Survival, mortality and morbidity outcomes after oesophagogastric cancer surgery in New South Wales, 2001-2008

Best Practices for Managing Patients with Unresectable Metastatic Gastric and Gastroesophageal Junction Cancer in Canada

Gastric cancer (GC) is one of the most common types of cancer and is associated with relatively low survival rates. Despite its considerable burden, there is limited guidance for Canadian clinicians on the management of unresectable metastatic GC and gastroesophageal junction cancer (GEJC). Therefore, we aimed to discuss best practices and provide expert recommendations for patient management within the current Canadian unresectable GC and GEJC landscape. A multidisciplinary group of Canadian healthcare practitioners was assembled to develop expert recommendations via a working group. The often-rapid progression of unresectable GC and GEJC and the associated malnutrition have a significant impact on the patient's quality of life and ability to tolerate treatment. Hence, recommendations include early diagnosis, identification of relevant biomarkers to improve personalized treatment, and relevant support to manage comorbidities. A multidisciplinary approach including early access to registered dietitians, personal support networks, and palliative care services, is needed to optimize possible outcomes for patients. Where possible, patients with unresectable GC and GEJC would benefit from access to clinical trials and innovative treatments.

Failure to rescue following oesophagectomy in Australia: a multi-site retrospective study using American College of Surgeons National Surgical Quality Improvement Program

BACKGROUND

Failure to rescue (FTR), defined as death after a major complication, is increasingly being used as a surrogate for assessing quality of care following major cancer resection. The aim of this paper is to determine the failure to rescue (FTR) rate after oesophagectomy and explore factors that may contribute to FTR within Australia.

METHODS

A retrospective review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2015 to 2023 at five Australian hospitals was conducted to identify patients who underwent an oesophagectomy. The primary outcome was FTR rate. Perioperative parameters were examined to evaluate predictive factors for FTR. Secondary outcomes include major complications, overall morbidity, mortality, length of stay and 30-day readmissions.

RESULTS

A total of 155 patients were included with a median age of 65.2 years, 74.8% being male. The FTR rate was 6.3%. In total, 50.3% of patients (n = 78) developed at least one postoperative complication with the most common complication being pneumonia (20.6%) followed by prolonged intubation (12.9%) and organ space SSI/anastomotic leak (11.0%). Multivariate logistic regression analysis was performed to determine any factors that were predictive for FTR however none reached statistical significance.

CONCLUSION

This study is the first to evaluate the FTR rates following oesophagectomy within Australia, with FTR rates and complication profile comparable to international benchmarks. Integration of multi-institutional national databases such as ACS NSQIP into units is essential to monitor and compare patient outcomes following major cancer surgery, especially in low to moderate volume centres.

Understanding Potentially Preventable Mortality Following Oesophago-Gastric Cancer Surgery: Analysis of a National Audit of Surgical Mortality

INTRODUCTION

At a national level, understanding preventable mortality after oesophago-gastric cancer surgery can direct quality-improvement efforts. Accordingly, utilizing the Australian and New Zealand Audit of Surgical Mortality (ANZASM), we aimed to: (1) determine the causes of death following oesophago-gastric cancer resections in Australia, (2) quantify the proportion of potentially preventable deaths, and (3) identify clinical management issues contributing to preventable mortality.

METHODS

All in-hospital mortalities following oesophago-gastric cancer surgery from 1 January 2010 to 31 December 2020 were analysed using ANZASM data. Potentially preventable and non-preventable cases were compared. Thematic analysis with a data-driven approach was used to classify clinical management issues.

RESULTS

Overall, 636 complications and 123 clinical management issues were identified in 105 mortalities. The most common causes of death were cardio-respiratory in aetiology. Forty-nine (46.7%) deaths were potentially preventable. These cases were characterized by higher rates of sepsis (59.2% vs 33.9%, p = 0.011), multiorgan dysfunction syndrome (40.8% vs 25.0%, p = 0.042), re-operation (63.3% vs 41.1%, p = 0.031) and other complications compared with non-preventable mortality. Potentially preventable mortalities also had more clinical management issues per patient [median (IQR): 2 (1-3) vs 0 (0-1), p < 0.001), which adversely impacted preoperative (30.6% vs 7.1%, p = 0.002), intraoperative (18.4% vs 5.4%, p = 0.037) and postoperative (51.0% vs 17.9%, p < 0.001) care. Thematic analysis highlighted recurrent areas of deficiency with preoperative, intraoperative and postoperative patient management.

CONCLUSIONS

Almost 50% of deaths following oesophago-gastric cancer resections were potentially preventable. These were characterized by higher complication rates and clinical management issues. We highlight recurrent themes in patient management to improve future quality of care.

Nanomaterials in tumor immunotherapy: new strategies and challenges

Tumor immunotherapy exerts its anti-tumor effects by stimulating and enhancing immune responses of the body. It has become another important modality of anti-tumor therapy with significant clinical efficacy and advantages compared to chemotherapy, radiotherapy and targeted therapy. Although various kinds of tumor immunotherapeutic drugs have emerged, the challenges faced in the delivery of these drugs, such as poor tumor permeability and low tumor cell uptake rate, had prevented their widespread application. Recently, nanomaterials had emerged as a means for treatment of different diseases due to their targeting properties, biocompatibility and functionalities. Moreover, nanomaterials possess various characteristics that overcome the defects of traditional tumor immunotherapy, such as large drug loading capacity, precise tumor targeting and easy modification, thus leading to their wide application in tumor immunotherapy. There are two main classes of novel nanoparticles mentioned in this review: organic (polymeric nanomaterials, liposomes and lipid nanoparticles) and inorganic (non-metallic nanomaterials and metallic nanomaterials). Besides, the fabrication method for nanoparticles, Nanoemulsions, was also introduced. In summary, this review article mainly discussed the research progress of tumor immunotherapy based on nanomaterials in the past few years and offers a theoretical basis for exploring novel tumor immunotherapy strategies in the future.

Association between hospital surgical case volume and postoperative mortality in patients undergoing gastrectomy for gastric cancer: a systematic review and meta-analysis

BACKGROUND

Postoperative mortality is an important indicator for evaluating surgical safety. Postoperative mortality is influenced by hospital volume; however, this association is not fully understood. This study aimed to investigate the volume-outcome association between the hospital surgical case volume for gastrectomies per year (hospital volume) and the risk of postoperative mortality in patients undergoing a gastrectomy for gastric cancer.

METHODS

Studies assessing the association between hospital volume and the postoperative mortality in patients who underwent gastrectomy for gastric cancer were searched for eligibility. Odds ratios were pooled for the highest versus lowest categories of hospital volume using a random-effects model. The volume-outcome association between hospital volume and the risk of postoperative mortality was analyzed. The study protocol was registered with Prospective Register of Systematic Reviews (PROSPERO).

RESULTS

Thirty studies including 586 993 participants were included. The risk of postgastrectomy mortality in patients with gastric cancer was 35% lower in hospitals with higher surgical case volumes than in their lower-volume counterparts (odds ratio: 0.65; 95% CI: 0.56-0.76; P <0.001). This relationship was consistent and robust in most subgroup analyses. Volume-outcome analysis found that the postgastrectomy mortality rate remained stable or was reduced after the hospital volume reached a plateau of 100 gastrectomy cases per year.

CONCLUSIONS

The current findings suggest that a higher-volume hospital can reduce the risk of postgastrectomy mortality in patients with gastric cancer, and that greater than or equal to 100 gastrectomies for gastric cancer per year may be defined as a high hospital surgical case volume.

Association of hospital volume and long-term survival after esophagectomy: A systematic review and meta-analysis

Background

It remains controversial whether esophageal cancer patients may benefit from esophagectomy in specialized high-volume hospitals. Here, the effect of hospital volume on overall survival (OS) of esophageal cancer patients post esophagectomy was assessed.

Methods

PubMed, Embase, and Cochrane Library were systematically searched for relevant published articles between January 1990 and May 2022. The primary outcome was OS after esophagectomy in high- vs. low-volume hospitals. Random effect models were applied for all meta-analyses. Subgroup analysis were performed based on volume grouping, sample size, study country, year of publication, follow-up or study quality. Sensitivity analyses were conducted using the leave-one-out method. The Newcastle-Ottawa Scale was used to assess the study quality. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidance, and was registered (identifier: INPLASY202270023).

Results

A total of twenty-four studies with 113,014 patients were finally included in the meta-analysis. A significant improvement in OS after esophagectomy was observed in high-volume hospitals as compared to that in their low-volume counterparts (HR: 0.77; 95% CI: 0.71-0.84, P < 0.01). Next, we conducted subgroup analysis based on volume grouping category, consistent results were found that high-volume hospitals significantly improved OS after esophagectomy than their low-volume counterparts. Subgroup analysis and sensitivity analyses further confirmed that all the results were robust.

Conclusions

Esophageal cancer should be centralized in high-volume hospitals.

The SYMPTOM-upper gastrointestinal study: A mixed methods study exploring symptom appraisal and help-seeking in Australian upper gastrointestinal cancer patients

Objective

There is limited evidence on the development of pancreatic and oesophagogastric cancer, how patients decide to seek help and the factors impacting help‐seeking. Our study, the first in Australia, aimed to explore symptom appraisal and diagnostic pathways in these patients. A secondary aim was to examine the potential to recruit cancer patients through a cancer quality registry.

Methods

Patients diagnosed with pancreatic or oesophagogastric cancer were recruited through Monash University's Upper‐Gastrointestinal Cancer Registry. Data collected through general practitioners (GP) and patient questionnaires included symptoms and their onset, whereas patient interviews focused on the patient's decision‐making in seeking help from healthcare pracitioners. Data collection and analysis was informed by the Aarhus statement. Coding was inductive, and themes were mapped onto the Model of Pathways to Treatment.

Results

Between November 2018 and March 2020, 27 patient questionnaires and 13 phone interviews were completed. Prior to diagnosis, patients lacked awareness of pancreatic and oesophagogastric cancer symptoms, leading to the normalisation, dismissal and misattribution of the symptoms. Patients initially self‐managed symptoms, but worsening of symptoms and jaundice triggered help‐seeking. Competing priorities, beliefs about illnesses and difficulties accessing healthcare delayed help‐seeking.

Conclusion

Increased awareness of insidious pancreatic and oesophagogastric cancer symptoms in patients and general practitioners may prompt more urgent investigations and lead to earlier diagnosis.

Gastrectomy mortality in Australia

BACKGROUND

Despite advances in medical management and endoscopic therapy, gastrectomy remains an important yet high-risk procedure for a range of benign and malignant upper gastrointestinal pathologies. No study has previously analysed Australian gastrectomy perioperative mortality rate (POMR). This retrospective, population-based cohort study was conducted to determine the Australian national gastrectomy POMR, allowing state-based and regional trends and outcomes to be assessed.

METHODS

Logistic regression models were compared using de-identified procedural data between 1 July 2005 and 30 June 2017 from the Australian Institute of Health and Welfare. Codes relating to total and subtotal gastrectomy contained in the Australian Classification of Health Interventions were used to extract patient data. Mortality rates were risk adjusted for age and gender. Temporal trends and differences between states/territories and regions were investigated.

RESULTS

The national average POMR throughout the study period was 2.1%. For subtotal gastrectomy, the national mean POMR was 1.1%, decreasing from 2.7% (2005) to 1.3% (2017). For total gastrectomy, the national mean POMR was 2.8%, decreasing from 3.3% (2005) to 1.7% (2017). POMR significantly reduced over time without variation between states or regions. Procedure volume steadily reduced in rural centres with a concomitant increase in metropolitan centres over time.

CONCLUSION

Pleasingly, the Australian gastrectomy POMR is favourable when compared to international cohorts. Improved outcomes were consistent between states and territories, and metropolitan and regional centres. Progressive metropolitan centralization of gastrectomy was demonstrated without evidence of improved outcomes.

Diabetes Adversely Influences Postoperative Outcomes After Oesophagectomy: An Analysis of the National Surgical Quality Improvement Program Database

INTRODUCTION

Diabetes is a recognised risk for several chronic and acute illnesses, including increased complications in surgery for oesophageal cancer. Our primary aim is to determine the impact of diabetes on postoperative surgical and medical complications after oesophagectomy.

METHODS

All oesophagectomies for malignancy as reflected in the 2016-2018 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) datasets were extracted and analysed. Current Procedural Terminology (CPT) codes used were 1) open procedures (43107, 43108, 43112, 43113, 43116, 43117, 43118, 43121, 43122, and 43123) and 2) hybrid procedures (43186, 43287, and 43288). Logistic regression models examined associations between diabetic status and adverse outcomes. The associations were adjusted for sex, race, age group, operation year, CPT code, body mass index (BMI), smoking, congestive heart failure, antihypertensives, renal failure, and dyspnoea.

RESULTS

Two thousand five hundred and thirty-eight oesophagectomies were identified. 86.45% (n=2,194) underwent open procedures and 13.55% (n=344) had hybrid procedures. There were 177 insulin-dependent diabetics (IDDM) and 320 (12.61%) non-insulin-dependent diabetics (NIDDM). 84.14% were male and 77.74% were Caucasian. 89.48% of the patients were between 50 and 79 years of age. 40.27% experienced postoperative complications. Medical complications (odds ratio [OR]: 1.7, p-value: 0.002), surgical complications (OR: 1.9, p-value: <0.001), wound complications (OR: 2.9, p-value: <0.001), and anastomotic leaks (OR: 2.4, p-value: <0.001) were more common in diabetic patients. Subgroup analysis showed that in hybrid procedures, there is a statistically significant increase in the OR of surgical complications (OR: 3.61, p-value: 0.05), medical complications (OR: 3.76, p-value: 0.04), and anastomotic leak (OR: 3.49, p-value: 0.27) in IDDM as compared to NIDDM.

CONCLUSION

Insulin-dependent diabetes doubles the risk of all major complications compared to nondiabetics. When considering surgical approach and diabetic status (IDDM vs nondiabetics, NIDDM vs nondiabetics), the risk of complications further doubles for hybrid oesophagectomies compared to open procedures.

Procedure-specific outcomes following gastrectomy for cancer compared by hospital volume and service capability

BACKGROUND

International literature recommends centralising gastric cancer surgery, however, with volumes that define 'high-volume resection' being higher than those in most major centres in Australia and New Zealand. These reports rarely focus on the difference between total (TG) and partial gastrectomy (PG). We assessed the impact of resection volume and service capability on operative mortality, morbidity and surgical quality in patients who had a PG and TG.

METHODS

Patients who had gastrectomy for adenocarcinoma, between 2001 and 2015, were collected from the Queensland Oncology Repository. Hospitals were characterised by cases-per-annum (high-volume [HV] ≥ 5 and low-volume [LV] < 5) and hospital service capability as (high-service [HS] and low-service [LS]), giving three hospital groups: HVHS, LVHS and LVLS. Chi-squared tests were used to compare post-operative mortality, morbidity, failure to rescue (FTR) from complications and surgical quality between these three groups.

RESULTS

There were 426 patients who had a TG and 827 having PG. HVHS centres performed 59% of PG with high surgical quality rates of: HVHS = 53%, LVHS = 34% and LVLS = 46% (p < 0.01). Surgical complications were highest in LVLS (LVLS = 19%, LVHS = 11%, HVHS = 11%; p = 0.02). There was no difference in 30-day mortality nor in FTR. For TG, HVHS performed 67% of these procedures, with lower 30-day mortality (2%) and FTR rates (5%) compared with LVHS (7%, 22%) and LVLS (12%, 28%; p < 0.01). There was no difference in operative morbidity and surgical quality between hospital groups.

CONCLUSION

Despite the 'high-volume' threshold for gastrectomy being the lowest described in the literature, we have shown that centralisation to HVHS centres was associated with lower operative mortality for TG and improved quality of surgery for PG.

Hospital characteristics associated with better 'quality of surgery' and survival following oesophagogastric cancer surgery in Queensland: a population-level study

BACKGROUND

The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high-volume, high service capability hospitals.

METHODS

All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi-squared tests. The 5-year overall survival was compared using log-rank tests and Cox proportional hazard models.

RESULTS

For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3- and 5-year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy.

CONCLUSION

In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.

Timeliness of cancer care in a regional Victorian health service: A comparison of high-volume (Lung) and low-volume (oesophagogastric) tumour streams

Background

Timeliness of cancer care is vital for improved survival and quality of life of patients. Service and care centralisation at larger‐volume centres has been associated with improved outcomes. However, there is a lack of systematic data on the impact of tumour stream volume on timeliness of care.

Aims

To investigate and compare timeliness of care for lung cancer, a high‐volume (more commonly diagnosed) tumour stream, and oesophagogastric (OG) cancer, a low‐volume (less commonly diagnosed) tumour stream, at a regional health service in Victoria, Australia.

Methods

A retrospective cohort study comprising random samples of 75 people newly diagnosed with lung cancer (International Classification of Diseases and Related Health Problems‐10 [ICD‐10] diagnosis codes C34 in the Victorian Cancer Registry [VCR]) and 50 people newly diagnosed with OG cancer (ICD‐10 diagnosis codes C15 or C16 in VCR) at one regional Victorian health service between 2016 and 2017. Binary logistic regression was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs) for associations between patient factors and suboptimal timeliness of care.

Results

In comparison to OG cancer patients, lung cancer patients had reduced odds of suboptimal timeliness of care in reference to times outside OCP for referral to diagnosis (OR [95% CI] = 0.34 [0.14 to 0.83]) but increased odds of suboptimal timeliness for diagnosis to treatment (OR [95% CI] = 2.48 [1.01 to 6.09]).

Conclusion

In the low‐volume OG cancer stream, patients had longer wait times from referral to an MDM, where treatment decisions occur, but shorter time to commencement of first treatment. Conversely in the high‐volume lung cancer group, there was delayed initiation of first treatment following presentation at MDM. There is need to explore ways to fast‐track MDM presentation and commencement of therapy among people diagnosed with low‐volume and high‐volume cancers, respectively.

Centralisation of oesophagectomy in Australia: is only caseload critical?

Objective High caseload is considered one of the most important factors for good outcomes after high-risk surgeries such as oesophagectomy. However, many Australian centres perform low volumes of oesophagectomies due to demographics. The aim of the present study was to audit outcome after oesophagectomy in an Australian low-volume centre over a period of 13 years and to discuss potential contributors to outcome other than just case volume. Methods Perioperative and long-term outcomes of all oesophagectomies over a 13-year period in a low-volume Australian tertiary care centre were analysed retrospectively. Data were compared in subgroups of patients in two separate time periods: 2000-05 (n=23) and 2006-12 (n=24). Results There were two perioperative deaths over the entire 13-year period with no postoperative mortality in the last decade. The complication and long-term survival rates for each of the two separate time periods were similar to those from high-volume centres, more so in the second half of the study period. Conclusions The data suggest that under specific conditions, oesophagectomies can be safely performed even in smaller- or low-volume centres in Australia. The policy of centralisation for these procedures in Australia needs to be carefully tailored to the needs of the population, clinical outcomes, cost-effectiveness and optimal utilisation of existing facilities rather than on caseload alone. What is known about the topic? High caseload is considered one of the most important factors for good outcomes after oesophagectomy and a driving force behind centralisation of this procedure. However, other factors may also affect outcome - such as availability of experienced surgeons, specialist nurses, interventional radiology, gastroenterology, etc. What does this paper add? With the availability of appropriate levels of expertise, infrastructure and specialist nursing staff as is the case in most Australian tertiary centres, good perioperative outcomes can be obtained despite low volumes. Case load only should not be used as a surrogate marker of quality. What are the implications for practitioners? The policy of centralisation for oesophagectomy in Australia needs to be carefully thought out on the basis of population demographics, outcomes and cost-effectiveness, with the appropriate use of existing facilities, rather than on a caseload basis alone.

Reflecting a crisis reaction: Narratives from patients with oesophageal cancer about the first 6 months after diagnosis and surgery

AIM

The aim of the study was to describe patients' experiences of emotional adaption following treatment for oesophageal cancer from diagnosis to 6 months after surgery.

DESIGN

A qualitative interview study using an inductive approach was carried out.

METHODS

Participants were recruited from two university hospitals in Sweden. Ten patients who had been operated for oesophageal cancer with curative intent 6 months earlier and consented to participate in the study were included. Patients who had a disease recurrence were not eligible for inclusion. Participants were interviewed with a semi-structured interview approach. Data were analysed using qualitative content analysis.

RESULTS

One overarching theme was identified; Experiencing a crisis reaction, which comprised three key categories; (a) From emotionally numb to feeling quite alright; (b) From a focus on cure to reflections about a whole new life; and (c) From a severe treatment to suffering an emaciated, non-compliant body, derived from 14 distinct sub-categories.

CONCLUSION

This study highlights the process of emotional adaptation following oesophageal cancer surgery that patients describe when reflecting back on the first 6 months postoperatively pointing to a crisis reaction in this early postoperative period.

Can We Increase the Resection Rate by Minimally Invasive Approach? Experience from 100 Minimally Invasive Esophagectomies

Background

Whether we can increase the resection rate of esophageal cancer by minimally invasive esophagectomy (MIE) is unknown. The aim was to report the number and results of MIE in high-risk patients considered unsuitable for open surgery and compare these results to other operated patients and to high-risk patients not undergoing surgery.

Methods

At Central Finland Central Hospital, between September 2012 and July 2018, the number of operated MIEs was 100. Of these, 10 patients were prospectively considered unfit for open approach. Nineteen additional high-risk patients with operable disease were ruled out of surgery. The short- and long-term outcomes of these 3 groups were compared.

Results

In patients eligible for any approach (n=90), MIE only (n=10), and no surgery (n=19), WHO performance status Grade 0 was observed in 66.7%, 20.0%, and 5.3%, respectively; stair climbing with ≥4 stairs was successfully completed in 77.8%, 50%, and 36.8%, respectively. Between any approach and MIE only groups, rate of major complications (Clavien-Dindo ≥3a) was 6.7% vs. 50.0% (p<0.001) without a difference in median hospital stay (9 vs. 10 days, p=0.542). Readmission rates were 4.4% vs. 30.0% (p=0.003). Survival rates were 100% vs. 80% (p<0.001) at 90-days, 91.5% vs. 66.7% (p=0.005) at 1-year, and 68.9% vs. 53.3% (p=0.024) at 3-years, respectively. In comparison between MIE only and no surgery groups, these survival rates from day of diagnosis were 80% vs. 100%, 68.6% vs. 67.1%, and 45.7% vs. 32.0% (p=0.290), respectively.

Conclusions

By operating patients unsuitable for open approach with MIE, the resection rate increased 11.1%. These high-risk patients had, however, higher early morbidity and reduced long-term survival compared to other operated patients. Though there seems to be long-term benefit of surgery compared to nonsurgical patients, we have to be cautious when offering surgery to those considered unfit for open surgery.

[Hospital volume effects in surgical treatment of gastric cancer : Results of a prospective multicenter observational study]

BACKGROUND

The impact of hospital and surgeon volume on the treatment outcome based on data obtained from cohort and register studies has been controversially discussed in the international literature. The results of large-scale prospective observational studies within the framework of clinical healthcare research may lead to relevant recommendations in this ongoing discussion.

MATERIAL AND METHODS

Within the framework of the prospective multicenter German Gastric Cancer Study 2 (QCGC 2), from 1 January 2007 to 31 December 2009 a total of 2897 patients with the histological diagnosis of gastric cancer from 140 surgical departments were registered and analyzed. The departments were subdivided according to the number of cases into 4 volume groups: I) <5, II) 5-10, III) 11-20 and IV) >20 patients with surgical interventions per year.

RESULTS

Overall 1163 patients (65.6 %) underwent surgical interventions in the departments of groups III and IV. Of the patients 521 (18 %) were scheduled for neoadjuvant treatment but with no significant differences among the various volume groups. In the departments of volume groups I and II subtotal gastric resection was performed significantly more often. Transthoracic extended surgical interventions in cases of a proximal tumor site were significantly more frequent in departments from volume group IV (p <0.001). The proportion of intraoperative fresh frozen sections correlated with the case volume: group I 23.2 % vs. group IV 61.2 %. Overall hospital mortality was 6.1 % and slightly higher in volume group I with 7.8 %. The median survival time and the 5‑year survival rate showed no significant differences between the various volume groups independent of tumor stages. There was a tendency towards a longer median survival time in volume group IV only for proximal tumor sites, i.e. adenocarcinoma of the esophagogastric junction (AEG). Using Cox regression analysis hospital volume did not have an independent impact on long-term survival.

CONCLUSION

Hospital volume effects could only be detected for the treatment of AEG. To improve oncological long-term outcome, centralization of treatment of proximal gastric cancer appears to be recommendable.

Are treatment outcomes in gastric cancer associated with either hospital volume or surgeon volume?

Surgical resection is the only curative treatment for gastric cancer. Postoperative outcomes may be affected by the average or total number of surgeries carried out at an institution (hospital volume) or by a surgeon (surgeon volume). Among seven large‐scale studies that each enrolled over 10 000 patients who underwent gastrectomy, six showed that higher hospital volume contributed to a lower mortality rate after gastrectomy. Surgeon volume was also reported by three of four studies that each included over 1000 patients to be a significant factor contributing to heterogeneity in mortality rates after gastrectomy. In contrast, most studies showed no relationship between hospital volume and postoperative morbidity. A significant long‐term relationship was demonstrated in four of nine studies that each included more than 1000 patients, but the other five studies showed negative results. A recent correlative study of randomized phase III trials for gastric cancer surgeries showed a significant relationship between hospital volume and postoperative morbidity in one trial but not in another trial. There was no correlation between overall survival and either hospital or surgeon volume. In addition, another correlative study of a phase III trial of randomized chemotherapy for unresectable or recurrent gastric cancer found that there was no correlation between hospital volume and overall survival, although there was a large degree of heterogeneity in median overall survival among participating institutions.

In-hospital clinical outcomes after upper gastrointestinal surgery: Data from an international observational study

AIMS

Previous research suggests that patients undergoing upper gastrointestinal surgery are at high risk of poor postoperative outcomes. The aim of our study was to describe patient outcomes after elective upper gastrointestinal surgery at a global level.

METHODS

Prospective analysis of data collected during an international seven-day cohort study of 474 hospitals in 27 countries. Patients undergoing elective upper gastrointestinal surgery were recruited. Outcome measures were in-hospital complications and mortality at 30-days. Results are presented as n(%) and odds ratios with 95% confidence intervals.

RESULTS

2139 patients were included, of whom 498 (23.2%) developed one or more postoperative complications, with 30 deaths (1.4%). Patients with complications had longer median hospital stay 11 (6-18) days vs. 5 (2-10) days. Infectious complications were most frequent, affecting 368 (17.2%) patients. 328 (15.3%) patients were admitted to critical care postoperatively, of whom 161 (49.1%) developed a complication with 14 deaths (4.3%). In a multivariable logistic regression model we identified age (OR 1.02 [1.01-1.03]), American Society of Anesthesiologists physical status III (OR 2.12 [1.44-3.16]) and IV (OR 3.23 [1.72-6.09]), surgery for cancer (OR 1.63 [1.27-2.11]), open procedure (OR 1.40 [1.10-1.78]), intermediate surgery (OR 1.75 [1.12-2.81]) and major surgery (OR 2.65 [1.72-4.23]) as independent risk factors for postoperative complications. Patients undergoing major surgery for upper gastrointestinal cancer experienced twice the rate of complications compared to those undergoing other procedures (224/578 patients [38.8%] versus 274/1561 patients [17.6%]).

CONCLUSIONS

Complications and death are common after upper gastrointestinal surgery. Patients undergoing major surgery for cancer are at greatest risk.

Hospital effect on infections after four major surgical procedures: outlier and volume-outcome analysis using all-inclusive state data

BACKGROUND

Hospital volume is known to have a direct impact on the outcomes of major surgical procedures. However, it is unclear if the evidence applies specifically to surgical site infections.

AIMS

To determine if there are procedure-specific hospital outliers [with higher surgical site infection rates (SSIRs)] for four major surgical procedures, and to examine if hospital volume is associated with SSIRs in the context of outlier performance in New South Wales (NSW), Australia.

METHODS

Adults who underwent one of four surgical procedures (colorectal, joint replacement, spinal and cardiac procedures) at a NSW healthcare facility between 2002 and 2013 were included. The hospital volume for each of the four surgical procedures was categorized into tertiles (low, medium and high). Multi-variable logistic regression models were built to estimate the expected SSIR for each procedure. The expected SSIRs were used to compute indirect standardized SSIRs which were then plotted in funnel plots to identify hospital outliers.

FINDINGS

One hospital was identified to be an overall outlier (higher SSIRs for three of the four procedures performed in its facilities), whereas two hospitals were outliers for one specific procedure throughout the entire study period. Low-volume facilities performed the best for colorectal surgery and worst for joint replacement and cardiac surgery. One high-volume facility was an outlier for spinal surgery.

CONCLUSIONS

Surgical site infections seem to be mainly a procedure-specific, as opposed to a hospital-specific, phenomenon in NSW. The association between hospital volume and SSIRs differs for different surgical procedures.

Administrative data provide vital research evidence for maximizing health-system performance and outcomes

Although the quality of administrative data is frequently questioned, these data are vital for health-services evaluation and complement data from trials, other research studies and registries for research. Trials generally provide the strongest evidence of outcomes in research settings but results may not apply in many service environments. High-quality observational research has a complementary role where trials are not applicable and for assessing whether trial results apply to groups excluded from trials. Administrative data have a broader system-wide reach, enabling system-wide health-services research and monitoring of performance markers. Where administrative data raise questions about service outcomes, follow-up enquiry may be required to investigate validity and service implications. Greater use should be made of administrative data for system-wide monitoring and for research on service effectiveness and equity.

Pancreatectomy is underused in NSW regions with low institutional surgical volumes: a population data linkage study

OBJECTIVE

To examine differences in the proportions of people diagnosed with pancreatic cancer who underwent pancreatectomy, post-operative outcomes and 5-year survival in different New South Wales administrative health regions of residence.

DESIGN, SETTING AND PARTICIPANTS

Retrospective analysis of NSW data on pancreatic cancer incidence and surgery, 2005-2013.

MAIN OUTCOME MEASURES

The proportion of newly diagnosed patients with pancreatic cancer who were resected in each region; 90-day post-operative mortality; one-year post-operative survival; 5-year post-diagnosis survival.

RESULTS

14% of people diagnosed with pancreatic cancer during 2010-2013 (431 of 3064) underwent pancreatectomy, an average of 108 resections per year. After adjusting for age, sex and comorbidities, the proportion that underwent resection varied significantly between regions, ranging between 8% and 21% (P<0.001). Higher resection rates were not associated with higher post-operative 90-day mortality or lower one-year survival (unadjusted and risk-adjusted analyses). Higher resection rates were associated with higher 5-year post-diagnosis survival: the mean survival in regions with resection rates below 10% was 3.4%, compared with 7.2% in regions with rates greater than 15% (unadjusted and adjusted survival analyses; P<0.001). There was a positive association between regional resection rate and the pancreatectomy volume of hospitals during 2005-2009. An additional 32 people would be resected annually if resection rates in low rate regions were increased to the 80th percentile regional resection rate (18%).

CONCLUSION

There is significant geographic variation in the proportion of people with pancreatic cancer undergoing pancreatectomy, and the 5-year survival rate is higher in regions where this proportion is higher.

Conditional Survival of Esophageal Cancer: An Analysis from the SEER Registry (1988-2011)

INTRODUCTION

Conditional survival can provide valuable predictive information for both patients and caregivers for patients surviving over time. The purpose of this study was to estimate conditional survival for esophageal cancer patients through analysis of a national population-based cancer registry.

METHODS

This retrospective cohort study analyzed 64,433 patients within the Surveillance, Epidemiology, and End Results (SEER) data set who were diagnosed with esophageal cancer from 1988 to 2011. Covariates included cancer characteristics and demographics. Overall survival (defined as time from diagnosis until death), cause-specific survival (defined as time from diagnosis until death from cancer), and 5-year conditional survivals (the probability of surviving an additional 5 years) were calculated. Significant prognostic variables of univariate and multivariable models of survival were identified.

RESULTS

The multivariable models of overall and cause-specific survivals included gender, age group, race, relationship status, year of diagnosis, site, grade, histology, and stage group. Although all patients showed an improvement in conditional survival over time, more dramatic improvements were seen in more advanced stage groups. At the 5-year mark, conditional cause-specific survival of distant stage (defined as having spread by direct extension or metastasis to distant organs, tissues, or lymph nodes) increased from 4% to 79%, whereas regional stage increased from 18% to 77% and localized stage increased from 38% to 85%.

CONCLUSIONS

Conditional survival showed improving prognosis over time. Patients with advanced stage had the most dramatic improvement. Clinicians, caregivers, and patients with esophageal cancer can feel encouraged by the improving prognosis with each year survived. This information has practical implications regarding longitudinal follow-up guidelines and survivorship planning.

The value of esophagectomy surgical apgar score (eSAS) in predicting the risk of major morbidity after open esophagectomy

BACKGROUND

Recently, surgical apgar score (SAS) has been reported to be strongly associated with major morbidity after major abdominal surgery. The aim of this study was to assess the value of esophagectomy SAS (eSAS) in predicting the risk of major morbidity after open esophagectomy in a high volume cancer center.

METHODS

The data of all patients who admitted to intensive care unit (ICU) after open esophagectomy at Cancer Hospital of Chinese Academy of Medical Sciences & Peking Union Medical College from September 2008 through August 2010 was retrospectively collected and reviewed. Preoperative and perioperative variables were recorded and compared. The eSAS was calculated as the sum of the points of EBL, lowest MAP and lowest HR for each patient. Patients were divided into high-risk (below the cutoff) and low-risk (above the cutoff) eSAS groups according to the cutoff score with optimal accuracy of eSAS for major morbidity. Univariable and multivariable regression analysis were used to define risk factors of the occurrence of major morbidity.

RESULTS

Of 189 patients, 110 patients developed major morbidities (58.2%) and 30-day operative mortality was 5.8% (11/189). There were 156 high risk patients (eSAS ≤7) and 33 low risk (eSAS >7) patients. Univariable analysis demonstrated that forced expiratory volume in one second of predicted (FEV1%) ≤78% (44% vs. 61%, P=0.024), McKeown approach (22.7% vs. 7.6%, P=0.011), duration of operation longer than 230 minutes, intraoperative estimated blood loss (347±263 vs. 500±510 mL, P=0.015) and eSAS ≤7 (62.2% vs. 90.0%, P=0.001) were predictive of major morbidity. Multivariable analysis demonstrated that FEV1% ≤78% (OR, 2.493; 95% CI, 1.279-4.858, P=0.007) and eSAS ≤7 (OR, 2.810; 95% CI, 1.105-7.144; P=0.030) were independent predictors of major morbidity after esophagectomy. Compared with patients who had eSAS >7, patients who had eSAS ≤7 had longer hospital length of stay (25.39±14.36 vs. 32.22±22.66 days, P=0.030). However, there were no significant differences in ICU length of stay, duration of mechanical ventilation, ICU death, 30-day death rate and in-hospital death rate between high risk and low risk patients.

CONCLUSIONS

The eSAS score is predictive of major morbidity, and lower eSAS is associated with longer hospital length of stay in esophageal cancer patients after open esophagectomy.

Changing roles of population-based cancer registries in Australia

Registries have key roles in cancer incidence, mortality and survival monitoring and in showing disparities across the population. Incidence monitoring began in New South Wales in 1972 and other jurisdictions soon followed. Registry data are used to evaluate outcomes of preventive, screening, treatment and support services. They have shown decreases in cancer incidence following interventions and have been used for workforce and other infrastructure planning. Crude markers of optimal radiotherapy and chemotherapy exist and registry data are used to show shortfalls against these markers. The data are also used to investigate cancer clusters and environmental concerns. Survival data are used to assess service performance and interval cancer data are used in screening accreditation. Registries enable determination of risk of multiple primary cancers. Clinical quality registries are used for clinical quality improvement. Population-based cancer registries and linked administrative data complement clinical registries by providing high-level system-wide data. The USA Commission on Cancer has long used registries for quality assurance and service accreditation. Increasingly population-based registry data in Australia are linked with administrative data on service delivery to assess system performance. Addition of tumour stage and other prognostic indicators is important for these analyses and is facilitated by the roll-out of structured pathology reporting. Data linkage with administrative data, following checks on the quality of these data, enables assessment of patterns of care and other performance indicators for health-system monitoring. Australian cancer registries have evolved and increasingly are contributing to broader information networks for health system management.

Realising opportunities for evidence-based cancer service delivery and research: linking cancer registry and administrative data in Australia

The traditional roles of Australian cancer registries have been incidence, mortality and survival surveillance although increasingly, roles are being broadened to include data support for health-service management and evaluation. In some Australian jurisdictions, cancer stage and other prognostic data are being included in registry databases and this is being facilitated by an increase in structured pathology reporting by pathology and haematology laboratories. Data linkage facilities are being extended across the country at national and jurisdictional level, facilitating data linkage between registry data and data extracts from administrative databases that include treatment, screening and vaccination data, and self-reported data from large population cohorts. Well-established linkage protocols exist to protect privacy. The aim is to gain better data on patterns of care, service outcomes and related performance indicators for health-service management and population health and health-services research, at a time of increasing cost pressures. Barriers include wariness among some data custodians towards releasing data and the need for clearance for data release from large numbers of research ethics committees. Progress is being made though, and proof of concept is being established.