Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes
Authors: Ketel Mirte H. M. , Klarenbeek Bastiaan R. , Abma Inger , Belgers Eric H. J. , Coene Peter-Paul L. O. , Dekker Jan Willem T. , van Duijvendijk Peter , Emous Marloes , Gisbertz Suzanne S. , Haveman Jan Willem , Heisterkamp Joos , Nieuwenhuijzen Grard A. P. , Ruurda Jelle P. , van Sandick Johanna W. , van der Sluis Pieter C. , van Det Marc J. , van Esser Stijn , Law Simon , de Steur Wobbe O. , Sosef Meindert N. , Wijnhoven Bas , Hannink Gerjon , Rosman Camiel , van Workum Frans ,   MIE-CAT Netherlands Collaborative Group, van Berge Henegouwen Mark I. , Schuring Nannet , Luye Misha , Geraedts Tessa , Lagarde Sjoerd , Pierie Jean-Pierre , Hess Daniël , Hartemink Koen J. , Veenhof Xander A.F.A. , Hutteman Merlijn , Dijkstra Frederieke , van Hillegersberg Richard , Kouwenhoven Ewout A. , Schaafsma Bob 
Published: April 2024

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.