Minimally invasive esophagectomy learning curves with different types of background experience

Proton Radiotherapy Significantly Reduces Pneumonia in Patients With Esophageal Cancer

PURPOSE

Neoadjuvant chemoradiation therapy (RT) (nCRT) followed by surgical resection is the current standard of care for patients with esophageal cancer (EC). This treatment is associated with a variety of complications, with pneumonia being the most common. We hypothesized that proton RT (PRT) can significantly reduce the incidence of pneumonia compared with photon RT (PhRT).

METHODS AND MATERIALS

We performed an analysis on a prospective cohort of patients with EC who completed nCRT with PRT or PhRT and underwent esophagectomy between October 2014 and June 2022. Multivariable logistic regression was used to analyze the effect of the RT technique on pneumonia while correcting for confounders. To access the dose-effect relationships, dose-volume histogram parameters of the lungs and the heart were analyzed using a principal component (PC) analysis.

RESULTS

We included 313 patients, of whom 28% developed pneumonia. The incidence was lower after PRT compared with PhRT (12% vs 32%, P < .01). PRT was associated with a significant reduction of the incidence of pneumonia (odds ratio [OR], 0.33; 95% CI, 0.14-0.72; P = .01), even when correcting for surgical approach and planning target volume size. Three PCs were identified: PC1: associated with the mean dose in the heart and lungs, PC2: associated with the distribution of dose between the lungs and the heart, and PC3: associated with the volume receiving a low dose (≤20 Gy). If the dose-related variables were replaced by the PCs, PC1 (OR, 1.1; 95% CI, 1.02-1.22) and PC3 (OR, 1.27; 95% CI, 1.06-1.53) were significantly associated with pneumonia. PRT had significantly lower values for both PC1 and PC3, compared with PhRT.

CONCLUSIONS

PRT significantly reduces the incidence of pneumonia compared with PhRT in patients with EC treated with nCRT followed by surgical resection. The reduction of pneumonia was associated with the lower mean dose and a reduction of the volume irradiated to low doses in the lungs and/or heart.

Triphasic Learning Curve of Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is an effective but costly procedure for select patients with peritoneal malignancies. The impact of progression along a learning curve on the cost of these procedures is unknown.

PATIENTS AND METHODS

We performed a retrospective cohort study of patients undergoing CRS-HIPEC from 2016 to 2022 at a single quaternary center. Our study cohort was temporally divided into four equally sized volume quartiles (A, B, C, and D). We utilized cumulative sum plots and split-group analysis to characterize the institutional learning curve based on cost, operative time, length of stay, and morbidity. Multivariable linear regression was performed to estimate costs after adjusting for covariates. Bivariate analysis was performed using a Kruskal-Wallis test to compare continuous variables and a χ2 test to compare categorical variables.

RESULTS

Of 201 patients, the median age [interquartile range (IQR)] was 57 (47-65) years, 113 (56%) patients were female, 143 (71%) were white, and 107 (53%) had private insurance. Median operating room charge [US$42,639 (US$32,477-54,872), p < 0.001] varied between volume quartiles, peaking in quartile C. Stabilization was achieved for 86 cases for operating room cost, 88 cases for routine cost, 96 cases for length of stay, 103 cases for operative time, 120 cases for intensive care unit length of stay, and 150 cases for overall and serious morbidity. The actual operating room and routine costs were similar to predicted costs at the end of the study period.

CONCLUSIONS

The CRS-HIPEC learning curve is triphasic, with cost stability achieved relatively early compared with other markers of surgical proficiency.

Evolution of a minimally invasive oesophagectomy program - effective complication management is key

Introduction

Despite improvements in patient selection, operative technique, and postoperative care, oesophagectomy remains one of the most morbid oncologic resection types. Introduction of minimally invasive practice has been shown to have a greater marginal benefit for oesophagectomy than most of the other types of procedures.

Aim

To evaluate early surgical outcomes through the adoption of totally minimally invasive oesophagectomy and accumulating experience in perioperative management.

Material and methods

All patients with mid and distal oesophageal carcinoma who underwent oesophagectomy and gastric conduit construction between June 2004 and December 2021 were recorded prospectively. Demographic information, neoadjuvant treatment, operative data, and perioperative mortality/morbidity were evaluated. Patients were classified depending on the timeline and predominant surgical approach: Group 1 (2004-2011, open surgery), Group 2 (2011-2015, adoption period of minimally invasive surgery), and Group 3 (2015-2021, routine minimally invasive surgery).

Results

In total, 167 patients were identified (Group 1, n = 48; Group 2, n = 44; Group 3, n = 75). Group 3 was significantly older (59.5 ±11.6 vs. 54.1 ±10.6 years and 56.2 ±10.8 years; p = 0.031).The likelihood of successful completion of a totally minimally invasive esophagectomy was increased as well as the preference for intrathoracic anastomosis (p < 0.0001 for both). The major morbidity rate was stable across the groups, but 90-day mortality significantly decreased for the most recent cohort.

Conclusions

Accumulating experience led to enhanced success in completion of minimally invasive oesophagectomy, and intrathoracic anastomosis was increasingly the preferred modality. Surgical mortality decreased over time despite the older patients and comparable perioperative morbidity including anastomotic leaks. Improvement in the management of complications is an apparent contributor to good perioperative outcomes as well as technical development.

Implementation of Multimodality Therapy and Minimally Invasive Surgery: Short- and Long-term Outcomes of Gastric Cancer Surgery in Medium-Volume Center

BACKGROUND

Multimodal treatment of gastric cancer includes careful preoperative staging, perioperative oncological treatment, and selective minimally invasive approach. The aim was to evaluate whether this approach improves short- and long-term outcomes in operable gastric cancer.

METHODS

This study included 181 gastric cancer patients who underwent curative intent surgery in Central Finland Central Hospital between years 2005 and 2021 for gastric or esophagogastric junction adenocarcinoma. Those 65 patients in group 1 operated between years 2005-2010 had open surgery with possible adjuvant therapy. During the second period including 58 patients (2011-2015), perioperative chemotherapy and minimally invasive surgery were implemented. The period, when these treatments were standard practise, was years 2016-2021 including 58 patients (group 3). Outcomes were lymph node yield, major complications and 1- and 3-year survival rates.

RESULTS

Median lymph node yield increased from 17 in group 1 and 20 in group 2 to 23 in group 3 (p < 0.001). Major complication rates in groups 1-3 were 12.3%, 32.8%, and 15.5% (group 1 vs. group 2, p = 0.007; group 2 vs. group 3, p = 0.018), respectively. Overall 1-year survival rates between study groups 1-3 were 78.5% vs. 69.0% vs. 90.2% (p = 0.018) and 3-year rates 44.6% vs. 44.8% vs. 68.1% (p = 0.016), respectively. For overall 3-year mortality, adjusted hazard ratio (HR) was 1.02 (95%CI 0.63-1.66) in group 2 and HR 0.37 (95%CI 0.20-0.68) in group 3 compared to group 1.

CONCLUSIONS

In medium-volume center, modern multimodal therapy in operable gastric cancer combined with minimally invasive surgery increased lymph node yield and improved long-term survival without increasing postoperative morbidity.