Outcomes of Esophagogastric Cancer Surgery During Eight Years of Surgical Auditing by the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

Abstract

Objective: To evaluate changes in treatment and outcomes of esophagogastric cancer surgery after introduction of the DUCA. In addition, the presence of risk-averse behavior was assessed. Summary of Background Data: Clinical auditing is seen as an important quality improvement tool; however, its long-term efficacy remains largely unknown. In addition, critics claim that enhancements result from risk-averse behavior rather than positive effects of auditing. Methods: DUCA data were used from registration start (1-1-2011) until 31-12-2018. Trends in patient, tumor, hospital and treatment characteristics were univariably assessed. Trends in short-term outcomes were investigated using multilevel multivariable logistic regression. Presence of risk aversion was described by the corrected proportion of patients undergoing surgery, using data from the Netherlands Cancer Registry. To evaluate the impact of centralization on time trends identified, the association between hospital volume and outcomes was investigated. Results: This study included 6172 patients with esophageal and 3,690 with gastric cancer who underwent surgery. Pathological outcomes (lymph node yield, radicality) improved and futile surgery decreased over the years. In-hospital/30-day mortality decreased for esophagectomy (4.2% to 2.5%) and for gastrectomy (7.1% to 4.3%). Reinterventions, (minor) complications and readmissions increased. Risk aversion appeared absent. Between 2011-2018, annual median hospital volumes increased from 38 to 53 for esophagectomy and from 14 to 29 for gastrectomy. Higher hospital volumes were associated with several improved outcomes measures. Conclusions: During 8 years of auditing, outcomes improved, with no signs of risk-averse behavior. These improvements occurred in parallel with centralization. Feedback on postoperative complications remains the focus of the DUCA.

Overall Volume Trends in Esophageal Cancer Surgery Results From the Dutch Upper Gastrointestinal Cancer Audit

“…Dutch leakage rates are relatively high due to the historical preference for a transhiatal approach with a cervical anastomosis (associated with higher leakage rates than intrathoracic anastomoses) and the transition in recent years towards minimally invasive surgery (31% in 2011 to 93% in 2019), transthoracic surgery (43% in 2011 to 83% in 2019), and intrathoracic anastomosis (11% in 2011 to 58% in 2019). 10 As shown by a recent Dutch study, implementation of such new techniques and the associated proficiency gain curves are correlated with an increase in complications. 34 The current study showed lower (severe) postoperative complication, technical complication, and anastomotic leakage rates in centers with an annual esophagectomy volume over 40.…”

“…Outcomes, like shortterm mortality and surgical radicality, improved over this time period. 10 However, it remains unknown whether these improvements are caused by centralization and whether currently (ie, with a volume threshold of 20) there still is a volume trend in clinical outcomes and if this trend eventually reaches a plateau. 11 The Dutch Upper Gastrointestinal Cancer Audit (DUCA) aims to improve Dutch esophagogastric cancer surgery by providing clinicians with benchmarked outcome feedback.…”

Conventional regression analysis and machine learning in prediction of anastomotic leakage and pulmonary complications after esophagogastric cancer surgery

“…Additionally, the anastomotic leakage rate of 18% following esophagectomy in the Netherlands is relatively high compared to other countries, an explanation is the learning curve for new techniques (e.g., minimally invasive) in recent years. Around 2010 minimally invasive surgery was introduced and many surgeons changed from a McKeown to an Ivor Lewis technique 38 . Furthermore, both clinically and radiologically proven anastomotic leakages were included.…”

“…Around 2010 minimally invasive surgery was introduced and many surgeons changed from a McKeown to an Ivor Lewis technique. 38 Furthermore, both clinically and radiologically proven anastomotic leakages were included. Finally, all patients included in this study were selected to be fit for surgery by expert opinion preoperatively, leading to allocation bias.…”

Surgical Therapy of Esophageal Adenocarcinoma—Current Standards and Future Perspectives

“…Especially in countries where hospital resources are comparable, it should not matter in what hospital a patient is being treated and every hospital should be able to perform up to the standard of the best-performing center. Disclosing and safe-sharing hospital results and discussing these outcomes with other surgeons has proven to be an effective tool towards quality improvement on a national level [ 87 ].…”