Dutch Upper Gastrointestinal Cancer Audit Research Articles

331. CASE-MIX ADJUSTMENT IN BETWEEN-HOSPITAL COMPARISONS ON CLINICAL OUTCOMES IN ESOPHAGEAL AND GASTRIC CANCER SURGERY: A NATIONWIDE POPULATION-BASED COHORT STUDY

Abstract Background Clinical outcomes of esophageal and gastric cancer surgery are used for internal and external benchmarking in clinical auditing. For true hospital comparisons, proper case-mix adjustment is required. This study aimed to develop distinct models that allow for case-mix adjusted quality assessment of esophageal and gastric cancer surgery separately and assessed the impact on between-hospital comparisons. Methods This study included all patients undergoing esophagogastric cancer surgery in the Netherlands between 2017-2022 registered in the Dutch Upper Gastrointestinal Cancer Audit. We developed distinct case-mix adjustment models for ten quality indicators (QIs) using backward selection. Model performance of each individual model was evaluated with area-under-the-receiving-operator-curve (AUC) statistics, representing the impact of case-mix on the QI scores. The impact on between-hospital comparisons was quantified using unadjusted and adjusted O/E ratios. Results A total of 4,354 esophageal cancer and 2,109 gastric cancer patients were included. The most frequently selected case-mix variables in the models for all QIs for esophageal cancer surgery were ASA-score, salvage surgery, peripheral vascular disease/aortic aneurysm, chronic lung disease, and tumor histology, whereas for gastric cancer these were age, preoperative weight loss, tumor location, and clinical M stage. The case-mix adjustment models for esophageal and gastric cancer surgery showed low to moderate performance, with internally validated AUCs of 0.58-0.73 and 0.58-0.74, respectively. Case-mix adjustment had low impact on between-hospital comparisons. For both types of cancer, case-mix adjustment had most pronounced impact on between-hospital comparisons for QIs 30-day/in-hospital mortality and failure-to-rescue. Conclusion This study showed that correct quality assessment requires different case-mix models per quality indicator for clinical outcomes of esophageal and gastric cancer surgery. The case-mix models had low to moderate performance scores, suggesting that case-mix has limited impact in between-hospital comparisons of oesopagogastric cancer surgery.

332. OUTCOMES OF SALVAGE SURGERY FOR ESOPHAGEAL CARCINOMA: A NATIONWIDE COHORT STUDY

Abstract Background Compared to a standard resection, salvage esophagectomy is a more complex procedure and associated with increased postoperative morbidity and mortality. This study aimed to investigate short-term outcomes of salvage surgery for esophageal carcinoma and the influence of hospital volume and baseline characteristics on outcomes. Methods All patients undergoing esophagectomy for esophageal cancer registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) between 2012-2022 in the Netherlands were included. Patients were classified as salvage or non-salvage by registering surgeons. The definition was: surgery after definitive chemoradiotherapy. Postoperative mortality (30-day/-in-hospital) and morbidity were compared between salvage and non-salvage patients using multilevel logistic regression analyses. Hospital variation in the use of salvage esophagectomy was investigated using funnel plots. The influence of annual hospital volume (<40->40) and annual salvage volume (<6->6) on outcomes of salvage patients were investigated. Using backward elimination, relevant baseline characteristics influencing outcomes after salvage surgery were identified. Results Between 2012-2022, 7,749 patients underwent esophagectomy, of whom 251 (3%) underwent salvage resection, varying from 0%-8% of esophagectomies between centers. Salvage surgery was associated with an increased risk of 30-day/in-hospital mortality (11% vs. 3%; OR:3.65; 95%CI:2.38-5.61) and severe complications (43% vs. 28%; OR:1.81; 95%CI:1.40-2.34). Salvage patients treated in high-volume esophagectomy centers (>40) had a decreased risk of 30-day/in-hospital mortality compared to low-volume centers (9% vs. 19%; OR:0.42; 95%CI:0.18-0.99), with no relation found between annual salvage volume and outcome. Certain baseline characteristics, foremost men, elderly (>75 years) and squamous cell carcinomas, were associated with worse short-term outcomes of salvage surgery. Conclusion Salvage surgery for esophageal carcinoma is infrequently but increasingly performed in the Netherlands, with wide hospital variation in its use. Salvage surgery is associated with worse short-term outcomes when compared with non-salvage esophagectomy. Outcomes after salvage surgery were favorable in high-volume esophagectomy centers, suggesting a volume-outcome relationship for salvage surgery.

Impact of Preoperative Time Intervals for Neoadjuvant Chemoradiotherapy on Short-term Postoperative Outcomes of Esophageal Cancer Surgery: A Population-Based Study Using the Dutch Upper Gastrointestinal Cancer Audit (DUCA) Data.

To clarify the impact of the preoperative time intervals on short-term postoperative and pathological outcomes in esophageal cancer patients who underwent neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy. The impact of preoperative intervals on esophageal cancer patients who received multimodality treatment remains unknown. Patients(cT1-4aN0-3M0) treated with nCRT plus esophagectomy were included using the Dutch national DUCA-database. Multivariate logistic regression was used to determine the effect of different time intervals upon short-term postoperative and pathological outcomes: diagnosis-to-nCRT intervals (≤5, 5-8 and 8-12wk), nCRT-to-surgery intervals (5-11, 11-17 and >17wk) and total preoperative intervals (≤16, 16-25 and >25wk). Between 2010-2021, a total of 5052 patients were included. Compared to diagnosis-to-nCRT interval ≤5 weeks, the interval 8-12 weeks was associated with higher risk of overall complications (P=0.049). Compared to nCRT-to-surgery interval 5-11 weeks, the longer intervals (11-17wk and >17wk) were associated with higher risk of overall complications (P-value=0.016; P-value<0.001) and anastomotic leakage (P-value=0.004; P-value=0.030), but the interval >17 weeks was associated with lower risk of ypN+ (P-value=0.021). The longer total preoperative intervals were not associated with the risk of 30-day mortality and complications compared to the interval ≤16 weeks, but the longer total preoperative interval (>25wk) was associated with higher ypT stage (P-value=0.010) and lower pCR rate (P-value=0.013). In patients with esophageal cancer undergoing nCRT and esophagectomy, prolonged preoperative time intervals may lead to higher morbidity and disease progression, and the causal relationship requires further confirmation.

Discontinuation of neoadjuvant therapy does not influence postoperative short-term outcomes in elderly patients (≥ 70 years) with resectable gastric cancer: a population-based study from the dutch upper gastrointestinal cancer audit (DUCA) data

BackgroundFor the elderly patients with gastric cancer, it may be more challenging to tolerate complete neoadjuvant therapy (NAT). The impact of discontinued NAT on the surgical safety and pathological outcomes of elderly patients with poor tolerance remains poorly understood.MethodsGastric cancer patients received gastrectomy with curative intent from the Dutch upper GI cancer audit (DUCA) database were included in this study. The independent association of age with not initiating and discontinuation of NAT was assessed with restricted cubic splines (RCS). According to the RCS results, age ≥ 70 years was defined as elderly. Short-term postoperative outcomes and pathological results were compared between elderly patients who completed and discontinued NAT.ResultsBetween 2011- 2021, total of 3049 patients were included. The risk of not initiating NAT increased from 70 years. In 1954 (64%) patients receiving NAT, the risk of discontinuation increased from 55 years, reaching the peak around 74 years. In the elderly, discontinued NAT was not independently associated with worse 30-day mortality, overall complications, anastomotic leakage, re-intervention, and pathologic complete response, but was associated with a higher risk of R1/2 resection (p-value = 0.001), higher ypT stage (p-value = 0.004), ypN + (p-value = 0.008), and non-response ( p-value = 0.012).ConclusionA decreased utilization of NAT has been observed in Dutch gastric cancer patients from 70 years due to old age considerations, possibly because of their high risk of discontinuation. Increasing the utilization of NAT may not adversely impact the surgical safety of gastric cancer population ≥ 70 years and may contribute to better pathological results.

Achieving a textbook outcome in patients undergoing gastric resections in a low incidence, high-volume Australian Upper GI unit

BackgroundTextbook outcome (TBO) has been proposed as a composite measure of quality in esophagogastric surgery, and achieving a TBO has been associated with improved overall survival (OS). The Dutch Upper Gastrointestinal Cancer Audit group determined their TBO rate for gastrectomy to be 32.1%, using 10 parameters. Our study aimed to assess the TBO rate in patients who had a gastrectomy for cancer in an Australian Upper GI unit, allowing for comparisons with international specialist centers. MethodsRetrospective analysis of a prospectively maintained database of patients who had a gastrectomy for cancer performed by the surgeons in a single Australian center between 2013 and 2018. Postoperative complications were analyzed using Clavien-Dindo (CD) ≥2 and CD ≥3 definitions. Baseline factors and their association with TBO were analyzed using multivariable logistical regression. The association between TBO and survival rates was determined by Cox proportional hazards regression analysis. ResultsIn 136 patients, 84 (62%) achieved a TBO when complications were graded as CD ≥2. Greatest negative impact on TBO was the complication rate, lymph node yield, and length of stay. Patients more likely to achieve a TBO were younger, with an increased body mass index and absence of underlying respiratory disease. A nonsignificant trend toward improved OS was seen when TBO was achieved. ConclusionOur TBO rate compares favorably with published data from high-volume centers. Assessment of a unit’s TBO may provide a stronger evaluation of quality when assessing where complex surgery should be performed within Australia.

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

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

Textbook outcome as indicator of surgical quality in a single Western center: results from 300 consecutive gastrectomies.

Textbook outcome (TO) has been proposed as a tool to evaluate surgical quality. Textbook oncological outcome (TOO) adds chemotherapeutic compliance to TO. This study was conducted to analyze the TO and TOO of patients with gastric adenocarcinoma who underwent surgery at our center. Data from a prospective database of patients operated on for gastric adenocarcinoma between September 2018 and September 2022 were analyzed. Postoperative management followed Enhanced Recovery After Surgery guidelines. The Dutch Upper Gastrointestinal Cancer Audit group defined TO as a multidimensional measure (10 items). TOO also considers guideline-accordant chemotherapeutic compliance. Three hundred patients underwent surgery during the study period (167 men, 133 women). One hundred seventy-six (58.7%) reached TO. Achieving TO was influenced by patients' comorbidities, calculated via the Charlson Comorbidity Score (3 vs. 4; p = 0.002) and surgery type (subtotal gastrectomy; p < 0.001), but not by the American Society of Anesthesiologists (ASA) score (p = 0.057) or surgical approach (laparoscopic vs. open; p = 0.208). The analysis of TOO included 213 patients. Of these, 71 (33%) underwent complete adequate systemic treatment. Compared with the non-TOO group, patients who achieved TOO had a lower median age (64 vs. 73years; p < 0.001) and lower ASA score (p < 0.001) and more frequently underwent preoperative chemotherapy (p < 0.001). Our results represent the experience of a single team at a high-volume Western institute. Patients' comorbidities and surgery type influenced whether TO was achieved. Conversely, younger age, lower ASA score and preoperative chemotherapy were associated with TOO.

The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive esophagectomy: a nationwide analysis.

Minimally invasive esophagectomy (MIE) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIE. Data on esophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case mix. Of 3371 patients undergoing esophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIE. Bariatric hospitals (N = 6) accounted for 1057 (43.1%) MIE. Annual volume of bariatric procedures was median 523 and esophagectomies 42. In non-bariatric hospitals, volume of esophagectomies was median 52 (P = 0.145). Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P < 0.001). Bariatric hospitals were associated with a reduced risk of overall complications (aOR 0.76 [95% CI 0.62-0.92]), length of hospital (aOR 0.79 [95% CI 0.65-0.95]), and ICU stay (aOR 0.81 [95% CI 0.67-0.98]) after MIE. Surgical radicality (R0) did not differ. Lymph node yield (≥ 15) was lower in bariatric hospitals (90.0% vs. 94.7%, P < 0.001). Over the years, several short-term outcomes improved in bariatric hospitals compared to non-bariatric hospitals. In this nationwide analysis, there was an association between bariatric hospitals and improved short-term outcomes after MIE. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.

OGC O03 Evolution in Laparoscopic Gastrectomy from a Randomized Controlled Trial through National Clinical Practice

Abstract Background Following Randomized Controlled Trials (RCT), the dissemination of complex interventions has been poorly studied. The LOGICA RCT included 10 Dutch centers and compared laparoscopic to open gastrectomy. The aim of this present study was to examine the influence of the LOGICA RCT upon the practice and outcomes from laparoscopic gastrectomy within the Netherlands. Methods Data were obtained from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) on all gastrectomies performed in the Netherlands (2012–2021), and the LOGICA RCT from (2015–2018). Multilevel multivariable logistic regression analyses were performed to assess the effect of laparoscopic versus open gastrectomy upon clinical outcomes with the LOGICA RCT and DUCA datasets. These analyses were repeated to assess the effect of laparoscopic gastrectomy upon outcomes before, during, and after the LOGICA trial in the DUCA dataset. Results In total, 211 patients from the LOGICA RCT (105 open vs. 106 laparoscopic) and 4,131 patients from the DUCA dataset (1884 open vs. 2247 laparoscopic) were included. In 2012, laparoscopic gastrectomy was performed in 6% of patients, increasing to 82% of patients in 2021. No significant effect of laparoscopic gastrectomy on postoperative clinical outcomes was observed within the LOGICA RCT. Nationally within DUCA, a shift towards a beneficial effect of laparoscopic gastrectomy upon complications was observed, reaching a significant reduction on overall complications (aOR:0.62; 95%CI:0.46-0.82), severe complications (aOR:0.64; 95%CI:0.46-0.90) and cardiac complications (aOR:0.51; 95%CI:0.30-0.89) after the LOGICA trial. Conclusions The wider benefits of the LOGICA trial include safe dissemination of laparoscopic gastrectomy across the Netherlands. The robust surgical quality assurance programme in the design of the LOGICA RCT was crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during surgeons learning curve.

OGC P38 The impact of hospital experience in bariatric surgery on short-term outcomes after minimally invasive oesophagectomy: a nationwide analysis

Abstract Background Minimally invasive oesophagectomy (MIO) is a technically challenging procedure with a substantial learning curve. Composite volume of upper gastrointestinal (upper GI) procedures for cancer has been previously linked to postoperative outcomes. This study aimed to investigate an association between hospital experience in bariatric surgery and short-term outcomes in MIO. Methods Data on oesophagectomy patients between 2016 and 2020 were collected from the Dutch Upper Gastrointestinal Cancer Audit, a mandatory nationwide registry. Hospitals were categorized as bariatric or non-bariatric. Dutch institutions have a mandatory annual threshold of 200 bariatric and 20 oesophagectomy procedures. Multivariable logistic regression investigated short-term postoperative outcomes, adjusting for case-mix. Results Of 3371 patients undergoing oesophagectomy in sixteen hospitals, 2450 (72.7%) underwent MIO. Bariatric hospitals (N=6) accounted for 1057 (43.1%) MIO. Overall postoperative complication rate was lower in bariatric hospitals (59.2% vs. 65.9%, P&amp;lt;0.001). Bariatric hospitals were associated with a reduced risk of overall complications (OR 0.72 [95%CI 0.60-0.87]), length of hospital (OR 0.73 [95%CI 0.61-0.87]) and ICU stay (OR 0.83 [95%CI 0.69-1.00] (P=0.046)) after MIO. Surgical radicality did not differ. Lymph node yield (≥15) was lower in bariatric hospitals (90.0% vs. 94.7%, P&amp;lt;0.001). Several short-term outcomes showed a significantly improving trend over the years in bariatric, but not non-bariatric hospitals. Conclusions In this nationwide analysis, bariatric hospitals were associated with improved short-term outcomes after MIO and further improved over the years. Characteristics of bariatric hospitals that could explain this phenomenon and whether this translates to other upper GI procedures may be warranted to identify.

Textbook outcomes for oesophagectomy: A valid composite measure assessment tool for surgical performance in a specialist unit

IntroductionIn 2017 the Dutch Upper Gastrointestinal Cancer Audit Group proposed a ten-item composite measure for a ‘textbook outcome’ (TBO) following oesophago-gastric resection. Studies have shown associations between TBO and improved conditional and overall survival. The aim of this study was to evaluate the use of TBO to assess the outcomes from a single specialist unit in a country, with low incidence of disease, allowing comparisons with international specialist centres. Materials and methodsRetrospective analysis of prospectively collected oesophageal cancer surgery data at a single centre, in Australia, between 2013 and 2018. Multivariable logistical regression assessed association between baseline factors and TBO. Post-operative complications were analysed in two separate groups as Clavien-Dindo ≥2 (CD ≥ 2) and Clavien-Dindo ≥3 (CD ≥ 3). Cox-proportional hazards regression analysis determined the association between TBO and survival. Results246 patients were analysed, with 50.8% (n = 125) achieving a TBO when complications were defined as CD ≥ 2 and 58.9% (n = 145) when using CD ≥ 3. Patients aged ≥75, and those with a pre-operative respiratory co-morbidity were less likely to achieve a TBO. Overall survival was not influenced by TBO when complications were defined as CD ≥ 2, however it was higher when a TBO was achieved, and complications were defined as CD ≥ 3 (HR 0.54, 95% CI, 0.35 to 0.84, P = 0.007). ConclusionTBO is a multi-parameter metric that allowed benchmarking of the quality of oesophageal cancer surgery in our unit, providing favourable outcomes compared with other published data. There was an association between TBO and improved overall survival when the definition of severe complications was CD ≥ 3.

The Impact of Paratracheal Lymphadenectomy on Lymph Node Yield and Short-Term Outcomes in Esophagectomy for Cancer: A Nation-Wide Propensity Score-Matched Analysis

Introduction: The balance between potential oncological merits and surgical risks is unclear for the additional step of performing paratracheal lymphadenectomy during esophagectomy for cancer. This study aimed to investigate the impact of paratracheal lymphadenectomy on lymph node yield and short-term outcomes in patients who underwent this procedure in the Netherlands. Methods: Patients who underwent neoadjuvant chemoradiotherapy followed by transthoracic esophagectomy were included from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). After propensity score matching Ivor Lewis and McKeown approaches separately, lymph node yield and short-term outcomes were compared between patients who underwent paratracheal lymphadenectomy versus patients who did not. Results: Between 2011 and 2017, 2,128 patients were included. Some 770 patients (n = 385 vs. n = 385) and 516 patients (n = 258 vs. n = 258) were matched for the Ivor Lewis and McKeown approaches, respectively. Paratracheal lymphadenectomy was associated with a higher lymph node yield in Ivor Lewis (23 vs. 19 nodes, p < 0.001) and McKeown (21 vs. 19 nodes, p = 0.015) esophagectomy. There were no significant differences in complications or mortality. After Ivor Lewis esophagectomy, paratracheal lymphadenectomy was associated with longer length of stay (12 vs. 11 days, p < 0.048). After McKeown esophagectomy, paratracheal lymphadenectomy was associated with more re-interventions (30% vs. 18%, p = 0.002). Conclusions: Paratracheal lymphadenectomy resulted in a higher lymph node yield but also in longer length of stay after Ivor Lewis and more re-interventions following McKeown esophagectomy.

Scientific and rigorous data registration of patients with gastric cancer is the cornerstone of high-quality surgical research on gastric cancer: lessons learned from the Dutch upper gastrointestinal cancer audit (DUCA)

The postoperative 30-day mortality and morbidity of gastric cancer surgery has markedly improved over the past years due to minimally invasive techniques, perioperative rehabilitation programs and centralization of care. However, there is still need for improvement as postoperative complications may have a serious negative impact on the efficacy of surgical treatment of gastric cancer. High-quality clinical research is a very important tool to analyze treatment outcomes and evaluate new treatment strategies. The meticulous registration of gastric cancer patient data is the basis of high-quality surgical research. In the past 11 years, the Dutch upper gastrointestinal cancer audit (DUCA) database has vast experience in data registration and maintenance of patients with upper gastrointestinal cancer. The effective measures it has taken in data registration, data quality control, data application and use, and data security have maintained quality at a high level. These data has been used for medical care quality monitoring and scientific research leading to a positive impact on the postoperative short-term outcomes of patients with upper gastrointestinal cancer. The work of DUCA may be a good incentive for the setup of population-based databases and clinical research in other countries.

Hospital variation in feeding jejunostomy policy for minimally invasive esophagectomy; population-based results from the Dutch Upper gastrointestinal Cancer Audit (DUCA)

Hospital variation in feeding jejunostomy policy for minimally invasive esophagectomy; population-based results from the Dutch Upper gastrointestinal Cancer Audit (DUCA)

Hospital Variation in Feeding Jejunostomy Policy for Minimally Invasive Esophagectomy: A Nationwide Cohort Study.

The purpose of this study was to investigate hospital variation in the placement, surgical techniques, and safety of feeding jejunostomies (FJ) during minimally invasive esophagectomy (MIE) in the Netherlands. This nationwide cohort study analyzed patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) that underwent MIE for cancer. Hospital variation in FJ placement rates were investigated using case-mix corrected funnel plots. Short-term outcomes were compared between patients with and without FJ using multilevel multivariable logistic regression analysis. The incidence of FJ-related complications was described and compared between hospitals performing routine and non-routine placement (≥90%−<90% of patients). Between 2018−2020, an FJ was placed in 1481/1811 (81.8%) patients. Rates ranged from 11−100% among hospitals. More patients were discharged within 10 days (median hospital stay) without FJ compared to patients with FJ (64.5% vs. 50.4%; OR: 0.62, 95% CI: 0.42−0.90). FJ-related complications occurred in 45 (3%) patients, of whom 23 (1.6%) experienced severe complications (≥Clavien−Dindo IIIa). The FJ-related complication rate was 13.7% in hospitals not routinely placing FJs vs. 1.7% in hospitals performing routine FJ placement (p < 0.001). Significant hospital variation in the use of FJs after MIE exists in the Netherlands. No effect of FJs on complications was observed. FJs can be placed safely, with lower FJ-related complication rates, in centers performing routine placement.

Age and Charlson Comorbidity Index score are not independent risk factors for severe complications after curative esophagectomy for esophageal cancer: a Dutch population-based cohort study

BackgroundThe number of older patients undergoing curative esophagectomy for esophageal cancer is increasing, and minimally invasive techniques are being increasingly used. The aim of this study is to compare postoperative outcomes after curative esophagectomy between older and younger patients. MethodsData was retrieved from the Dutch Upper Gastrointestinal Cancer Audit (DUCA), a national surgical outcome registry. The primary outcome was severe complications, defined as complications graded Clavien-Dindo ≥ 3. The secondary outcomes were postoperative complications, reintervention rates, length of hospital stays, and mortality. Outcomes were compared between patients aged ≥75 and < 75 years. We performed additional subgroup analyses between these age groups after totally minimally invasive esophagectomy (TMIE) and in patients with severe complications. We adjusted for the following parameters: gender, BMI, Charlson Comorbidity Index score (CCI), ASA score, histology, type of neoadjuvant therapy, and surgical technique. ResultsOf all 3775 included patients, 455 (12.1%) were aged ≥75 years and 3302 (87.9%) were aged <75 years. Overall, severe complications occurred in 184 (40.4%) older and in 1140 (34.5%) younger patients (CI = 1.009–1.080). After TMIE, severe complications occurred in 150 (42.1%) older and in 891 (35.8%) younger patients (CI = 1.007–1.088). In patients with severe complications, rates of complications, reinterventions, mortality, and ICU stays were comparable between older and younger patients. After adjustment for casemix, age and CCI score were not independent risk factors for (severe) complications and mortality. ConclusionsAge and Charlson Comorbidity Index are not adequate predictors of postoperative morbidity and mortality after curative esophagectomy for esophageal cancer.

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

Background and ObjectivesWith the current advanced data‐driven approach to health care, machine learning is gaining more interest. The current study investigates the added value of machine learning to linear regression in predicting anastomotic leakage and pulmonary complications after upper gastrointestinal cancer surgery.MethodsAll patients in the Dutch Upper Gastrointestinal Cancer Audit undergoing curatively intended esophageal or gastric cancer surgeries from 2011 to 2017 were included. Anastomotic leakage was defined as any clinically or radiologically proven anastomotic leakage. Pulmonary complications entailed: pneumonia, pleural effusion, respiratory failure, pneumothorax, and/or acute respiratory distress syndrome. Different machine learning models were tested. Nomograms were constructed using Least Absolute Shrinkage and Selection Operator.ResultsBetween 2011 and 2017, 4228 patients underwent surgical resection for esophageal cancer, of which 18% developed anastomotic leakage and 30% a pulmonary complication. Of the 2199 patients with surgical resection for gastric cancer, 7% developed anastomotic leakage and 15% a pulmonary complication. In all cases, linear regression had the highest predictive value with the area under the curves varying between 61.9 and 68.0, but the difference with machine learning models did not reach statistical significance.ConclusionMachine learning models can predict postoperative complications in upper gastrointestinal cancer surgery, but they do not outperform the current gold standard, linear regression

The impact of performing gastric cancer surgery during holiday periods. A population-based study using Dutch upper gastrointestinal cancer audit (DUCA) data

Existing literature suggests inferior quality of oncologic surgery during holiday periods. This study aimed to investigate the impact of holiday periods on surgical treatment of gastric cancer in the Netherlands. This nationwide study included all gastric cancer patients undergoing potentially curative surgery registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA). For each patient it was established whether they underwent surgery during or outside the 11 Dutch holiday weeks, based on date and region of surgery. Separate, single-day holidays were not included. Baseline and treatment characteristics were compared using descriptive statistics. Time from diagnosis to treatment and short-term surgical outcomes were compared using multilevel multivariable logistic regression analyses. To prevent bias from recent advancements, analyses were repeated in a recent cohort of patients (2015-2018). Between 2011-2018, 3440 patients were included in the DUCA. Some 555 (16.1%) patients underwent surgery during 11 holiday weeks. There were no differences in patient, tumor and treatment characteristics and time to treatment between holidays and non-holidays. Tumor-positive resection margins (R1/R2 vs R0) occurred more frequent during holidays (aOR:1.47, 95%CI:1.07-2.04). Subgroup analyses in a recent cohort of patients also found higher tumor-positive resection margins (aOR:1.59, 95%CI:1.01-2.43) and higher failure-to-rescue rates (aOR:2.55, 95%CI:1.18-5.49) during holidays. Even though time to treatment and patient, tumor and treatment characteristics were comparable between holidays and non-holidays, tumor-positive resection margin and failure-to-rescue rates were higher during holidays. This suggests that steps must be taken to keep specialized and dedicated gastric cancer expertise up to standard during holiday periods.

The effect of preoperative body mass index on short-term outcome after esophagectomy for cancer: A nationwide propensity score–matched analysis

BackgroundThe true influence of body mass index on the outcome of esophageal cancer surgery is unclear. The aim of this study was to determine the relation between preoperative body mass index and clinical and oncological outcomes of esophagectomy for cancer in a patient cohort from the Dutch nationwide audit. MethodsAll patients who underwent esophagectomy for cancer between January 2011 and 2016 were identified in the Dutch Upper Gastrointestinal Cancer Audit. Patients were divided into 4 body mass index categories (<18.5 kg/m2 underweight, 18.5 to 25 kg/m2 normal weight, 25 to 30 kg/m2 overweight, and >30 kg/m2 obese) and were compared for clinical and oncological outcomes with the use of propensity score–matched analysis. ResultsOf the patients, 2,598 were included (underweight = 70, normal weight = 1,097, overweight = 1,007, and obese = 424). Before propensity score–matched analysis, underweight patients had a significantly longer hospital stay, more chyle leakage, underwent more re-operations, and had a higher in-hospital/30-day mortality compared to the other weight groups. After propensity score–matched analysis, 560 patients were included: 62 were underweight, 180 were normal weight, 165 were overweight, and 153 were obese. Length of hospital stay, chyle leakage, necrosis of the reconstruction, re-interventions, re-operations, re-admittance to the intensive care unit/medium care unit, and in-hospital/30-day mortality were seen most in the underweight group. No differences were seen in intraoperative complications and oncological outcomes. ConclusionUnderweight patients are more prone for the development of postoperative complications after esophagectomy. Physicians and dieticians should be aware of the impact of underweight on postoperative outcome. Future studies should focus on nutritional status and the effect of preoperative correction of body weight.

548 COMPARISON OF ESOPHAGECTOMY OUTCOMES BETWEEN A NATIONAL CENTER, A NATIONAL AUDIT COLLABORATIVE, AND AN INTERNATIONAL DATABASE USING ECCG STANDARDIZED DEFINITIONS

Abstract The ECCG developed a standardized platform for reporting operative complications, with consensus definitions, and DUCA adopted these definitions and have reported a comparison against these benchmarks. The aim of this study was to report five year complications data using the standardized definitions of the Esophageal Complications Consensus Group (ECCG), and to compare with published ECCG benchmark studies from the collaborative group and from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). Methods All patients undergoing multimodal therapy or surgery with curative intent from 2014 to 2018 inclusive were studied. All data were recorded prospectively and maintained internally as well as entered onto a secure online database (Esodata.org) from 2015. Statistical analysis was performed using SPSS® (version 18.0). Results 219 patients (mean age 67; 77% male) underwent open resection, 66.6% via transthoracic en bloc resection. 30-day and 90-day mortality were 0.0 and 0.9%, respectively. The anastomotic leak rate was 5.4%, and chyle leak 5.4%. Pneumonia was recorded in 18.2%, respiratory failure 10.9%, and ARDS in 2.7%. Atrial dysrhythmia occurred in 22.8%, recurrent nerve injury 3.1%, and delirium in 5.0%. Compared with both ECCG and DUCA, where MIE constituted 47% and 86% of surgical approaches, respectively, overall complications were similar in this open series, as was complications severity, however anastomotic leak rate were several-fold less, and mortality rates were lower. Conclusion In this unselected consecutive series and comparative audit with benchmark averages from the ECCG and DUCA publication, a low mortality and anastomotic leak rate were the key differential findings. Although not risk-stratified or directly matched, the severity of complications from this ‘open’ series is consistent with series containing large numbers of total or hybrid MIE, highlighting a need to adhere to these strictly defined definitions in further prospective research and randomized studies.