Defining Benchmarks for Transthoracic Esophagectomy: A Multicenter Analysis of Total Minimally Invasive Esophagectomy in Low Risk Patients : Annals of Surgery

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Defining Benchmarks for Transthoracic Esophagectomy

A Multicenter Analysis of Total Minimally Invasive Esophagectomy in Low Risk Patients

Schmidt, Henner M. MD*; Gisbertz, Susanne S. MD, PhD†; Moons, Johnny‡; Rouvelas, Ioannis MD, PhD§; Kauppi, Juha MD; Brown, Andrew MD||; Asti, Emanuele MD**; Luyer, Misha MD, PhD††; Lagarde, Sjoerd M. MD, PhD‡‡; Berlth, Felix MD§§; Philippron, Annouck MD¶¶; Bruns, Christiane MD§§; Hölscher, Arnulf MD§§; Schneider, Paul M. MD*; Raptis, Dimitri A. MD, MSc, PhD*; Henegouwen, Mark I. van Berge MD, PhD†; Nafteux, Philippe MD, PhD‡; Nilsson, Magnus MD, PhD§; Räsanen, Jari MD; Palazzo, Francesco MD||; Rosato, Ernest MD||; Mercer, Stuart DM, FRCS||||; Bonavina, Luigi MD**; Nieuwenhuijzen, Grard MD, PhD††; Wijnhoven, Bas P. L. MD, PhD‡‡; Schröder, Wolfgang MD§§; Pattyn, Piet MD, PhD¶¶; Grimminger, Peter P. MD***; Gutschow, Christian A. MD*

Author Information

*Department of General and Transplantation Surgery, University Hospital Zurich, Zurich, Switzerland

†Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands

‡Department of Thoracic Surgery, University Ziekenhuisen Leuven, Leuven, Belgium

§Division of Surgery, CLINTEC, Karolinska Institutet, Stockholm, Sweden

Department of General Thoracic and Esophageal Surgery, Helsinki University Hospital, Helsinki, Finland

||Department of Surgery, Thomas Jefferson University, Philadelphia, PA

**Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy

††Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands

‡‡Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands

§§Department of General, Visceral and Cancer Surgery, University Hospital Cologne, Cologne, Germany

¶¶Department of Surgery, University Center Ghent, Ghent, Belgium

||||Department of Upper GI Surgery, Queen Alexandra Hospital, Portsmouth, United Kingdom

***Department of General, Visceral and Transplant Surgery, University Medical Center, Mainz, Germany.

Reprints: Prof. Christian A. Gutschow, MD, Division Head Upper Gastrointestinal Surgery, Department for General and Transplantation Surgery, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland. E-mail: [email protected].

The authors declare no conflict of interests.

Annals of Surgery 266(5):p 814-821, November 2017. | DOI: 10.1097/SLA.0000000000002445

Abstract

Objective: 

To define “best possible” outcomes in total minimally invasive transthoracic esophagectomy (ttMIE).

Background: 

TtMIE, performed by experts in patients with low comorbidity, may serve as a benchmark procedure for esophagectomy.

Patients and Methods: 

From a cohort of 1057 ttMIE, performed over a 5-year period in 13 high-volume centers for esophageal surgery, we selected a study group of 334 patients (31.6%) that fulfilled criteria of low comorbidity (American Society of Anesthesiologists score ≤2, WHO/ECOG score ≤1, age ≤65 years, body mass index 19–29 kg/m2). Endpoints included postoperative morbidity measured by the Clavien-Dindo classification and the comprehensive complication index. Benchmark values were defined as the 75th percentile of the median outcome parameters of the participating centers to represent best achievable results.

Results: 

Benchmark patients were predominantly male (82.9%) with a median age of 58 years (53–62). High intrathoracic (Ivor Lewis) and cervical esophagogastrostomy (McKeown) were performed in 188 (56.3%) and 146 (43.7%) patients, respectively. Median (IQR) ICU and hospital stay was 0 (0–2) and 12 (9–18) days, respectively. 56.0% of patients developed at least 1 complication, and 26.9% experienced major morbidity (≥grade III), mostly related to pulmonary complications (25.7%), anastomotic leakage (15.9%), and cardiac events (13.5%). Benchmark values at 30 days after hospital discharge were ≤55.7% and ≤30.8% for overall and major complications, ≤18.0% for readmission, ≤3.1% for positive resection margins, and ≥23 for lymph node yield. Benchmarks at 30 and 90 days were ≤1.0% and ≤4.6% for mortality, and ≤40.8 and ≤42.8 for the comprehensive complication index, respectively.

Conclusion: 

This outcome analysis of patients with low comorbidity undergoing ttMIE may serve as a reference to evaluate surgical performance in major esophageal resection.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.

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