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. 2024 Apr 1;7(4):e246556.
doi: 10.1001/jamanetworkopen.2024.6556.

Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes

Mirte H M Ketel  1 , Bastiaan R Klarenbeek  1 , Inger Abma  2 , Eric H J Belgers  3 , Peter-Paul L O Coene  4 , Jan Willem T Dekker  5 , Peter van Duijvendijk  6 , Marloes Emous  7 , Suzanne S Gisbertz  8   9 , Jan Willem Haveman  10 , Joos Heisterkamp  11 , Grard A P Nieuwenhuijzen  12 , Jelle P Ruurda  13 , Johanna W van Sandick  14 , Pieter C van der Sluis  15 , Marc J van Det  16 , Stijn van Esser  5 , Simon Law  17 , Wobbe O de Steur  18 , Meindert N Sosef  3 , Bas Wijnhoven  14 , Gerjon Hannink  19 , Camiel Rosman  1 , Frans van Workum  1   20 ; MIE-CAT Netherlands Collaborative Group
Collaborators, Affiliations

Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes

Mirte H M Ketel et al. JAMA Netw Open. .

Abstract

Importance: Suboptimal surgical performance is hypothesized to be associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association may lead to programs that promote better surgical performance of MIE and improve patient outcomes.

Objective: To investigate associations between surgical performance and postoperative outcomes after MIE.

Design, setting, and participants: In this nationwide cohort study of 15 Dutch hospitals that perform more than 20 MIEs per year, 7 masked expert MIE surgeons assessed surgical performance using videos and a previously developed and validated competency assessment tool (CAT). Each hospital submitted 2 representative videos of MIEs performed between November 4, 2021, and September 13, 2022. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit between January 1, 2020, and December 31, 2021, were included to examine patient outcomes.

Exposure: Hospitals were divided into quartiles based on their MIE-CAT performance score. Outcomes were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Transthoracic MIE with gastric tube reconstruction.

Main outcome and measure: The primary outcome was severe postoperative complications (Clavien-Dindo ≥3) within 30 days after surgery. Multilevel logistic regression, with clustering of patients within hospitals, was used to analyze associations between performance and outcomes.

Results: In total, 30 videos and 970 patients (mean [SD] age, 66.6 [9.1] years; 719 men [74.1%]) were included. The mean (SD) MIE-CAT score was 113.6 (5.5) in the highest performance quartile vs 94.1 (5.9) in the lowest. Severe postoperative complications occurred in 18.7% (41 of 219) of patients in the highest performance quartile vs 39.2% (40 of 102) in the lowest (risk ratio [RR], 0.50; 95% CI, 0.24-0.99). The highest vs the lowest performance quartile showed lower rates of conversions (1.8% vs 8.9%; RR, 0.21; 95% CI, 0.21-0.21), intraoperative complications (2.7% vs 7.8%; RR, 0.21; 95% CI, 0.04-0.94), and overall postoperative complications (46.1% vs 65.7%; RR, 0.54; 95% CI, 0.24-0.96). The R0 resection rate (96.8% vs 94.2%; RR, 1.03; 95% CI, 0.97-1.05) and lymph node yield (mean [SD], 38.9 [14.7] vs 26.2 [9.0]; RR, 3.20; 95% CI, 0.27-3.21) increased with oncologic-specific performance (eg, hiatus dissection, lymph node dissection). In addition, a high anastomotic phase score was associated with a lower anastomotic leakage rate (4.6% vs 17.7%; RR, 0.14; 95% CI, 0.06-0.31).

Conclusions and relevance: These findings suggest that better surgical performance is associated with fewer perioperative complications for patients with esophageal cancer on a national level. If surgical performance of MIE can be improved with MIE-CAT implementation, substantially better patient outcomes may be achievable.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Klarenbeek reported receiving grants from Medtronic, Stichting Bergh in het Zadel, ZonMw, and BENEFIT outside the submitted work. Dr van Det reported receiving proctor and consulting fees from Intuitive Surgical outside the submitted work. Dr Wijnhoven reported receiving grants and speaker’s fees paid to his institution from Bristol-Myers Squibb outside the submitted work. Dr van Workum reported receiving grants and other support from Medtronic outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Distribution of Minimally Invasive Esophagectomy Competency Assessment Tool (MIE-CAT) Performances Scores
Total MIE-CAT scores range from 32 to 128, with higher scores indicating better performance.
Figure 2.
Figure 2.. Absolute Risks in Obtaining Clinical Outcomes Based on Multilevel Analysis of Surgical Performance
See this image and copyright information in PMC

Comment in

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