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Objective: The aim was to develop a reliable surgical quality assurance system for 2-stage esophagectomy. This development was conducted during the pilot phase of the multicenter ROMIO trial, collaborating with international experts., Summary of Background Data: There is evidence that the quality of surgical performance in randomized controlled trials influences clinical outcomes, quality of lymphadenectomy and loco-regional recurrence., Methods: Standardization of 2-stage esophagectomy was based on structured observations, semi-structured interviews, hierarchical task analysis, and a Delphi consensus process. This standardization provided the structure for the operation manual and video and photographic assessment tools. Reliability was examined using generalizability theory., Results: Hierarchical task analysis for 2-stage esophagectomy comprised fifty-four steps. Consensus (75%) agreement was reached on thirty-nine steps, whereas fifteen steps had a majority decision. An operation manual and record were created. A thirty five-item video assessment tool was developed that assessed the process (safety and efficiency) and quality of the end product (anatomy exposed and lymphadenectomy performed) of the operation. The quality of the end product section was used as a twenty seven-item photographic assessment tool. Thirty-one videos and fifty-three photographic series were submitted from the ROMIO pilot phase for assessment. The overall G-coefficient for the video assessment tool was 0.744, and for the photographic assessment tool was 0.700., Conclusions: A reliable surgical quality assurance system for 2-stage esophagectomy has been developed for surgical oncology randomized controlled trials., Ethical Approval: 11/NW/0895 and confirmed locally as appropriate, 12/SW/0161, 16/SW/0098.Trial registration number: ISRCTN59036820, ISRCTN10386621., Competing Interests: The authors declare no conflict of interests., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Although robotic techniques have been used for oesophagectomy for many years, whether robot-assisted minimally invasive oesophagectomy (RAMIE) can actually improve outcomes and surpass thoraco-laparoscopic minimally invasive oesophagectomy (MIE) in the success rate of lymph node dissection remains to be empirically demonstrated. Therefore, we performed this systematic review and meta-analysis of case-control studies to systematically compare the effect of lymph node dissection and the incidence of vocal cord palsy between RAMIE and MIE. The PubMed, EMBASE, and Web of Science databases were systematically searched up to December 1, 2019, for case-control studies that compared RAMIE with MIE. Thirteen articles were included, with a total of 1,749 patients with esophageal cancer, including 866 patients in the RAMIE group and 883 patients in the MIE group. RAMIE yielded significantly larger numbers of total dissected lymph nodes (WMD = 1.985; 95% CI, 0.448-3.523; P = 0.011) and abdominal lymph nodes (WMD = 1.686; 95% CI, 0.420-2.951; P = 0.009) as well as lymph nodes along RLN (WMD = 0.729; 95% CI, 0.348-1.109; P < 0.001) than MIE. Additionally, RAMIE could significantly decrease estimated blood loss (WMD = -11.208; 95% CI, -19.358 to -3.058; P = 0.007) and the incidence of vocal cord palsy (OR = 0.624; 95% CI, 0.411-0.947; P = 0.027) compared to MIE. Compared with MIE, RAMIE resulted in a higher total lymph node yield and a higher lymph node yield in the abdomen and along RLN, along with reduced blood loss during surgery and the incidence of vocal cord palsy. Therefore, RAMIE could be considered to be a standard treatment, with less blood loss, lower incidence of vocal cord palsy, and more radical lymph node dissection, exhibiting superiority over MIE., (© The Author(s) 2020. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Histopathological outcomes, such as lymph node yield and margin positivity, are used to benchmark and assess surgical centre quality, and are reported annually by the National Oesophago-Gastric Cancer Audit (NOGCA) in England and Wales. The variation in pathological specimen assessment and how this affects these outcomes is not known., Methods: A survey of practice was circulated to all tertiary oesophagogastric cancer centres across England and Wales. Questions captured demographic data, and information on how specimens were prepared and analysed. National performance data were retrieved from the NOGCA. Survey results were compared for tertiles of lymph node yield, and circumferential and longitudinal margins., Results: Survey responses were received from 32 of 37 units (86 per cent response rate), accounting for 93.1 per cent of the total oesophagectomy volume in England and Wales. Only 5 of 32 units met or exceeded current guidelines on specimen preparation according to the Royal College of Pathologists guidelines. There was wide variation in how centres defined positive (R1) margins, and how margins and lymph nodes were assessed. Centres with the highest nodal yield were more likely to use systematic fat blocking, and to re-examine specimens when the initial load was low. Systematic blocking of lesser curve fat resulted in significantly higher rates of patients with at least 15 lymph nodes examined (91.4 versus 86.5 per cent; P = 0.027)., Conclusion: Preparation and histopathological assessment of specimens varies significantly across institutions. This challenges the validity of currently used surgical quality metrics for oesophageal and other tumours., (© The Author(s) 2020. Published by Oxford University Press on behalf of BJS Society Ltd. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Assessment of quality in oncologic operations traditionally involves use of discrete metrics reported individually. Such metrics have limited value to payers and patients making broad comparisons of clinical programs. We define a composite textbook oncologic outcome for esophagectomy., Methods: The National Cancer Database was queried to identify patients presenting with clinically resectable esophageal cancer between 2004 and 2015. Textbook oncologic outcome was defined as stage-appropriate use of neoadjuvant chemoradiation followed by margin negative esophagectomy with formal lymph node assessment and having no prolonged hospitalization, readmission, or 30-day mortality., Results: Fourteen thousand nine hundred and sixty-nine patients underwent esophagectomy. Of those, 5,561 (37.2%) had textbook oncologic outcome. The overall survival of patients having textbook oncologic outcome was significantly longer than those who did not (52.1 (95% confidence interval [49.0-58.8]) vs 29.1 months (95% confidence interval [29.1-32.3]). On multivariable modeling adjusted for age, comorbid conditions, demographics, treatment characteristics, and esophagectomy volume, volume (odds ratio 1.38, 95% confidence interval [1.16-1.65]) and minimally invasive approach were independently associated with textbook oncologic outcome (odds ratio 1.15, 95% confidence interval [1.02-1.30]), and textbook oncologic outcome was independently associated with improved overall survival (hazard ratio 0.74, 95% confidence interval [0.68-0.80])., Conclusion: Textbook oncologic outcome is achieved in a minority of patients undergoing esophagectomy. Textbook oncologic outcome is independently associated with improved overall survival., (Published by Elsevier Inc.)

Background and Aims: Minimally invasive esophagectomy is a favored alternative in high-volume centers. We evaluated the introduction of, and transition to, minimally invasive esophagectomy at a medium volume tertiary referral center (10-20 esophagectomies annually) with focus on surgical results., Material and Methods: Patients who underwent minimally invasive esophagectomy or open transthoracic surgery for carcinoma of the esophagus or gastroesophageal junction (Siewert I and II) during 2007-2016 were retrospectively studied. Sorted on surgical approach, perioperative data, surgical outcomes, and postoperative complications were analyzed and multivariate regression models were used to adjust for possible confounders., Results: One hundred and sixteen patients were included, 51 minimally invasive esophagectomy (21 hybrid and 30 totally minimally invasive) and 65 open resections. The groups were well matched. However, higher body mass index, neoadjuvant chemoradiotherapy, and cervical anastomosis were more frequent in the minimally invasive esophagectomy group. Minimally invasive esophagectomy was associated with less peroperative bleeding (384 vs 607 mL, p = 0.036) and reduced length of stay (14 vs 15 days, p = 0.042). Duration of surgery, radical resection rate, and postoperative complications did not differ between groups. Lymph node yield was higher in the minimally invasive esophagectomy group, 18 (13-23) vs 12 (8-16), p < 0.001, confirmed in a multivariate regression model (adjusted odds ratio 3.15, 95% class interval 1.11-8.98, p = 0.032)., Conclusion: The introduction of minimally invasive esophagectomy at a medium volume tertiary referral center resulted in superior lymph node yield, less peroperative blood loss and shorter length of stay, without compromising the rate of radical resection, or increasing the complication rate.

Background: Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy., Methods: A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1β, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method., Results: The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1β, IL-6, and TNF-α levels and less pain when coughing after surgery., Conclusions: Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.

Background: Surgeon-level operative mortality is widely seen as a measure of quality after gastric and oesophageal resection. This study aimed to evaluate this alongside a compound-level outcome analysis., Methods: Consecutive patients who underwent treatment including surgery delivered by a multidisciplinary team, which included seven specialist surgeons, were studied. The primary outcome was death within 30 days of surgery; secondary outcomes were anastomotic leak, Clavien-Dindo morbidity score, lymph node harvest, circumferential resection margin (CRM) status, disease-free (DFS), and overall (OS) survival., Results: The median number of annual resections per surgeon was 10 (range 5-25), compared with 14 (5-25) for joint consultant teams (P = 0·855). The median annual surgeon-level mortality rate was 0 (0-9) per cent versus an overall network annual operative mortality rate of 1·8 (0-3·7) per cent. Joint consultant team procedures were associated with fewer operative deaths (0·5 per cent versus 3·4 per cent at surgeon level; P = 0·027). The median surgeon anastomotic leak rate was 12·4 (range 9-20) per cent (P = 0·625 versus the whole surgical range), overall morbidity 46·5 (31-60) per cent (P = 0·066), lymph node harvest 16 (9-29) (P < 0·001), CRM positivity 32·0 (16-46) per cent (P = 0·003), 5-year DFS rate 44·8 (29-60) per cent and OS rate 46·5 (35-53) per cent. No designated metrics were independently associated with DFS or OS in multivariable analysis., Conclusion: Annual surgeon-level metrics demonstrated wide variations (fivefold), but these performance metrics were not associated with survival., (© 2019 The Authors. BJS Open published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.)

Importance: Various clinical societies and patient advocacy organizations continue to encourage minimum volume standards at hospitals that perform certain high-risk operations. Although many clinicians and quality and safety experts believe this can improve outcomes, the extent to which hospitals have responded to these discretionary standards remains unclear., Objective: To evaluate the association between short-term clinical outcomes and hospitals' adherence to the Leapfrog Group's minimum volume standards for high-risk cancer surgery., Design, Setting, and Participants: Longitudinal cohort study using 100% of the Medicare claims for 516 392 patients undergoing pancreatic, esophageal, rectal, or lung resection for cancer between January 1, 2005, and December 31, 2016. Data were accessed between December 1, 2018, and April 30, 2019., Exposures: High-risk cancer surgery in hospitals meeting and not meeting the minimum volume standards., Main Outcomes and Measures: Patients having surgery in hospitals meeting the volume standard and 30-day and in-hospital mortality and complication rates., Results: Overall, a total of 516 392 procedures (47 318 pancreatic resections, 29 812 esophageal resections, 116 383 rectal resections, and 322 879 lung resections) were included in the study, and patient mean (SD) age was 73.1 (7.5) years. Outcomes improved over time in both hospitals meeting and not meeting the minimum volume standards. Mortality after pancreatic resection decreased from 5.5% in 2005 to 4.8% in 2016 (P for trend <.001). Mortality after esophageal resection decreased from in 6.7% 2005 to 5.0% in 2016 (P for trend <.001). Mortality after rectal resection decreased from 3.6% in 2005 to 2.7 % in 2016 (P for trend <.001). Mortality after lung resection decreased from 4.2% in 2005 to 2.7 % in 2016 (P for trend <.001). Throughout the study period, there were no statistically significant differences in risk-adjusted mortality between hospitals meeting and not meeting the volume standards for esophageal, lung, and rectal cancer resections. Mortality rates after pancreatic resection were consistently lower at hospitals meeting the volume standard, although mortality at all hospitals decreased over the study period. For example, in 2016, risk-adjusted mortality rates for hospitals meeting the volume standard were 3.8% (95% CI, 3.3%-4.3%) compared with 5.7% (95% CI, 5.1%-6.5%) for hospitals that did not. Although an increasing majority of patients underwent surgery in hospitals meeting the Leapfrog volume standards over time, the overall proportion of hospitals meeting the standards in 2016 ranged from 5.6% for esophageal resection to 23.3% for pancreatic resection., Conclusions and Relevance: Although volume remains an important factor for patient safety, the Leapfrog Group's minimum volume standards did not differentiate hospitals based on mortality for 3 of the 4 high-risk cancer operations assessed, and few hospitals were able to meet these standards. These findings highlight important tradeoffs between setting effective volume thresholds and practical expectations for hospital adherence and patient access to centers that meet those standards.

Background and Objectives : Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results : Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals ( P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions : After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.

Surgical treatment of oesophagogastric junction adenocarcinomas is based on total gastrectomies or oesophagectomies, which are complex procedures with potentially high morbidity and mortality. Population-based registers show a considerable variability of protocols and outcomes among different hospitals and regions. One of the main strategies to improve global results is centralization at high-volume hospitals, a process that should take into account the benchmarking of processes and outcomes at referral hospitals. Minimally invasive surgery can improve postoperative morbidity while maintaining oncological guaranties, but is technically more demanding than open surgery. This fact underlines the need for structured training and mentorship programs that minimize the impact of surgical teams' training curves without affecting morbidity, mortality or oncologic radicality., (Copyright © 2019 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: It remains unknown how much institutional medical structure and process of implementation of clinical practice guidelines for esophageal cancers can improve quality of surgical outcome in Japan., Methods: A web-based questionnaire survey was performed for departments registered in the National Clinical Database in Japan from October 2014 to January 2015. Quality indicators (QIs) including structure and process indicators (clinical practice guideline adherence) were evaluated on the risk-adjusted odds ratio for operative mortality (AOR) of the patients using registered cases in the database who underwent esophagectomy and reconstruction in 2013 and 2014., Results: Among 916 departments which registered at least one esophagectomy case during the study period, 454 departments (49.6%) responded to the questionnaire. Analyses of 6661 cases revealed that two structure QIs (certification of training hospitals by Japan Esophageal Society and presence of board-certified esophageal surgeons) were associated with significantly lower AOR (p < 0.001 and p = 0.005, respectively). One highly recommended process QI regarding preoperative chemotherapy had strong tendency to associate with lower AOR (p = 0.053). In two process QIs, the answer "performed at the doctor's discretion" showed a significant negative impact on prognosis, suggesting importance of institutional uniformity., Conclusions: The medical institutional structure of board-certified training sites for esophageal surgeons and of participation of board-certified esophageal surgeons improves surgical outcome in Japan. Establishment of appropriate QIs and their uniform implementation would be crucial for future quality improvement of medical care in esophagectomy.

In this review, we would like to illustrate our experience with the da Vinci ® Xi system in case of esophageal surgery. Since the da Vinci ® Xi system was installed in our department, it has resulted in a great improvement in cases of minimally invasive surgery. After the successful establishment in the field of colorectal surgery, the next step was surgery of the upper gastrointestinal tract. Due to the features of the robotic system, we can definitely observe the advantages and a positive effect in case of minimal invasive esophagectomy (MIE). We have also tried to develop an adequate surgical standard of the robotic-assisted minimal invasive esophagectomy with the da Vinci ® Xi.

Background: Since 2013, The Japan Esophageal Society has been certifying "Authorized Institute for Board Certified Esophageal Surgeon (AIBCES)" to contribute to improving national medical care by enhancing the professional knowledge and skills of esophageal surgeons. However, the appropriateness on this certification system has not yet been verified. Our aim was to assess the appropriateness of the institute certification system for esophageal surgeries used by the medical society., Methods: Using data from the National Database of Hospital-based Cancer Registries, we analyzed the 5-year overall survival rates among 2135 patients with thoracic esophageal cancer who underwent an esophagectomy at 53 AIBCES or 141 non-AIBCES., Results: There were 1343 (63%) patients who underwent surgery at an AIBCES and 792 (37%) who underwent surgery at a non-AIBCES. Registered patients were followed up for a median of 53 (range 1-88) months. Over the followed-up period examined, 670 (50%) patients treated at an AIBCES died and 455 (57%) treated at a non-AIBCES died. Comparison of the Kaplan-Meier survival curves indicated that patients with cStage II or cStage III disease treated at an AIBCES had significantly better 5-year survival rates than those treated at a non-AIBCES (55.4% vs. 44.9% and 38.0% vs. 30.3%, respectively). Univariate and multivariate analyses stratified based on stages and adjuvant therapies revealed that institute certification (AIBCES vs. non-AIBCES) is a significant independent factor for 5-year survival., Conclusions: The institute certification system used by the Japan Esophageal Society may be appropriate, as indicated by improved 5-year survival outcomes. The institute certification system has the potential to contribute to a more appropriate medical delivery system in the future.

Background: Benchmarking on an international level might lead to improved outcomes at a national level. The aim of this study was to compare treatment and surgical outcome data from the Swedish National Register for Oesophageal and Gastric Cancer (NREV) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)., Methods: All patients with primary oesophageal or gastric cancer who underwent a resection and were registered in NREV or DUCA between 2012 and 2014 were included. Differences in 30-day mortality were analysed using case mix-adjusted multivariable logistic regression., Results: In total, 4439 patients underwent oesophagectomy (2509 patients) or gastrectomy (1930 patients). Estimated resection rates were comparable. Swedish patients were older but had less advanced disease and less co-morbidity than Dutch patients. Neoadjuvant treatment rates were lower in Sweden than in the Netherlands, both for patients who underwent oesophagectomy (68·6 versus 90·0 per cent respectively; P  < 0·001) and for those having gastrectomy (38·3 versus 56·6 per cent; P  < 0·001). In Sweden, transthoracic oesophagectomy was performed in 94·7 per cent of patients, whereas in the Netherlands, a transhiatal approach was undertaken in 35·8 per cent. Higher annual procedural volumes per hospital were observed in the Netherlands. Adjusted 30-day and/or in-hospital mortality after gastrectomy was statistically significantly lower in Sweden than in the Netherlands (odds ratio 0·53, 95 per cent c.i. 0·29 to 0·95)., Conclusion: For oesophageal and gastric cancer, there are differences in patient, tumour and treatment characteristics between Sweden and the Netherlands. Postoperative mortality in patients with gastric cancer was lower in Sweden.

Background: Minimally invasive esophagectomy (MIE) Ivor Lewis has been increasingly performed over the last two decades. To guide the implementation of this technically demanding procedure, a comprehensive assessment of MIE-Ivor Lewis learning curves should include both the general competence to accomplish the procedure and the ability to generate oncological benefits. These objectives are believed to be associated with different phases of the learning curve., Methods: A retrospective review of the first 109 patients who underwent MIE-Ivor Lewis by a single qualified surgeon was conducted. Relevant variables were collected and assessed by regression analysis to identify suitable indicators for patient stratification and learning curve assessment. Thereafter, the differential analysis was performed among groups to validate the learning curve model., Results: Two variables, intrathoracic gastroesophageal anastomosis time and bilateral recurrent laryngeal nerve (RLN) lymphadenectomy number, which plateaued, respectively, after the 26th and 88th cases, were selected as meaningful indicators to identify different competence levels. Therefore, 109 patients were chronologically subcategorized into three groups (the first 26 MIEs as the early group, the next 62 cases as the middle group, and 21 most recent cases as the late group). Perioperative data were compared between groups with positive results to indicate a three-phase model for a learning curve for MIE-Ivor Lewis., Conclusions: An MIE-Ivor Lewis learning curve should include three discrete phases that indicate, successively, unskilled operation (general competence to accomplish, less proficiency), surgical proficiency, and oncological efficacy. Intrathoracic anastomosis time and bilateral RLN lymphadenectomy were identified as suitable indicators delineate the different stages of an MIE-Ivor Lewis learning curve., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Several medical systems have adopted minimum volume standards for surgical procedures, including lung and esophageal resection. We sought to determine whether these proposed hospital cutoffs are associated with differences in outcomes., Methods: Analyzing the State Inpatient Databases and Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality, we evaluated all patients (aged ≥ 18 years) who underwent lobectomy/pneumonectomy or esophagectomy for cancer in California, Florida, and New York (2009-2011). Hospitals were defined as low volume for each procedure per proposed minimum volume standards by year: <40 lung resections and <20 esophagectomies. We compared demographic data and determined the incidence of complications and mortality between patients operated on at low- versus high-volume hospitals. Propensity matching (of demographic characteristics, income, payer, and comorbidities) was performed to balance the cohorts for analysis., Results: During the time period, 20,138 patients underwent lobectomy/pneumonectomy of which 12,432 operations (61.7%) were performed at low-volume hospitals (n = 456) and 7706 operations were performed at high-volume hospitals (n = 48). Of 1324 patients undergoing esophagectomy, 1087 operations (82.1%) were performed at low-volume hospitals (n = 184), whereas only 237 operations were at high-volume hospitals (n = 6). After propensity matching (lung 1:1 and esophagus 2:1), no major differences were apparent for in-hospital mortality nor major complications for either lung or esophageal resection. Length of stay was longer in low-volume hospitals after lung resection (median 6 vs 5 days; P < .001), but not after esophageal resection., Discussion: Although several groups have publicly called for minimum volume requirements for surgical procedures, the majority of patients undergo lung and esophageal resection at hospitals below the proposed cutoffs. The proposed standards for lung and esophageal resection are not associated with a difference in outcomes in this large administrative database. Efforts should be made to determine more meaningful minimum volume requirements and to determine whether such standards are appropriate., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Minimally invasive esophagectomy has several benefits as an effective alternative treatment for esophageal cancer. The three-phase esophageal resection may be the most popular approach to esophagectomy. Numerous thoracoport designs are available for the thoracoscopic procedure. The present study aims to contribute a distinctive three-port technique that is designed to minimize surgical trauma and facilitate operation during the thoracoscopic procedure. In this paper, we describe and demonstrate the details of the port design and each operation step. Based on our practical experience, the rational combination of the port design and instrument usage of the three-port technique makes the thorascopic procedure more convenient., (© 2018 Wiley Periodicals, Inc.)

Background: Minimally invasive esophagectomy (MIE) is being increasingly performed; however, it is still associated with high morbidity and mortality. The correlation between surgical team proficiency and patient load lacks clarity. This study evaluates surgical outcomes during the first 3-year period after establishment of a new surgical team., Methods: A new surgical team was established in September 2013 by two expert surgeons having experience of performing more than 100 MIEs. We assessed 237 consecutive patients who underwent MIE for esophageal cancer and evaluated the impact of surgical team proficiency on postoperative outcomes, as well as the team learning curve., Results: In the cumulative sum analysis, a point of downward inflection for operative time and blood loss was observed in case 175. After 175 cases, both operative time and blood loss significantly decreased (P < 0.001 and P < 0.001, respectively), and postoperative incidence of pneumonia significantly decreased from 18.9 to 6.5% (P = 0.024). Median postoperative hospital stay also decreased from 20 to 18 days (P = 0.022). Additionally, serum CRP levels on postoperative day 1 showed a significant, but weak inverse association with the number of cases (P = 0.024)., Conclusions: After 175 cases, both operative time and blood loss significantly decreased. In addition, the incidence of pneumonia decreased significantly. Additionally, surgical team proficiency may decrease serum CRP levels immediately after MIE. Surgical team proficiency based on team experience had beneficial effects on patients undergoing MIE.

Background: Textbook outcome is a multidimensional measure representing an ideal course after oesophagogastric cancer surgery. It comprises ten perioperative quality-of-care parameters and has been developed recently using population-based data. Its association with long-term outcome is unknown. The objectives of this study were to validate the clinical relevance of textbook outcome at a hospital level, and to assess its relation with long-term survival after treatment for oesophagogastric cancer., Methods: All patients with oesophageal or gastric cancer scheduled for surgery with curative intent between January 2009 and June 2015 were selected from an institutional database. A Cox model was used to study the association between textbook outcome and survival., Results: A textbook outcome was achieved in 58 of 144 patients (40·3 per cent) with oesophageal cancer and in 48 of 105 (45·7 per cent) with gastric cancer. Factors associated with not achieving a textbook outcome were failure to achieve a lymph node yield of at least 15 (after oesophagectomy) and postoperative complications of grade II or more. After oesophagectomy, median overall survival was longer for patients with a textbook outcome than for patients without (median not reached versus 33 months; P = 0·012). After gastrectomy, median survival was 54 versus 33 months respectively (P = 0·018). In multivariable analysis, textbook outcome was associated with overall survival after oesophagectomy (hazard ratio 2·38, 95 per cent c.i. 1·29 to 4·42) and gastrectomy (hazard ratio 2·58, 1·25 to 5·32)., Conclusion: Textbook outcome is a clinically relevant measure in patients undergoing oesophagogastric cancer surgery as it can identify underperforming parameters in a hospital setting. Overall survival in patients with a textbook outcome is better than in patients without a textbook outcome., (© 2018 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Outcomes of oesophago-gastric cancer are poor and highly variable between centres. It is important that complex multimodal treatments are applied optimally. Low case volumes at Australian centres mean that the analysis of crude outcomes is an inadequate assessment of overall quality of care. Detailed analysis across a range of quality domains offers the opportunity to measure performance., Methods: We compared data from the UK National Oesophago-gastric Cancer Audit 2010 with the prospective Alfred Hospital oesophago-gastric cancer database., Results: There were 314 Alfred and 17 279 UK patients identified. The volume of patients assessed by the Alfred was equal to the second highest quartile in the UK trust (4-5 new cases per month). Case ascertainment was better, capturing 84% of all oesophago-gastric cancer within the Alfred prospective audit (P < 0.001). The use of staging CT and PET scans was more common among Alfred patients (99% versus 89%, P < 0.01 and 83.8% versus 17%, P < 0.01, respectively). More patients embarked on a curative pathway (P < 0.01), with greater use of neo-adjuvant therapies. Acceptable lymph node yields were less in oesophagectomies (88.2% versus 96.2%, P < 0.01) and similar in gastrectomies (77.4% versus 74.6%, P = 0.61). Higher overall complications were observed in Alfred patients (P < 0.01), predominantly due to respiratory complications. Perioperative mortality after resection and 1-year survival was similar., Conclusions: Comparing a range of quality domains as a means of identifying areas of deficiency is feasible. This allows for contemporaneous improvements in service quality and may be more appropriate in the Australian setting than focusing on volume., (© 2016 Royal Australasian College of Surgeons.)

Evidence suggests that structured training programs for laparoscopic procedures can ensure a safe standard of skill acquisition prior to independent practice. Although minimally invasive esophagectomy (MIO) is technically demanding, no consensus on requirements for training for the MIO procedure exists. The aim of this study is to determine essential steps required for a structured training program in MIO using the Delphi consensus methodology. Eighteen MIO experts from 13 European hospitals were asked to participate in this study. The consensus process consisted of two structured meetings with the expert panel, and two Delphi questionnaire rounds. A list of items required for training MIO were constructed for three key domains of MIO, including (1) requisite criteria for units wishing to be trained and (2) to proctor MIO, and (3) a framework of a MIO training program. Items were rated by the experts on a scale 1-5, where 1 signified 'not important' and 5 represented 'very important.' Consensus for each domain was defined as achieving Cronbach alpha ≥0.70. Items were considered as fundamental when ≥75% of experts rated it important (4) or very important (5). Both Delphi rounds were completed by 16 (89%) of the 18 invited experts, with a median experience of 18 years with minimally invasive surgery. Consensus was achieved for all three key domains. Following two rounds of a 107-item questionnaire, 50 items were rated as essential for training MIO. A consensus among European MIO experts on essential items required for training MIO is presented. The identified items can serve as directive principles and core standards for creating a comprehensive training program for MIO.

Objective: To define "best possible" outcomes in total minimally invasive transthoracic esophagectomy (ttMIE)., Background: TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy., Patients and Methods: From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ≤2, WHO/ECOG score ≤1, age ≤65 years, body mass index 19-29 kg/m). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results., Results: Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53-62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0-2) and 12 (9-18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ≤55.7% and ≤30.8% for overall and major complications, ≤18.0% for readmission, ≤3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ≤1.0% and ≤4.6% for mortality, and ≤40.8 and ≤42.8 for the comprehensive complication index, respectively., Conclusion: This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.

Background: Surgery for benign esophageal disease is mostly performed either by general surgeons (GS) or cardiothoracic surgeons (CTS) in the United States. The purpose of this study was to evaluate the effect of surgeon specialty on perioperative outcomes of surgery for benign esophageal diseases., Materials and Methods: We have conducted a retrospective analysis using the ACS-NSQIP during the period of 2006-2013. Patients who underwent paraesophageal hernia (PEH) repair, gastric fundoplication, or Heller esophagomyotomy were divided into two groups according to the specialty of the surgeon (GS or CTS). Outcomes compared between the two groups using multivariable logistic regression included 30-day mortality, overall morbidity, discharge destination, hospital length of stay (LOS), and readmission rates., Results: Most of the surgeries were performed by general surgeons (PEH: 97.1%; fundoplication: 97.6%; Heller: 91.6%). Patients had lower comorbidities, better physical condition, and underwent a laparoscopic approach more frequently in the GS group. Regression analysis showed that GS group had a lower mortality rate (operating room, 0.44; 95% confidence interval [CI]: 0.23-0.86; P = .017), shorter LOS, and more home discharge for patients undergoing PEH repair. Mortality, morbidity, readmission, LOS, and home discharge were comparable between GS and CTS in fundoplication and Heller esophagomyotomy., Conclusion: GS perform most of esophageal surgeries for benign diseases. GS group has better outcomes in PEH repair compared with CTS, whereas there is no difference in the overall outcomes between GS and CTS in fundoplication and Heller esophagomyotomy. These results show that specialization is not always the answer to better outcomes. Difference in outcomes, however, might be related to disease severity, approach needed, or case volume.

Background: Quality assurance is acknowledged as a crucial factor in the assessment of oncological surgical care. The aim of this study was to develop a composite measure of multiple outcome parameters defined as 'textbook outcome', to assess quality of care for patients undergoing oesophagogastric cancer surgery., Methods: Patients with oesophagogastric cancer, operated on with the intent of curative resection between 2011 and 2014, were identified from a national database (Dutch Upper Gastrointestinal Cancer Audit). Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. Hospital variation in textbook outcome was analysed after adjustment for case-mix factors., Results: In total, 2748 patients with oesophageal cancer and 1772 with gastric cancer were included in this study. A textbook outcome was achieved in 29·7 per cent of patients with oesophageal cancer and 32·1 per cent of those with gastric cancer. Adjusted textbook outcome rates varied from 8·5 to 52·4 per cent between hospitals. The outcome parameter 'at least 15 lymph nodes examined' had the greatest negative impact on a textbook outcome both for patients with oesophageal cancer and for those with gastric cancer., Conclusion: Most patients did not achieve a textbook outcome and there was wide variation between hospitals., (© 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Quality measures for patients with early and locally advanced esophageal cancer undergoing esophagectomy have been made by national organizations. The rate of adherence to these measures as well as their association with overall survival are unknown., Methods: Esophagectomy patients were abstracted from the National Cancer Database. Because neoadjuvant status was available since 2006, the analysis of locally advanced patients began at this time point. Selected measures included: R0 resection, evaluation of 15 or more lymph nodes, and induction therapy for locally advanced tumors. Multivariate models identified variables associated with achieving quality measures. A Cox proportional hazards model evaluated factors associated with mortality., Results: From 1998 to 2012, 4,908 of 16,040 (30.6%) early-stage esophageal cancer patients (clinical T1A to T2N0 <2cm, well-differentiated) underwent esophagectomy. Of 4,672 patients 4,518 (96.7%) achieved R0 resection and 1,395 of 4,686 (29.8%) had 15 or more lymph nodes sampled. High-volume center type (>20 esophagectomies/year) was independently associated with meeting both measures (odds ratio [OR] 2.2, 95% confidence interval [CI]: 1.9 to 2.5). From 2006 to 2012, 7,747 of 20,437 (37.9%) locally advanced patients (clinical Stage IIB to IIIB) received esophagectomy. Of 6,966 patients 5,977 (85.8%) received induction therapy, 6,394 (91.8%) had R0 resection, and 2,852 (40.9%) had 15 or more lymph nodes sampled. High-volume center type was, again, associated with increased likelihood of meeting all quality measures (OR 2.17, 95% CI: 1.92 to 2.46). Meeting all quality measures was associated with the largest decrease in mortality for both early-stage (hazard ratio [HR] 0.27, 95% CI: 0.18 to 0.39) and locally advanced (HR 0.54, 95% CI: 0.40 to 0.73) esophageal cancer patients., Conclusions: Adherence to recommended quality measures is independently associated with improved overall survival in both early and locally advanced stages of esophageal cancer. Currently, few patients are receiving care in accordance with these recommendations., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background and Objectives: In 1975, a modification of popular two-stage Ivor-Lewis oesophagectomy was published with synchronous resection in chest and abdomen. As data on this technique are rare and inconsistent, we aimed to investigate safety, feasibility, and outcome of this approach., Methods: Outcome of 201 patients undergoing synchronous oesophagectomy from 2000 to 2013 was analysed retrospectively. Two groups (early: 2000-2006; late: 2007-2013) were analysed to allow comparison of outcome over time., Results: Patients in the later period had fewer respiratory comorbidities (P = 0.010), median blood loss decreased significantly over time while lymph node yield increased (P < 0.001). Overall complications occurred in 58.9 (early) versus 51.7% (late) of patients (P = 0.320), anastomotic leaks in 14.3 versus 6.7% (P = 0.112), respiratory complications in 48.2 versus 34.8% (P = 0.063). Thirty-day/90-day mortality was 2.7% versus 3.4, respectively, 8.1% versus 6.8% (P ≤ 0.793). Long-term survival was better in the later cohort (P = 0.004)., Conclusions: Our data of 201 patients over a period of 14 years suggests that this technique is a quick, feasible, safe, and reasonable alternative to standard two-stage Ivor-Lewis oesophagectomy. Quality of this approach and ultimate outcomes have improved over time, with similar complication rates/outcomes to literature accepted standards for two-stage approach, especially in the later time period. J. Surg. Oncol. 2016;114:719-724. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Objective: Robotic-assisted minimally invasive esophagectomy (RAMIE) is an emerging complex operation with limited reports detailing morbidity, mortality, and requirements for attaining proficiency. Our objective was to develop a standardized RAMIE technique, evaluate procedure safety, and assess outcomes using a dedicated operative team and 2-surgeon approach., Methods: We conducted a study of sequential patients undergoing RAMIE from January 25, 2011, to May 5, 2014. Intermedian demographics and perioperative data were compared between sequential halves of the experience using the Wilcoxon rank sum test and the Fischer exact test. Median operative time was tracked over successive 15-patient cohorts., Results: One hundred of 313 esophageal resections performed at our institution underwent RAMIE during the study period. A dedicated team including 2 attending surgeons and uniform anesthesia and OR staff was established. There were no significant differences in age, sex, histology, stage, induction therapy, or risk class between the 2 halves of the study. Estimated blood loss, conversions, operative times, and overall complications significantly decreased. The median resected lymph nodes increased but was not statistically significant. Median operative time decreased to approximately 370 minutes between the 30th and the 45th cases. There were no emergent intraoperative complications, and the anastomotic leak rate was 6% (6/100). The 30-day mortality was 0% (0/100), and the 90-day mortality was 1% (1/100)., Conclusions: Excellent perioperative and short-term patient outcomes with minimal mortality can be achieved using a standardized RAMIE procedure and a dedicated team approach. The structured process described may serve as a model to maximize patients' safety during development and assessment of complex novel procedures.

Objective: To examine the content and quality of written information provided by surgical centres for patients undergoing oesophagectomy for cancer., Design: Cross-sectional study of the content of National Health Service (NHS) patient information leaflets (PILs) about oesophageal cancer surgery, using a modified framework approach., Data Sources: Written information leaflets from 41 of 43 cancer centres undertaking surgery for oesophageal cancer in England and Wales (response rate 95.3%)., Eligibility Criteria: All English language versions of PILs about oesophagectomy., Results: 32 different PILs were identified, of which 2 were generic tools (Macmillan 'understanding cancer of the gullet' and EIDO 'oesophagectomy'). Although most PILs focused on describing in-hospital adverse events, information varied widely and was often misleading. Just 1 leaflet described survival benefits of surgery and 2 mentioned the possibility of disease recurrence., Conclusions: Written information provided for patients by NHS cancer centres undertaking oesophagectomy is inconsistent and incomplete. It is recommended that surgeons work together with patients to agree on standards of information provision of relevance to all stakeholders' needs., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

A previously published study regarding the outcomes of oesophagectomy at a provincial hospital identified issues with perioperative care (Al-Herz et al 2012). The aim of this study was to evaluate the effect of changes in management at the institution concerned. This was a cohort study which compared the outcomes of 30 patients undergoing oesophagectomy before the unit audit and 30 patients after it. Demographics, operative details, recovery parameters, and oncological data were collected retrospectively. There was a significant reduction in the use of intravenous fluid, both intraoperatively (6.6 vs 3.3L, P < 0.0001) and during the first 24 hours (9.2 vs 5.5L, P < 0.0001). Patients were extubated three days earlier (P < 0.001) after the audit, and the percentage of patients requiring tracheostomy was smaller (26.7% vs 0%, P = 0.003). The length of total hospital stay was shorter (15 vs 13 days, P = 0.035). We conclude that the publication of a unit audit changed perioperative practice and resulted in a significant improvement in the short term outcomes after oesophagectomy.

Multicentre, randomised, controlled trials (RCTs) provide level 1 evidence for surgery in the treatment of gastro-oesophageal cancer. This systematic review investigated whether standardisation of surgical techniques in RCTs reduces the variation in lymph-node harvest, in-hospital mortality, and locoregional cancer recurrence. The range in the coefficients of variation for lymph-node harvest (0.07-0.61), proportion of patients with locoregional cancer recurrence (1.1-46.2%), and in-hospital mortality (0-10%) was wide. Credentialing of surgeons through assessment of operative reports and monitoring of their performance through data collection were important factors that reduced the variation in lymph-node harvest. Factors that reduced adjusted in-hospital mortality included credentialing surgeons through procedural volume and operative reports, and standardisation of surgical techniques. Future RCTs should include an assessment of surgical performance as an important aspect of study design to reduce variation in clinical outcomes., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Objective: To analyze survival differences between transthoracic esophagectomy (TTE) and limited transhiatal esophagectomy (THE) in clinically (cT3) and pathologically (pT3) staged advanced tumors without neoadjuvant treatment., Background: Debate exists whether in the type of resection in locally advanced cancer plays a role in prognosis and whether THE is a valuable alternative to TTE regarding oncological doctrine and overall survival., Methods: In a retrospective study of 2 high-volume centers, 468 patients with cT3NXM0 esophageal cancer, including 242 (51.7%) squamous cell carcinomas (SCCs) and 226 (48.3%) adenocarcinomas (ACs), were analyzed. A total of 341 (72.9%) TTE and 127 (27.1%) THE were performed. We used the propensity score matching to build comparable groups. Primary endpoint was the overall survival; secondary endpoints included resection status and lymph node yield., Results: TTE achieved a higher rate of R0 resections (86.2% vs 73.2%; P = 0.001) and a higher median lymph node yield (27.0 ± 12.4 vs 17.0 ± 6.4; P < 0.001) than THE. Thirty-day mortality rate was 6.6% (8/121) for TTE and 7.4% (9/121) for THE (P = 0.600). In the matched groups, TTE was beneficial for pT3 SCC (P = 0.004), pT3 AC (P = 0.029), cT3 SCC (P = 0.018), and cT3 AC (P = 0.028) patients. TTE was either beneficial in pN2 disease for cT3 AC + SCC or pT3 SCC but not for pT3 AC patients, without nodal stratification in pT3 and cT3 SCC node-positive patients. On multivariable analysis, TTE remained an independent factor for survival., Conclusions: Extended TTE achieved a higher rate of R0 resections, a higher lymph node yield, and resulted in a prolonged survival than THE in pT3, cT3, and node-positive patients.

Objective: To describe causes of death in the first year after esophagectomy and determine the time frame that should be used for measurement of quality of surgery. A case-mix adjustment model was developed for the comparison between hospitals., Background: The time period in which postoperative mortality should be measured as a performance indicator is debated., Methods: Cause of death was identified for patients in a tertiary referral hospital who died within 1 year after surgery and classified as surgery related or not surgery related. Sensitivity and specificity for detecting deaths related to surgery were calculated for different periods of follow-up. Case-mix adjustment models for 30-day mortality (30DM), in-hospital mortality, and 90-day mortality (90DM) were developed., Results: In total, 1282 patients underwent esophagectomy. 30DM was 2.9%, the in-hospital mortality rate was 5.1% and 90DM was 7%. Beyond 30 days, a substantial number of deaths were related to the operation, especially due to anastomotic leakage. Postdischarge nononcological mortality was most frequently caused by sudden death. One in 5 patients died because of recurrent disease, being the most important threat in the first year after surgery. The 30DM had a sensitivity for detecting surgery-related deaths of 33% and a specificity of 100%. The 90DM had a sensitivity of 74% and a specificity of 96%., Conclusions: A period of postoperative follow-up longer than 30 days needs to be considered when comparing surgical performance between institutes. In the case-mix adjustment model for 90DM, no other variables have to be taken into account compared to those involved in 30DM.

Background: The aim of this study is to determine the effect of the implementation and evolution of a multidisciplinary esophagectomy care pathway on postoperative outcomes over a 20-year experience., Study Design: All patients undergoing esophagectomy for cancer between 1991 and 2012 were included. Patients were divided into four groups (Gp1 1991-1996, Gp2 1997-2002, Gp3 2003-2007, and Gp4 2008-2012)., Results: Five hundred and ninety-five patients were included (Gp1 92, Gp2 159, Gp3 161, and Gp4 183). Age remained consistent over time; however, a progressive significant increase was observed in BMI and Charlson comorbidity index. Increases were also noted in patients with clinical stage III cancers, in the use of neoadjuvant chemoradiotherapy, in salvage esophagectomy and in the utilization of pretreatment jejunostomy. We observed a significant reduction in estimated blood loss (EBL) and operative room IV fluid administration (ORFA) during the study period. Median ICU stay and length of hospital stay (LOS) (10 (5-50) to 8 (5-115) days) decreased over time. In-hospital mortality (0.3 %) and postoperative complications remained consistent over time. cumulative sum (CUSUM) analysis showed that EBL, ORFA, and LOS all declined during the study period, reaching mean values at case 120, 310, and 175, respectively., Conclusions: The results of this study show that process improvement within the pathway is likely more significant than the level of comorbidities, application of neoadjuvant chemoradiation, or technical approach in patients undergoing esophagectomy.

Worldwide an increasing part of oncologic oesophagectomies is performed in a minimally invasive way. Over the past decades multiple reports have addressed the perioperative outcomes and oncologic safety of minimally invasive oesophageal surgery. Although many of these (retrospective) case-control studies identified minimally invasive oesophagectomy as a safe alternative to open techniques, the clear benefit remained subject to debate. Recently, this controversy has partially resolved due to the results of the first randomized controlled trial that compared both techniques. In this trial short-term benefits of minimally invasive oesophagectomy were demonstrated in terms of lower incidence of pulmonary infections, shorter hospital stay and better postoperative quality of life. However, the current lack of long-term data on recurrence rate and overall survival precludes a comprehensive comparison of minimally invasive and open oesophagectomy. Proclaiming minimally invasive oesophagectomy as the standard of care for patients with resectable oesophageal cancer would therefore be a premature decision., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Thoracoscopic esophagectomy in the prone position (TEPP) might enable solo-surgery in cases requiring resection of the esophagus and the surrounding lymph nodes due to the associated advantages of good exposure of the surgical field and ergonomic considerations for the surgeon. However, no one approach can be for all patients requiring extensive lymphadenectomy. We recently developed an assistant-based procedure to standardize exposure of the surgical field. Patients were divided into 1 of 2 groups:a pre-standardization group (n=37) and a post-standardization group (n=28). The thoracoscopic operative time was significantly shorter (p=0.0037) in the post-standardization group (n=28; 267 ± 31 min) than in the pre-standardization group (n=37;301 ± 53 min). Further, learning curve analysis using the moving average method showed stabilization of the thoracoscopic operative time after the standardization. No significant differences were found in the number of mediastinal lymph nodes dissected or intraoperative blood loss between the 2 groups. There were also no significant differences in the complication rate. Assistant-based surgery and standardization of the procedure resulted in a well-exposed and safe surgical field. TEPP decreased the operative time, even in patients requiring extensive lymphadenectomy.

Background: To analyze treatment outcomes and patterns of recurrence, and to examine the impact of adjuvant postoperative radiotherapy (PORT) after esophagectomy in esophageal squamous cell carcinoma (SqCC) regarding the status of circumferential resection margin (CRM)., Patients and Methods: We performed a retrospective review of esophageal cancer patients operated in Seoul National University Hospital between 2003 and 2010. Pathologically proven T3 SqCC patients with written reports mentioning the status of CRM were selected. Fifty-nine out of 71 patients (83.1%) had CRM+. Twenty-eight patients had radiotherapy in CRM+ and CRM-, respectively. The median follow-up period was 17.1 months (range: 5.2-63.1)., Results: Median survival and 2-year overall survival were 13.8 months and 41.9% in CRM+, and 27.3 months and 74.1% in CRM-, respectively. Loco-regional relapse-free survival (LRRFS) rate at 2 years was 33.6% and 74.1% in each groups (P = 0.029). Loco-regional recurrence was the major pattern of failure in CRM+. PORT did not improve LRRFS., Conclusion: The esophageal SqCC patients with CRM+ after resection showed worse LRRFS. This finding validated the prognostic value of CRM status. Nevertheless, we failed to demonstrate the benefits of adjuvant PORT in CRM+. This might suggest the necessity of neoadjuvant therapy to decrease the CRM+ rate after esophagectomy., (Copyright © 2012 Wiley Periodicals, Inc.)

Aim: Centralisation of oesophageal resection for cancer remains an area of debate. However, no consensus for the requirements of high volume centres yet exists and some low volume centres have been able to produce a comparable outcome. With the small population of New Zealand more than one high volume centre might not be achievable. We reviewed our series of oesophageal resections and compared them to outcomes in the literature to challenge the need for only high volume centres within New Zealand, Methods: A retrospective analysis of all consecutive oesophagogastrectomies performed in Christchurch Public Hospital (Christchurch City, New Zealand) from January 1998 until June 2009 was undertaken., Results: Within this period 128 oesophagogastrectomies were performed. Median admission duration was 12 days. The overall complication rate was 53.9% of which 5.5% was an anastomotic leak. Combined in-hospital and 30-day-mortality was 1.6% (2/128). The 5-year-survival was 32.4% for adenocarcinoma and 47.7% for squamous cell carcinoma. Conclusion This series has shown that a low volume centre within New Zealand is able to deliver a satisfactory level of care for oesophagectomy. Given New Zealand's low population density it is debatable to what extent care should be centralised for treatment of oesophageal carcinoma.

Objectives: The aim of this study was to assess the experience of a high-volume centre with thoracolaparoscopy radical oesophagectomy and to evaluate the feasibility, tumour clearance, the learning curve and reproducibility of this technique., Methods: Eighty patients with thoracic oesophageal cancer who underwent thoracolaparoscopic oesophagectomy (TLE) were enrolled in this study. Two attending surgeons (Mingqiang Kang and Ruobai Lin) independently performed the procedure as operating surgeons. The 60 patients who had surgery performed on them by the senior attending surgeon, Mingqiang Kang, were divided into three groups of 20 patients: groups A, B and C. The results from the three groups were compared in order to detect any changes in the success of TLE as a way of monitoring the development of the surgeon's technical skill. Another 20 patients had surgery performed on them by the new attending surgeon, Ruobai Lin, and were classified into the fourth group, D. The results from Group D were compared with those of the other three groups to evaluate the reproducibility of our technique., Results: There was no significant difference between the four groups with respect to age, gender, location of tumour or staging. The duration of both the thoracoscopic and laparoscopic procedures was significantly longer in Group A. The amount of estimated blood loss was significantly more in Group A than in the other groups. The number of lymph nodes dissected was similar in Groups A and D, whereas that of retrieved nodes was larger in Groups B and C. There was no significant difference in the incidence of respiratory complications, recurrent nerve palsy, anastomotic leaks, arrhythmia, chylothorax and delayed gastric emptying among the four groups., Conclusions: When TLE procedures are started in units with a large volume of oesophageal resections, and when there is support from colleagues within the unit, transition from open to TLE can be achieved safely, with a satisfactory oncological outcome. A plateau of TLE skill was reached after 40 cases had been performed. If mini-fellowship training with supervision from senior surgeons is used, it is possible for a new attending surgeon to attain the requisite basic skill to perform TLE in a relatively short period of time.

Background: Multimodal strategies before surgery are often used to improve outcomes, but disease progression (precluding surgical resection) and inoperability at planned surgery still occur following neoadjuvant treatment. The standards of reporting of these outcomes have not previously been considered. This study examined reporting of rates of progression to surgical resection and inoperability at planned surgery following neoadjuvant treatment in surgical oncology, using esophageal cancer as a case study., Methods: A systematic review identified randomized trials and prospective nonrandomized studies reporting short-term outcomes of neoadjuvant treatment and surgery for esophageal cancer., Results: Of 4,763 abstracts, 224 papers were retrieved and 76 studies included (8 randomized trials and 68 cohort studies of 19,441 esophagectomies). Articles reported outcomes of preoperative chemotherapy (n = 33, 43.4 %), chemoradiotherapy (n = 13, 17.1 %), or both within one paper (n = 18, 23.7 %) and 12 (15.8 %) did not specify the type of neoadjuvant treatment. Also, 20 papers (26.3 %) reported numbers of patients not progressing to surgery after neoadjuvant treatment (with rates of nonprogression ranging between 2.0 and 35.3 %). In addition, 24 papers (31.6 %) reported rates of inoperability at planned surgery (with inoperability rates ranging between 0 and 26.2 %). More randomized controlled trials (RCTs) than observational studies reported nonprogression (4 randomized and 16 nonrandomized studies, 95 % CI -9.6 to 62.6 %, p = 0.108) and inoperability (6 randomized trials and 18 observational studies, 95 % CI 16.8-80.3 %, p = 0.005). Some 17 and 10 articles provided reasons for the observed rates of nonprogression and inoperability, respectively., Conclusions: Reporting rates of progression to surgery after neoadjuvant treatment and inoperability at planned surgery for esophageal cancer were poor, limiting data synthesis and comparisons. It is suggested that core outcome sets for trials in surgical oncology are developed with inclusion of these important endpoints. Collaboration between medical and surgical oncologists is necessary to achieve this.

Introduction: The Agency for Healthcare Research and Quality and the Leapfrog Group use hospital procedure volume as a quality measure for pancreatic resection (PR), abdominal aortic aneurysm (AAA) repair, esophageal resection (ER), and coronary artery bypass grafting (CABG). However, controversy exists regarding the strength and validity of the evidence for the volume-outcome association. The purpose of this study was to reevaluate the volume-outcome relationship for these procedures., Methods: Discharge data for 261,412 patients were extracted from the 2008 Nationwide Inpatient Sample. The relationship between hospital procedure volume and mortality was rigorously assessed using hierarchical general linear modeling with restricted cubic splines, adjusted for patient demographics, comorbid disease, and elective procedure status., Results: Unadjusted mortality rates were PR (4.7%), AAA (12.7%), ER (5.8%), and CABG (2.2%), and the majority of operations were elective. Hospital procedure volume was not a statistically significant predictor of in-hospital mortality for any of the 4 procedures. Strong predictors of mortality included age, elective procedure status, renal failure, and malnutrition (P < 0.001). Each of the models demonstrated excellent performance in estimating the probability of death., Conclusions: Hospital procedure volume is not a significant predictor of mortality for the performance of pancreatectomy, AAA repair, esophagectomy, or CABG. Procedure volume by itself should not be used as a proxy measure for surgical quality. Patient mortality risk is primarily attributable to patient-level characteristics such as age and comorbidity.

Objective: To assess the value of a novel composite measure for identifying the best hospitals for major procedures., Data Source: We used national Medicare data for patients undergoing five high-risk surgical procedures between 2005 and 2008., Study Design: For each procedure, we used empirical Bayes techniques to create a composite measure combining hospital volume, risk-adjusted mortality with the procedure of interest, risk-adjusted mortality with other related procedures, and other variables. Hospitals were ranked based on 2005-2006 data and placed in one of three groups: 1-star (bottom 20 percent), 2-star (middle 60 percent), and 3-star (top 20 percent). We assessed how well these ratings forecasted risk-adjusted mortality rates in the next 2 years (2007-2008), compared to other measures., Principal Findings: For all five procedures, the composite measures based on 2005-2006 data performed well in predicting future hospital performance. Compared to 1-star hospitals, risk-adjusted mortality was much lower at 3-star hospitals for esophagectomy (6.7 versus 14.4 percent), pancreatectomy (4.7 versus 9.2 percent), coronary artery bypass surgery (2.6 versus 5.0 percent), aortic valve replacement (4.5 versus 8.5 percent), and percutaneous coronary interventions (2.4 versus 4.1 percent). Compared to individual surgical quality measures, the composite measures were better at forecasting future risk-adjusted mortality. These measures also outperformed the Center for Medicare and Medicaid Services (CMS) Hospital Compare ratings., Conclusion: Composite measures of surgical quality are very effective at predicting hospital mortality rates with major procedures. Such measures would be more informative than existing quality indicators in helping patients and payers identify high-quality hospitals with specific procedures., (© Health Research and Educational Trust.)

Minimally invasive esophagectomy (MIE) has been increasingly performed to treat esophageal cancer. Studies published between 1990 and 2012 that described the use of MIE for cancer in at least 50 patients were included for systematic review. The literature search retrieved 34 publications comprising 18 case series, 15 comparative studies, and 1 randomized control trial. Results revealed a wide variability in surgical techniques and perioperative outcomes with a lack of standardized definitions of postoperative complications. In most studies, radical formal lymphadenectomy was not performed and the lymph node harvest fell below the minimum number recommended to achieve survival benefits. There is a need to reach a consensus regarding surgical approaches in MIE, the definition of postoperative complications and the extent of lymphadenectomy before embarking on further randomized controlled trials comparing MIE vs. open approach., (Copyright © 2012. Published by Elsevier Inc.)

A best evidence topic in surgery was written according to a structured protocol. The question addressed was whether laparoscopic mobilisation of the stomach as part of a trans-thoracic oesophageal resection results in improved peri-operative outcomes as compared with an open approach. 319 papers were found using the reported search; the 5 representing the best evidence to answer the question are discussed. The evidence on this subject is poor, none of the studies were randomised and only one was prospective. We conclude that laparoscopically-assisted gastric mobilisation during trans-thoracic oesophageal resection may have advantages over open surgery in terms of short-term peri-operative outcomes including reduced blood loss, reduced dependence on ventilatory support and shortened intensive care and overall hospital stay. However there was no difference between laparoscopic and open surgery in terms of overall morbidity or mortality rates., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

A best evidence topic was written according to a structured protocol. The question addressed was whether endoscopic mucosal resection (EMR) for early oesophageal cancer gives equivalent oncological outcomes as compared to oesophagectomy. A total of 340 papers were found using the reported searches of which 7 represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. Oesophagectomy with lymph node dissection for early oesophageal cancer is the standard to which every other treatment modality is compared to. However, the associated mortality and morbidity rates highlight the need for the development of effective, less invasive procedures. The evidence from the present review supports the use of EMR in this context as a first line treatment in T1a (mucosal) oesophageal cancer. The trade-off is a higher recurrence rate which can be dealt with successfully using a tight follow-up schedule and retreatment. The higher rates of lymph node involvement in T1b (submucosal) cancers preclude the use of endoscopic treatment in this setting except for patients unfit for surgery., (Copyright © 2012 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.)

Purpose: In the new era of revalidation, there is an increasing need to measure surgical outcome objectively. We apply a graphical method, the Variable Life Adjusted Display (VLAD), to esophagogastric resection for malignancy. This technique charts the cumulative difference between expected and actual risk-adjusted mortality over time, allowing observation of performance trends irrespective of case-mix., Methods: P-POSSUM was applied retrospectively to 182 consecutive patients who underwent resection for esophageal or gastric malignancy in a district general hospital. The primary outcome measured was 30-day mortality., Results: A total of 168 patients were eligible for inclusion, with a median age of 68 years. The overall 30-day mortality rate was 4.2% compared with 7.1% as predicted by P-POSSUM. The resulting VLAD plot demonstrates an upward trend of better than predicted surgical performance., Conclusions: VLAD has been hereby applied to esophagogastric surgery and has graphically demonstrated risk-adjusted trends in a single general surgeon's performance. For qualitative comparative purposes, including recertification, VLAD is judged to be a simple, directly interpretable, and useful technique for monitoring surgical performance.