Dutch Upper GI Cancer Audit Research Articles

Outcomes after gastrectomy according to the Gastrectomy Complications Consensus Group (GCCG) in the Dutch Upper GI Cancer Audit (DUCA)

BackgroundIn 2019, the Gastrectomy Complications Consensus Group (GCCG) published a standardized set of complications aiming toward uniform reporting of post-gastrectomy complications. This study aimed to report outcomes after gastrectomy in the Netherlands according to GCCG definitions and compare them to previously reported national results and the European database reported by the GCCG.MethodsThis nationwide, population-based cohort study included all patients undergoing gastrectomy for gastric cancer registered in the DUCA in 2020–2021. Postoperative morbidity and 30-day/in-hospital mortality were analyzed according to the GCCG definitions. For all patients, baseline characteristics and outcomes were compared with the GCCG cohort consisting of 27 European expert centers (GASTRODATA; 2017–2018).ResultsIn 2020–2021, 782 patients underwent gastrectomy in the Netherlands. Variation was seen in baseline characteristics between the Dutch and the GCCG cohort (N = 1349), most notably in minimally invasive surgery (80.6% vs 19.6%, p < 0.001). In the Netherlands, 223 (28.5%) patients developed a total of 407 complications, the most frequent being non-surgical infections (28.5%) and anastomotic leakage (13.4%). The overall complication and 30-day mortality rates were similar between the Dutch and GCCG cohort (28.5% vs 29.8%, p = 0.563; 3.7% vs 3.6%, p = 0.953). Higher surgical and endoscopic/radiologic reintervention rates were observed in the Netherlands compared to the GCCG cohort (10.7% vs 7.8%, p = 0.025; 10.9% vs 2.9%, p < 0.001).ConclusionReporting outcomes according to the standardized GCCG definitions allows for international benchmarking. Postoperative outcomes were comparable between Dutch and GCCG cohorts, but both exceed the international benchmark for expert gastrectomy care, highlighting targets for national and international quality improvement.

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.

Risk Factors for Tumor Positive Resection Margins After Neoadjuvant Chemoradiotherapy for Esophageal Cancer: Results from the Dutch Upper GI Cancer Audit: A Nationwide Population-Based Study.

To identify risk factors for tumor positive resection margins after neoadjuvant chemoradiotherapy (nCRT) followed by esophagectomy for esophageal cancer. Esophagectomy after nCRT is associated with tumor positive resection margins in 4-9% of patients. This study evaluates potential risk factors for positive resection margins after nCRT followed by esophagectomy. All patients who underwent an elective esophagectomy following nCRT in 2011-2017 in the Netherlands were included. A multivariable logistic regression was performed to assess the association between potential risk factors and tumor positive resection margins. In total, 3900 patients were included. Tumor positive resection margins were observed in 150 (4%) patients. Risk factors for tumor positive resection margins included tumor length (in centimeters, OR:1.1, 95% CI: 1.0-1.1), cT4-stage (OR:3.0, 95% CI: 1.2 - 6.7) and an Ivor Lewis esophagectomy (OR:1.6, 95% CI: 1.0 - 2.6). Predictors associated with a lower risk of tumor positive resection margins were; squamous cell carcinoma (OR:0.4, 95% CI: 0.2 - 0.7), distal tumors (OR:0.5, 95% CI: 0.3 - 1.0), minimally invasive surgery (OR:0.6, 95% CI: 0.4 - 0.9) and a hospital volume of >60 esophagectomies per year (OR:0.6, 95%CI: 0.4 - 1.0). In this nationwide cohort study, tumor and surgical related factors (tumor length, histology, cT-stage, tumor location, surgical procedure, surgical approach, hospital volume) were identified as risk factors for tumor positive resection margins after nCRT for esophageal cancer. These results can be used to improve the radical resection rate by careful selection of patients and surgical approach and are a plea for centralization of esophageal cancer care.

Short-term outcome for high-risk patients after esophagectomy.

Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection; however, it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Of 5,438 patients, 945 and 431 high-risk patients underwent TTE and THE, respectively. After propensity score matching, mortality (6.3 vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥ 3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0 vs. 2.2%, P = 0.020). Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice, these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.

636 SHORT-TERM OUTCOME FOR HIGH-RISK PATIENTS AFTER ESOPHAGECTOMY

Abstract Transthoracic esophagectomy (TTE) for esophageal cancer facilitates mediastinal dissection, however it has a significant impact on cardiopulmonary status. High-risk patients may therefore be better candidates for transhiatal esophagectomy (THE) in order to prevent serious complications. This study addressed short-term outcome following TTE and THE in patients that are considered to have a higher risk of surgery-related morbidity. Methods This population-based study included patients who underwent a curative esophagectomy between 2011 and 2018, registered in the Dutch Upper GI Cancer Audit. The Charlson comorbidity index was used to assign patients to a low-risk (score ≤ 1) and high-risk group (score ≥ 2). Propensity score matching was applied to produce comparable groups between high-risk patients receiving TTE and THE. Primary endpoint was mortality (in-hospital/30-day mortality), secondary endpoints included morbidity and oncological outcomes. Additionally, a matched subgroup analysis was performed, including only cervical reconstructions. Results Of 5438 patients, 945 and 431 high-risk patients underwent TTE and THE respectively. After propensity score matching, mortality (6.3% vs 3.3%, P = 0.050), overall morbidity, Clavien-Dindo ≥3 complications, pulmonary complications, cardiac complications and re-interventions were significantly more observed after TTE compared to THE. A significantly higher mortality after TTE with a cervical reconstruction was found compared to THE (7.0% vs 2.2%, P = 0.020). Conclusion Patients with a high Charlson comorbidity index predispose for a complicated postoperative course after esophagectomy, this was more outspoken after TTE compared to THE. In daily practice these outcomes should be balanced with the lower lymph node yield, but comparable positive node count and radicality after THE.

Sex differences in tumor characteristics, treatment, and outcomes of gastric and esophageal cancer surgery: nationwide cohort data from the Dutch Upper GI Cancer Audit

BackgroundSex differences in clinicopathological characteristics, treatment, and postoperative outcomes of gastric and esophageal cancer are largely undefined. This study aimed to compare tumor and treatment characteristics and outcomes of gastric and esophageal cancer surgery between male and female patients.MethodsPatients after elective surgery for primary esophageal (EAC) or gastric adenocarcinoma (GAC) registered in the Dutch Upper GI Cancer Audit between 2011 and 2016 were included. The primary endpoint, 5-year relative survival with relative excess risk (RER), i.e., adjusted for the normal life expectancy, was compared between male and female patients with EAC and GAC.ResultsIn total, 4937 patients were included (75% male) with a mean age of 66 years. cT and cN-stages showed a similar distribution in male and female patients. In females, antrum GAC was more frequent (47% vs. 38%, p < 0.001). Female patients with EAC less frequently received neo-adjuvant treatment (OR = 0.60, 95% CI 0.38–0.96, p = 0.033). For GAC, less postoperative morbidity (33% vs. 38% p = 0.017) and less re-interventions (12% vs. 16%, p = 0.008) were observed in females, although they had inferior 5-year relative survival (49% vs. 56%, RER = 1.31, 95% CI 1.09–1.58, p = 0.004). No differences in relative survival of EAC were observed.ConclusionsIn addition to significant sex differences in tumor location, female patients with esophageal adenocarcinoma less frequently received neo-adjuvant therapy, and female patients with gastric adenocarcinoma had inferior relative survival. Further consideration and exploration of sex differences in surgical treatment and outcomes are necessary to improve tailored treatment and outcomes.

Gastrectomy Versus Esophagectomy for Gastroesophageal Junction Tumors: Short- and Long-Term Outcomes From the Dutch Upper Gastrointestinal Cancer Audit.

Investigate long-term survival, morbidity, mortality, and pathology results in patients following esophagectomy or total gastrectomy for gastroesophageal junction (GEJ) cancer. Both a total gastrectomy and an esophagectomy may be valid treatment options in patients with GEJ cancer. Which procedure results in the most optimal patient outcome is not well studied. The aim of this study was to investigate the long-term survival, morbidity, mortality, and pathology results in patients following esophagectomy or total gastrectomy for GEJ cancer. A retrospective comparative cohort study of prospectively collected data from the Dutch Upper GI Cancer Audit combined with survival data of the Dutch medical insurance database was performed. Patients with GEJ cancer in whom a total gastrectomy or an esophagectomy was performed between 2011 and 2016 were compared. The primary outcome was 3-year overall survival. Postoperative morbidity, mortality, 3-year conditional survival, radicality of resection, and lymph node yield were secondary endpoints. A total of 871 patients were included: 790 following esophagectomy and 81 following gastrectomy. The 3-year overall survival was 35.8% after esophagectomy and 28.4% after gastrectomy (hazard ratio 1.2, 95% confidence interval 0.721-1.836, P = 0.557). Postoperative morbidity, mortality, radicality of resection, lymph node yield, and 3-year conditional survival did not differ significantly between groups. A total gastrectomy and an esophagectomy for GEJ cancer show largely comparable results with regard to long-term survival, postoperative morbidity, mortality, and pathology results. If both procedures are feasible, other parameters such as surgeon's experience and quality of life should be considered when planning for surgery.

Staging laparoscopy in gastric cancer surgery. A population-based cohort study in patients undergoing gastrectomy with curative intent

BackgroundStudies on the value of a staging laparoscopy in detecting metastases in gastric cancer patients show great variation. This study investigates the avoidable surgery rate in patients with and without a staging laparoscopy scheduled for surgery with curative intent. MethodsThis population-based cohort study included all patients with an intentional resection for a potentially curable gastric adenocarcinoma, between 2011 and 2016, registered in the Dutch Upper GI Cancer audit. Patients with and without a staging laparoscopy were compared. The primary outcome was the avoidable surgery rate (detection of metastases and/or locoregional non-resectable tumor during intentional gastrectomy). Secondary outcomes were the negative predictive value, postoperative morbidity and pathology parameters. Results2849 patients who underwent an intentional gastrectomy were included. 414 of 2849 (14.5%) patients underwent a staging laparoscopy before initiation of treatment. The avoidable surgery rate was 16.2% in the staging laparoscopy group, compared to 8.5% in the non-staging group (P < 0.001), resulting in a negative predictive value of 83.8%. The avoidable surgery rate remained significantly different after correction for possible confounders. The main reason for not executing the gastrectomy was the presence of distant metastasis in both groups. cT and cN stage were significantly higher in patients who underwent a staging laparoscopy. ConclusionsThe staging laparoscopy group had a higher cTN and pTN stage, implicating selection of patients with more advanced disease for a staging laparoscopy. Despite the staging laparoscopy, a higher rate of avoidable surgery was found, suggesting a low sensitivity for detecting metastases or locoregional non-resectability in this patient group.

260 FAILURE TO CURE IN PATIENTS UNDERGOING ESOPHAGEAL CARCINOMA SURGERY: HOSPITAL OF SURGERY INFLUENCES PROSPECTS FOR CURE. A NATIONWIDE COHORT STUDY.

Abstract Failure to cure is a composite outcome measure that could be used for hospital comparison in surgical esophageal carcinoma care. It was first described by Clavien et al. in 1992 and was defined as the event where the procedural purpose was not fulfilled. The aim of the current study was to describe failure to cure in terms of incidence, hospital variation, and as an outcome parameter for salvage esophagectomy (surgical resection after definitive chemoradiotherapy). Methods All patients registered in the Dutch Upper GI Cancer Audit (DUCA) who underwent potentially curative esophageal carcinoma surgery between 2011 and 2018, were included in this nationwide cohort study. Failure to cure was defined as: 1) no esophagectomy due to intra-operative metastasis or locally irresectable tumour, 2) macroscopically or microscopically incomplete resection (pR1, R2), or 3) 30-day or in-hospital mortality. Association of patient, tumor and hospital characteristics with failure to cure was analyzed using multivariable logistic regression in the total population and in salvage surgery patients. Hospital variation was evaluated using multivariable regression and displayed in a case-mix corrected funnelplot. Results Some 6,045 patients from 22 hospitals were included of whom 701 (11.6%) had failure to cure (hospital variation [5.9%–19.0%]). Higher age, more preoperative weight loss, higher ASA-score, junctional tumors, higher T-stage and N-stage, no neoadjuvant chemoradiotherapy, and resection before 2014 were associated with failure to cure. After case-mix correction, 2 hospitals had statistically significant lower than expected failure to cure percentages, and 2 hospitals had higher percentages (figure1). In the patients undergoing salvage esophagectomy (n = 151), the failure to cure percentage was 32.5%. This was 27.6% in high-volume hospitals (&amp;gt;40 annual esophagectomies) and 47.6% in medium-volume hospitals (20–40 annual esophagectomies) (p = 0.03). Conclusion This was the first study to describe failure to cure for oesophageal carcinoma patients. The incidence of failure to cure was 11.6%, which is an important prognostic parameter for patients that should be used for expectation management. Given the significant hospital variation in the incidence of failure to cure, improvement is needed. Since salvage procedures are more often successful in high-volume hospitals, further centralization of this technically challenging procedure is warranted.

261 LENGTH OF HOSPITAL STAY AND THE ASSOCIATION WITH READMISSION AFTER UNCOMPLICATED ESOPHAGECTOMY. SIGNIFICANT HOSPITAL VARIATION IN THE NETHERLANDS.

Abstract Prolonged length of hospital stay is a negative outcome of esophageal cancer surgery, not only for the patient; it also leads to increased hospital costs. Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay and to investigate its association with readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients after an uncomplicated esophagectomy. Methods All patients registered in the Dutch Upper GI Cancer Audit (DUCA) who underwent a potentially curative esophageal cancer resection between 2015 and 2018 were considered for inclusion. Patients were excluded if they had an intraoperative and/or postoperative complication, if they were retransferred to the intensive care unit, or if they had undergone a re-intervention. Length of hospital stay was dichotomized around the national median into “short admissions” and “long admissions”. Hospital variation was evaluated using a case-mix corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with readmission rates was investigated using the χ2-statistic. Results A total of 1,007 patients was included for analyses. National median length of hospital stay was 9 days, ranging from 6.5–12.5 days among 17 hospitals. The percentage of “short admissions” per hospital ranged from 7.7% to 93.5%. After correction for case-mix variables, 2 hospitals had significantly higher “short admission” rates and 4 hospitals had significantly lower “short admission” rates (figure 1). Overall, 6.2% (hospital variation [0.0%–13.2%]) of patients was readmitted. Hospital readmission rates were not significantly different between hospitals with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19). Conclusion Based on these nationwide audit data, length of hospital stay after an uncomplicated esophagectomy varied significantly between hospitals and ranged from 6.5 to 12.5 days among Dutch hospitals. Short length of hospital stay was not associated with a higher readmission rate. The hospital variation indicates that enhanced recovery programs are not implemented at the same level of efficacy among hospitals in the Netherlands. Nationwide improvement might lead to a substantial reduction of hospital costs.

329 GASTRECTOMY VERSUS ESOPHAGECTOMY FOR GASTROESOPHAGEAL-JUNCTION TUMORS: SHORT- AND LONG-TERM OUTCOMES FROM A NATIONAL AUDIT

Abstract Both a total gastrectomy and an esophagectomy may be technically possible in a patient with a gastroesophageal (GEJ) carcinoma. The aim of this study was to investigate the morbidity, mortality, pathology results and long-term survival in patients following an esophagectomy or a total gastrectomy for GEJ cancer. Methods A retrospective comparative cohort study of prospectively collected data from the Dutch Upper-GI Cancer Audit combined with survival data of the medical insurance database of the Netherlands was performed. Patients with a GEJ carcinoma in whom a total gastrectomy or an esophagectomy was performed, between 2011–2016 were included. Primary outcome was 3-year overall survival. Postoperative morbidity, mortality, 3-year conditional survival, reinterventions, radicality of surgery, (y)pTNM stage and lymph node yield were secondary endpoints. Results A total of 999 patients were included: 918 underwent an esophagectomy and 81 underwent a gastrectomy. Postoperative morbidity (54.9% vs 49.4%, p = 0.336), mortality (30-day; 2.3% vs 3.7%, p = 0.436; 90-day: 1.9% vs 2.5%, p = 0.662) and 3-year conditional survival (38.3% vs 30.3%, p = 0.553) did not differ significantly between groups. A longer ICU-stay (median 2 [IQR1–4] vs 1 days [IQR0–2], p &amp;lt; 0.001) and a lower lymph node yield (median 17 [IQR 12–23] vs 21 [IQR 16–31], p &amp;lt; 0.001) were seen following esophagectomy. The 3-year overall survival was 37.4% after esophagectomy and 28.4% after gastrectomy (HR 1.047, 95%CI 0.795–1.380, p = 0.742). Conclusion Patients with GEJ tumors after an esophagectomy required longer ICU-stay and had comparable short-term morbidity and mortality when compared to a total gastrectomy. Long-term overall and conditional survival was not significantly different between groups. The two procedures are therefore largely comparable from an oncological viewpoint, and the choice for either procedure might also be based on other outcomes such as quality of life.

Evaluation of the Implementation of FDG-PET/CT and Staging Laparoscopy for Gastric Cancer in The Netherlands

BackgroundThe role of 18F-fluorodeoxyglucose positron emission tomography with computed tomography (FDG-PET/CT) and staging laparoscopy (SL) has increased in the preoperative staging of gastric cancer. Dutch national guidelines have recommended the use of FDG-PET/CT and SL for patients with locally advanced tumors since July 2016.ObjectiveThe aim of this study was to evaluate the implementation of FDG-PET/CT and SL in The Netherlands.MethodsBetween 2011 and 2018, all patients who underwent surgery for gastric cancer were included from the Dutch Upper GI Cancer Audit. The use of FDG-PET/CT and SL was evaluated before and after revision of the Dutch guidelines. Outcomes included the number of non-curative procedures (e.g. palliative and futile procedures) and the association of FDG-PET/CT and SL, with waiting times from diagnosis to the start of treatment.ResultsA total of 3310 patients were analyzed. After July 2016, the use of FDG-PET/CT (23% vs. 61%; p < 0.001) and SL (21% vs. 58%; p < 0.001) increased. FDG-PET/CT was associated with additional waiting time to neoadjuvant therapy (4 days), as well as primary surgical treatment (20 days), and SL was associated with 8 additional days of waiting time to neoadjuvant therapy. Performing SL or both modalities consecutively in patients in whom it was indicated was not associated with the number of non-curative procedures.ConclusionDuring implementation of FDG-PET/CT and SL after revision of the guidelines, both have increasingly been used in The Netherlands. The addition of these staging methods was associated with increased waiting time to treatment. The number of non-curative procedures did not differ after performing none, solely one, or both staging modalities.

1426P Gender differences in treatment characteristics and outcomes of esophagogastric cancer surgery - Data from the Dutch upper-GI cancer audit

1426P Gender differences in treatment characteristics and outcomes of esophagogastric cancer surgery - Data from the Dutch upper-GI cancer audit

Failure to Cure in Patients Undergoing Surgery for Esophageal Carcinoma: Hospital of Surgery Influences Prospects for Cure: A Nation-wide Cohort Study.

This study aimed to describe failure to cure in terms of incidence, hospital variation, and as an outcome parameter for salvage esophagectomy. Failure to cure is a composite outcome measure that could be used for hospital comparison in esophageal carcinoma care. All patients registered in the Dutch Upper GI Cancer Audit who underwent potentially curative esophageal carcinoma surgery in 2011 to 2018, were included in this nationwide cohort study. Failure to cure was defined as: 1) no surgical resection due to intraoperative metastasis or locally irresectable tumor, 2) macroscopically or microscopically incomplete resection, or 3) 30-day/in-hospital mortality. Association of baseline characteristics with failure to cure was analyzed using multivariable logistic regression in the total population and in salvage patients. Some 5894 patients from 22 hospitals were included, of whom 630 (10.7%) had failure to cure (hospital variation [5.5%-19.1%]). Higher age, preoperative weight loss, higher ASA-score, higher N-stage, neoadjuvant chemotherapy, or no neoadjuvant therapy (compared with neoadjuvant chemoradiotherapy), open surgery, and resection before 2014 were associated with failure to cure. After case-mix correction, 2 hospitals had statistically significant higher failure to cure percentages, whereas 2 had lower percentages. Of 151 salvage esophagectomy patients, 32.5% had failure to cure. The failure to cure rate after salvage surgery was 27.6% in high-volume hospitals and 47.6% in medium-volume hospitals. The incidence of failure to cure was 10.7%. Given the significant hospital variation in the percentage of failure to cure, improvement is needed. Since salvage procedures are more often successful in high-volume hospitals, further centralization of this procedure is warranted.

Non-curative gastrectomy for advanced gastric cancer does not result in additional risk of postoperative morbidity compared to curative gastrectomy

BackgroundNon-curative gastrectomy (nCG) for gastric cancer can be considered in selected cases to relieve symptoms. The aim of this study was to evaluate postoperative morbidity and mortality in patients who underwent nCG and compare these results with an intended curative gastrectomy (CG). Materials and methodsAll patients who underwent both nCG and CG in the Netherlands were included from the Dutch Upper GI Cancer Audit (2011–2016). In this population-based cohort study postoperative morbidity, mortality, readmissions and short-term oncological outcomes were appraised. Propensity score matching (PSM) was applied to create comparable groups of patients who underwent nCG versus CG, using patient and tumor characteristics. ResultsOf the 2202 eligible patients, 115 patients underwent nCG and 2087 underwent CG. After PSM, 115 nCG-patients were matched to 227 CG-patients. More conversions from laparoscopic to open surgery occurred during nCG (10·4 versus 2·6%, p = 0·007). Although postoperative mortality was higher after nCG in the original cohort (9·6 versus 4·8%, p = 0·026), after PSM there was no difference between groups (9·6 versus 7·0%, p = 0·415). Postoperative morbidity, re-interventions and readmission rates did not differ significantly between groups. Resection of additional organs (30·4 versus 11·5%, p < 0·001) and R+ resections (65·2 versus 12·3%, p < 0·001) occurred more frequently during nCG. ConclusionsnCG does not lead to additional postoperative risks compared to CG in patients with similar characteristics, and may be considered in fit patients with advanced gastric cancer. However, randomized trials evaluating potential (survival) benefits of nCG should be awaited.

Transthoracic Versus Transhiatal Esophagectomy for Esophageal Cancer: A Nationwide Propensity Score-Matched Cohort Analysis

BackgroundChemoradiation followed by resection has been the standard therapy for resectable (cT1-4aN0-3M0) esophageal carcinoma in the Netherlands since 2010. The optimal surgical approach remains a matter of debate. Therefore, the purpose of this study was to compare the transhiatal and the transthoracic approach concerning morbidity, mortality and oncological quality.MethodsData was acquired from the Dutch Upper GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma (cT1-4aN0-3M0) from 2011 to 2016 were included. Patients who underwent a transthoracic and transhiatal esophagectomy were compared after propensity score matching.ResultsAfter propensity score matching, 1532 of 4143 patients were included for analysis. The transthoracic approach yielded more lymph nodes (transthoracic median 19, transhiatal median 14; p < 0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher in the transthoracic group (p = 0.044). The transthoracic group experienced more chyle leakage (9.7% vs. 2.7%, p < 0.001), more pulmonary complications (35.5% vs. 26.1%, p < 0.001), and more cardiac complications (15.4% vs. 10.3%, p = 0.003). The transthoracic group required a longer hospital stay (median 14 vs. 11 days, p < 0.001), ICU stay (median 3 vs. 1 day, p < 0.001), and had a higher 30-day/in-hospital mortality rate (4.0% vs. 1.7%, p = 0.009).ConclusionsIn a propensity score-matched cohort, the transthoracic esophagectomy provided a more extensive lymph node dissection, which resulted in a higher lymph node yield, at the cost of increased morbidity and short-term mortality.

Implementation of Minimally Invasive Esophagectomy From a Randomized Controlled Trial Setting to National Practice.

The aim of this study was to examine the external validity of the randomized TIME trial, when minimally invasive esophagectomy (MIE) was implemented nationally in the Netherlands, using data from the Dutch Upper GI Cancer Audit (DUCA) for transthoracic esophagectomy. Original patient data from the TIME trial were extracted along with data from the DUCA dataset (2011-2017). Multivariate analysis, with adjustment for patient factors, tumor factors, and year of surgery, was performed for the effect of MIE versus open esophagectomy on clinical outcomes. One hundred fifteen patients from the TIME trial (59 MIE v 56 open) and 4,605 patients from the DUCA dataset (2,652 MIE v 1,953 open) were included. In the TIME trial, univariate analysis showed that MIE reduced pulmonary complications and length of hospital stay. On the contrary, in the DUCA dataset, MIE was associated with increased total and pulmonary complications and reoperations; however, benefits included increased proportion of R0 margin and lymph nodes harvested, and reduced 30-day mortality. Multivariate analysis from the TIME trial showed that MIE reduced pulmonary complications (odds ratio [OR], 0.19; 95% CI, 0.06 to 0.61). In the DUCA dataset, MIE was associated with increased total complications (OR, 1.36; 95% CI, 1.19 to 1.57), pulmonary complications (OR, 1.50; 95% CI, 1.29 to 1.74), reoperations (OR, 1.74; 95% CI, 1.42 to 2.14), and length of hospital stay. Multivariate analysis of the combined and MIE datasets showed that inclusion in the TIME trial was associated with a reduction in reoperations, Clavien-Dindo grade > 1 complications, and length of hospital stay. When adopted nationally outside the TIME trial, MIE was associated with an increase in total and pulmonary complications and reoperation rate. This may reflect nonexpert surgeons outside of high-volume centers performing this minimally invasive technique in a nonstandardized fashion outside of a controlled environment.

Safety and feasibility of minimally invasive surgical interventions for esophageal and gastric cancer in the acute setting: a nationwide cohort study

BackgroundMinimally invasive esophagectomy and gastrectomy are increasingly performed and might be superior to their open equivalents in an elective setting. The aim of this study was to evaluate whether minimally invasive approaches can be safely applied in the acute setting as well.MethodsAll patients who underwent an acute surgical intervention for primary esophageal or gastric cancer between 2011 and 2017 were identified from the nationwide database of the Dutch Upper GI Cancer Audit (DUCA). Conversion rates, postoperative complications, re-interventions, postoperative mortality, hospital stay and oncological outcomes (radical resection rates and median lymph node yield) were evaluated.ResultsBetween 2011 and 2017, surgery for esophagogastric cancer was performed in an acute setting in 2% (190/8861) in The Netherlands. A total of 14 acute resections for esophageal cancer were performed, which included 7 minimally invasive esophagectomies and 7 open esophagectomies. As these numbers were very low, no comparison between minimally invasive and open esophagectomies was made. A total of 122 acute resections for gastric cancer were performed, which included 39 minimally invasive gastrectomies and 83 open gastrectomies. Conversion occurred in 9 patients (23%). Minimally invasive gastrectomy was at least comparable to open gastrectomy regarding postoperative complications (36% versus 51%), median hospital stay (9 days [IQR: 7–16 days] versus 11 days [IQR: 7–17 days]), readmissions (8% versus 11%) and oncological outcomes (radical resection rate: 87% versus 66%, median lymph node yield: 21 [IQR: 15–32 days] versus 16 [IQR: 11–24 days]).ConclusionsMinimally invasive surgery for gastric cancer is safe and feasible in the acute setting, with at least comparable postoperative clinical and short-term oncological outcomes compared to open surgery but a relatively high conversion rate.

P46 TRANSTHORACIC VERSUS TRANSHIATAL ESOPHAGECTOMY FOR ESOPHAGEAL CANCER: A NATION-WIDE PROPENSITY SCORE MATCHED COHORT ANALYSIS

Abstract Aim The current study aims to compare transthoracic and transhiatal esophagectomy in a propensity score matched nation-wide cohort study. Background &amp; Methods Chemoradiotherapy followed by resection is the standard therapy for resectable esophageal carcinoma in the Netherlands. The optimal surgical approach remains a matter of debate. Data was acquired from the Dutch Upper-GI Cancer Audit. Patients who underwent esophagectomy with curative intent and gastric tube reconstruction for mid/distal esophageal or esophagogastric junction carcinoma from 2011-2016 were included. Patients with missing baseline data and patients undergoing emergency or hybrid surgery were excluded. Patients who underwent a transthoracic (TTE) or transhiatal (THE) esophagectomy were compared after propensity score matching. Results After propensity score matching, 1532 patients were included for analysis. The transthoracic approach yielded more lymph nodes (median 19 vs 14; p&lt;0.001). There was no difference in the number of positive lymph nodes, however, the median (y)pN-stage was higher after TTE (p=0.044). The TTE group experienced more chyle leakage (9.7% vs 2.7%, p&lt;0.001) and more pulmonary (35.5% vs 26.1%, p&lt;0.001) and cardiac complications (15.4% vs 10.3%, p=0.003). The TTE group required a longer hospital stay (median 14 vs 11 days, p&lt;0.001), ICU stay (median 3 vs 1 day, p&lt;0.001) and had a higher early mortality rate (4.0% vs 1.7%, p=0.009). Subgroup analysis on anastomotic level showed that TTE with intrathoracic anastomosis (TTEi) had a significantly lower recurrent nerve lesion incidence (0.5%) compared to TTE with cervical anastomosis (TTEc) (7.4%, p=&lt;0.001) and THE (5.9%, p=&lt;0.001). There was no statistical difference in anastomotic leakage rates on anastomotic level, however incidence was lowest after TTEi (TTEc 21.5%, TTEi 15.1%, THE 19.5%). The higher early mortality rate after TTE was mainly caused by TTEc (4.6%), however, only the difference of early mortality between TTEc and THE (1.7%) reached statistical significance (p=0.006). Conclusion TTE provided a more extensive lymph node dissection which resulted in a higher N-stage, at the cost of increased morbidity and short-term mortality. Although results in high-volume centers are often superior, these data reflect nationwide results. Future research should investigate if a more extensive lymph node dissection leads to an improved long-term survival.

Identification of the clinically most relevant postoperative complications after gastrectomy: a population-based cohort study

BackgroundPostoperative complications frequently occur after gastrectomy for gastric cancer and are associated with poor clinical outcomes, such as mortality and reoperations. The aim of study was to identify the clinically most relevantcomplications after gastrectomy, using the population-attributable fraction (PAF).MethodsBetween 2011 and 2017, all patients who underwent potentially curative gastrectomy for gastric adenocarcinoma were included from the Dutch Upper GI Cancer Audit. Postoperative outcomes (morbidity, mortality, recovery and hospitalization) were evaluated. The prevalence of postoperative complications (e.g., anastomotic leakage and pneumonia) and of the study outcomes were calculated. The adjusted relative risk and Confidence Interval (CI) for each complication-outcome pair were calculated. Subsequently, the PAF was calculated, which represents the percentage of a given outcome occurring in the population, caused by individual complications, taking both the relative risk and the frequency in which a complication occurs into account.ResultsIn total, 2176 patients were analyzed. Anastomotic leakage and pulmonary complications had the greatest overall impact on postoperative mortality (PAF 29.2% [95% CI 19.3–39.1] and 21.6% [95% CI 10.5–32.7], respectively) and prolonged hospitalization (PAF 12.9% [95% CI 9.7–16.0] and 14.7% [95% CI 11.0–18.8], respectively). Anastomotic leakage had the greatest overall impact on re-interventions (PAF 25.1% [95% CI 20.5–29.7]) and reoperations (PAF 30.3% [95% CI 24.3–36.3]). Intra-abdominal abscesses had the largest impact on readmissions (PAF 7.0% [95% CI 3.2–10.9]). Other complications only had a small effect on these outcomes.ConclusionSurgical improvement programs should focus on preventing or managing anastomotic leakage and pulmonary complications, since these complications have the greatest overall impact on clinical outcomes after gastrectomy.