously defined “fit for discharge criteria”. Secondary outcomes will include postoperative morbidity, mortality and postoperative AL-rates based on 90-day follow-up. A confirmatory analysis based on intention-to-treat will be performed.

Ethics and dissemination:

The ethics committee of the University of Zurich approved this study (2019-00562), which has been registered with ClinicalTrials.gov on 14.11.2019 (NCT04162860) and the Swiss National Clinical Trials Portal (SNCTP000003524). The results of the study will be published and presented at appropriate conferences.