Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 1/2019

01-01-2019 | Gastrointestinal Oncology

Quality Improvement in Minimally Invasive Esophagectomy: Outcome Improvement Through Data Review

Published in: Annals of Surgical Oncology | Issue 1/2019

Login to get access

Abstract

Background

Esophagectomy is a complex operation in which outcomes are profoundly influenced by operative experience and volume. We report the effects of experience and innovation on outcomes in minimally invasive esophagectomy.

Methods

Esophageal resections for cancer from 2007 to 2016 at Levine Cancer Institute at Carolinas Medical Center (Charlotte, NC) were reviewed. During this time, three changes in technique were made to improve outcomes: vascular evaluation of the gastric conduit to improve anastomotic healing (beginning at case #63), one-stage approach to permit access to abdomen and chest through one draped surgical field (case #82), and adoption of a lung-protective anesthetic protocol (case #101). Mortality, operative time, complications, and length of stay were analyzed relative to these interventions using GLM regression.

Results

200 patients underwent minimally invasive esophagectomy. There were no mortalities at 30 days, and no change in mortality rate at 60 and 90 days. Anastomotic leak decreased significantly after the introduction of intraoperative vascular evaluation of the gastric conduit (3.6 vs 19.4%). Operative time decreased with adoption of a one-stage approach (416 vs 536 min). Pulmonary complications decreased coincident with a change in anesthetic technique (pneumonia 6 vs 28%). Lymph node harvest increased over time. Length of stay was driven primarily by complications and decreased with operative experience.

Conclusions

Postoperative complications, operative time, and length of stay decreased with case experience and alterations in surgical and anesthetic technique. We believe that adoption of the techniques and technology described herein can reduce complications, reduce hospital stay, and improve patient outcomes.
Literature
1.
Litle VR, Buenaventura PO, Luketich JD. Minimally invasive resection for esophageal cancer. Surg Clin North Am. 2002;82(4):711–28.CrossRefPubMed
2.
Osugi H, Takemura M, Higashino M, et al. Learning curve of video-assisted thoracoscopic esophagectomy and extensive lymphadenectomy for squamous cell cancer of the thoracic esophagus and results. Surg Endosc. 2003;17(3):515–9.CrossRefPubMed
3.
Osugi H, Takemura M, Lee S, et al. Thoracoscopic esophagectomy for intrathoracic esophageal cancer. Ann Thorac Cardiovasc Surg. 2005;11(4):221–7.PubMed
4.
Watson DI, Davies N, Jamieson GG. Totally endoscopic Ivor Lewis esophagectomy. Surg Endosc. 1999;13(3):293–7.CrossRefPubMed
5.
Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N Engl J Med. 2003;349(22):2117–27.CrossRefPubMed
6.
Dimick JB, Pronovost PJ, Cowan JA, Lipsett PA. Surgical volume and quality of care for esophageal resection: do high-volume hospitals have fewer complications? Ann Thorac Surg. 2003;75(2):337–41.CrossRefPubMed
7.
Birkmeyer JD, Dimick JB, Staiger DO. Operative mortality and procedure volume as predictors of subsequent hospital performance. Ann Surg. 2006;243(3):411–7.CrossRefPubMedPubMedCentral
8.
Yun YH, Kim YA, Min YH, et al. The influence of hospital volume and surgical treatment delay on long-term survival after cancer surgery. Ann Oncol. 2012;23(10):2731–7.CrossRefPubMed
9.
Campbell C, Reames MK, Robinson M, Symanowski J, Salo JC. Conduit vascular evaluation is associated with reduction in anastomotic leak after esophagectomy. J Gastrointest Surg. 2015;19(5):806–12.CrossRefPubMed
10.
Motz BM, Lorimer PD, Boselli D, et al. One-stage minimally-invasive Ivor-Lewis esophagectomy without patient repositioning. Surg Endosc. 2017;Annual SAGES conference proceedings.
11.
Lorimer PD, Pollard RJ, Salo JC, Buhrman WC. Use of a standard evidence-based ventilation protocol reduces the incidence of pulmonary complications in minimally invasive esophagectomy. Society of Cardiovascular Anesthesiology. 2017; Annual Symposium Proceedings.
12.
Hanna EM, Norton HJ, Reames MK, Salo JC. Minimally invasive esophagectomy in the community hospital setting. Surg Oncol Clin N Am. 2011;20(3):521–30.CrossRefPubMed
13.
Bizekis C, Kent MS, Luketich JD, et al. Initial experience with minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg. 2006;82(2):402–6. (discussion 406–7). CrossRefPubMed
14.
Pennathur A, Awais O, Luketich JD. Technique of minimally invasive Ivor Lewis esophagectomy. Ann Thorac Surg. 2010;89(6):S2159–62.CrossRefPubMed
15.
Nguyen NT, Hinojosa MW, Smith BR, Chang KJ, Gray J, Hoyt D. Minimally invasive esophagectomy: lessons learned from 104 operations. Ann Surg. 2008;248(6):1081–91.CrossRefPubMed
16.
Crenshaw GD, Shankar SS, Brown RE, Abbas AE, Bolton JS. Extracorporeal gastric stapling reduces the incidence of gastric conduit failure after minimally invasive esophagectomy. Am Surg. 2010;76(8):823–8.PubMed
17.
Rice TW, Blackstone EH, Rusch VW. 7th edition of the AJCC cancer staging manual: esophagus and esophagogastric junction. Ann Surg Oncol. 2010;17(7):1721–24.CrossRefPubMed
18.
Yap CH, Colson ME, Watters DA. Cumulative sum techniques for surgeons: a brief review. ANZ J Surg. 2007;77(7):583–6.CrossRefPubMed
19.
Van Rij AM, McDonald JR, Pettigrew RA, Putterill MJ, Reddy CK, Wright JJ. Cusum as an aid to early assessment of the surgical trainee. Br J Surg. 1995;82(11):1500–3.CrossRefPubMed
20.
Dhamija A, Rosen JE, Dhamija A, et al. Learning curve to lymph node resection in minimally invasive esophagectomy for cancer. Innovations (Phila). 2014;9(4):286–91.CrossRef
21.
Fabian T, Martin JT, McKelvey AA, Federico JA. Minimally invasive esophagectomy: a teaching hospital’s first year experience. Dis Esophagus. 2008;21(3):220–5.CrossRefPubMed
22.
23.
Guo W, Zou YB, Ma Z, et al. One surgeon’s learning curve for video-assisted thoracoscopic esophagectomy for esophageal cancer with the patient in lateral position: how many cases are needed to reach competence? Surg Endosc. 2013;27(4):1346–52.CrossRefPubMed
24.
Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256(1):95–103.CrossRefPubMedPubMedCentral
25.
Markar SR, Mackenzie H, Lagergren P, Hanna GB, Lagergren J. Surgical proficiency gain and survival after esophagectomy for cancer. J Clin Oncol. 2016;34(13):1528–36.CrossRefPubMed
26.
Mu JW, Gao SG, Xue Q, et al. Updated experiences with minimally invasive McKeown esophagectomy for esophageal cancer. World J Gastroenterol. 2015;21(45):12873–81.CrossRefPubMedPubMedCentral
27.
Mungo B, Lidor AO, Stem M, Molena D. Early experience and lessons learned in a new minimally invasive esophagectomy program. Surg Endosc. 2015;30(4):1692–8.CrossRefPubMed
28.
Ninomiya I, Osugi H, Tomizawa N, et al. Learning of thoracoscopic radical esophagectomy: how can the learning curve be made short and flat? Dis Esophagus. 2010;23(8):618–26.CrossRefPubMed
29.
Song SY, Na KJ, Oh SG, Ahn BH. Learning curves of minimally invasive esophageal cancer surgery. Eur J Cardiothorac Surg. 2009;35(4):689–93.CrossRefPubMed
30.
Tapias LF, Morse CR. Minimally invasive Ivor Lewis esophagectomy: description of a learning curve. J Am Coll Surg. 2014;218(6):1130–40.CrossRefPubMed
31.
Jobe BA, Kim CY, Minjarez RC, O’Rourke R, Chang EY, Hunter JG. Simplifying minimally invasive transhiatal esophagectomy with the inversion approach: lessons learned from the first 20 cases. Arch Surg. 2006;141(9):857–65. (discussion 865–56).CrossRefPubMed
32.
Rohatgi A, Sutcliffe R, Forshaw MJ, Strauss D, Mason RC. Training in oesophageal surgery: the gold standard: a prospective study. Int J Surg. 2008;6(3):230–3.CrossRefPubMed
33.
Schoppmann SF, Prager G, Langer F, Riegler M, Fleischman E, Zacherl J. Fifty-five minimally invasive esophagectomies: a single centre experience. Anticancer Res. 2009;29(7):2719–25.PubMed
34.
Bailey MB, Davenport DL, Vargas HD, Evers BM, McKenzie SP. Longer operative time: deterioration of clinical outcomes of laparoscopic colectomy versus open colectomy. Dis Colon Rectum. 2014;57(5):616–22.CrossRefPubMed
35.
Daley BJ, Cecil W, Clarke PC, Cofer JB, Guillamondegui OD. How slow is too slow? Correlation of operative time to complications: an analysis from the Tennessee Surgical Quality Collaborative. J Am Coll Surg. 2015;220(4):550–8.CrossRefPubMed
36.
Ross SW, Oommen B, Wormer BA, et al. National outcomes of laparoscopic Heller myotomy: operative complications and risk factors for adverse events. Surg Endosc. 2015;29(11):3097–105.CrossRefPubMed
37.
Kunisaki C, Kosaka T, Ono HA, et al. Significance of thoracoscopy-assisted surgery with a minithoracotomy and hand-assisted laparoscopic surgery for esophageal cancer: the experience of a single surgeon. J Gastrointest Surg. 2011;15(11):1939–51.CrossRefPubMed
38.
Zhou J, Chen H, Lu JJ, et al. Application of a modified McKeown procedure (thoracoscopic esophageal mobilization three-incision esophagectomy) in esophageal cancer surgery: initial experience with 30 cases. Dis Esophagus. 2009;22(8):687–93.CrossRefPubMed
39.
Ben-David K, Rossidis G, Zlotecki RA, et al. Minimally invasive esophagectomy is safe and effective following neoadjuvant chemoradiation therapy. Ann Surg Oncol. 2011;18(12):3324–29.CrossRefPubMed
40.
Giglia MD, DeRussy A, Morris MS, et al. Racial disparities in length-of-stay persist even with no postoperative complications. J Surg Res. 2017;214:14–22.CrossRefPubMed
Metadata
Title
Quality Improvement in Minimally Invasive Esophagectomy: Outcome Improvement Through Data Review
Publication date
01-01-2019
Published in
Annals of Surgical Oncology / Issue 1/2019
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-018-6938-z

Other articles of this Issue 1/2019

Annals of Surgical Oncology 1/2019 Go to the issue

Health Services Research and Global Oncology

The Surgical Care Improvement Project (2004), and Finally Some Progress

Breast Oncology

Evaluating the Rate of Upgrade to Invasive Breast Cancer and/or Ductal Carcinoma In Situ Following a Core Biopsy Diagnosis of Non-classic Lobular Carcinoma In Situ

ASO Author Reflections

ASO Author Reflections: Is It Important to Do Exercise Before Surgery for HPB Malignancy?

Pancreatic Tumors

How Does Chemoradiotherapy Following Induction FOLFIRINOX Improve the Results in Resected Borderline or Locally Advanced Pancreatic Adenocarcinoma? An AGEO-FRENCH Multicentric Cohort

Health Services Research and Global Oncology

An Overview of Bundled Payments for Surgical Oncologists: Origins, Progress to Date, Terminology, and Future Directions

ASO Author Reflections

Robotic Nipple-Sparing Mastectomy and Immediate Breast Reconstruction with Gel Implant