Interhospital variability of risk-adjusted mortality rates and associated structural factors in patients undergoing emergency laparotomy: England and Wales population-level analysis.

BACKGROUND: Emergency surgical admissions represent the majority of general surgical workload. Interhospital variations in outcomes are well recognized. This analysis of a national laparotomy data set compared the best- and worst-performing hospitals according to 30-day mortality and examined differences in process and structural factors. METHODS: A retrospective multicenter cohort study was performed using data from the England and Wales National Emergency Laparotomy Audit (December 2013 to November 2020). The data set was divided into quintiles based on the risk-adjusted mortality calculated using the National Emergency Laparotomy Audit score risk prediction model. Primary outcome was 30-day mortality. Hospital-level factors were compared across all five quintiles, and logistic regression analysis was conducted comparing the lowest with the highest risk-adjusted mortality quintiles. RESULTS: Risk-adjusted 30-day mortality in the poorest performing quintile was significantly higher than that of the best performing (11.4% vs. 6.6%) despite equivalent predicted mortality (9.4% vs. 9.7%). The best-performing quintile was more likely to be a tertiary surgical (49.5% vs. 37.1%, p < 0.001) or medical school-affiliated center (26.4% vs. 18.0%, p < 0.001). In logistic regression analysis, the strongest associations were for surgery performed in a tertiary center (odds ratio, 0.690 [95% confidence interval, 0.652-0.731], p < 0.001) and if surgery was performed by a gastrointestinal specialist (0.655 [0.626-0.685], p < 0.001). Smaller differences were seen for postoperative intensive care stay (0.848 [0.808-0.890], p < 0.001) and consultant anesthetist involvement (0.900 [0.837-0.967], p = 0.004). DISCUSSION: This study has identified significant variability in postoperative mortality across hospitals. Structural factors such as gastrointestinal specialist delivered emergency laparotomy and tertiary surgical center status appear to be associated with improved outcomes. LEVEL OF EVIDENCE: Original Research Article; Level II.

Comparison of major abdominal emergency surgery outcomes across organizational models of emergency surgical care: Analysis of the UK NELA national database.

BACKGROUND: Emergency general surgery (EGS) admissions account for a large proportion of surgical care and represent the majority of surgical patients who suffer in-hospital mortality. Health care systems continue to experience growing demand for emergency services: one way in which this is being increasingly addressed is dedicated subspecialty teams for emergency surgical admissions, most commonly termed "emergency general surgery" in the United Kingdom. This study aims to understand the impact of the emergency general surgery model of care on outcomes from emergency laparotomies. METHODS: Data was obtained from the National Emergency Laparotomy Audit database. Patients were dichotomized into EGS hospital or non-EGS hospital. Emergency general surgery hospital is defined as a hospital where >50% of in-hours emergency laparotomy operating is performed by an emergency general surgeon. The primary outcome was in-hospital mortality. Secondary outcomes were intensive therapy unit (ITU) length of stay and duration of hospital stay. A propensity score weighting approach was used to reduce confounding and selection bias. RESULTS: There were 115,509 patients from 175 hospitals included in the final analysis. The EGS hospital care group included 5,789 patients versus 109,720 patients in the non-EGS group. Following propensity score weighting, mean standardized mean difference reduced from 0.055 to <0.001. In-hospital mortality was similar (10.8% vs. 11.1%, p = 0.094), with mean length of stay (16.7 days vs. 16.1 days, p < 0.001) and ITU stay (2.8 days vs. 2.6 days, p < 0.001) persistently longer in patients treated in EGS systems. CONCLUSION: No significant association between the emergency surgery hospital model of care and in-hospital mortality in emergency laparotomy patients was seen. There is a significant association between the emergency surgery hospital model of care and an increased length of ITU stay and overall hospital stay. Further studies are required to examine the impact of changing models of EGS delivery in the United Kingdom. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Intra-operative ultrasound assessment of the biliary tree during robotic cholecystectomy.

Image-guided assessment of bile ducts and associated anatomy during laparoscopic cholecystectomy can be achieved with intra-operative cholangiography (IOC) or laparoscopic ultrasound (LUS). Rates of robotically assisted cholecystectomy (RC) are increasing and herein we describe the technique of intra-corporeal biliary ultrasound during RC using the Da Vinci system. For intraoperative evaluation of the biliary tree during RC, in cases of suspected choledocholithiasis, the L51K Ultrasound Probe (Hitachi, Tokyo, Japan) is used. The extrahepatic biliary tree is scanned along its length, capitalising on the benefits of the full range of motion offered by the articulated robotic instruments and integrated ultrasonic image display using TileProTM software. Additionally, this technique avoids the additional time and efforts required to undock and re-dock the robot that would otherwise be required for selective IOC or LUS. The average time taken to perform a comprehensive evaluation of the biliary tree, from the hepatic ducts to the ampulla of Vater, is 164.1 s. This assessment is supplemented by Doppler ultrasound, which is used to fully delineate anatomy of the porta hepatis, and accurate measurements of the biliary tree and any ductal stones can be taken, allowing for contemporaneous decision making and management of ductal pathologies. Biliary tract ultrasound has been shown to be equal to IOC in its ability to diagnose choledocholithiasis, but with the additional benefits of being quicker and having higher completion rates. We have described our practice of using biliary ultrasound during robotically assisted cholecystectomy, which is ergonomically superior to LUS, accurate and reproducible.

Proctored adoption of robotic hiatus hernia surgery: outcomes and learning curves in a high-volume UK centre.

BACKGROUND: The adoption of new surgical technologies is inevitably accompanied by a learning curve. With the increasing adoption of robotic techniques in benign foregut surgery, it is imperative to define optimal learning pathways, to ensure a clinically safe introduction of such a technique. The aim of this study was to assess the learning curve for robotic hiatal hernia repair with a pre-defined adoption process and proctoring. METHODS: The learning curve was assessed in four surgeons in a high-volume tertiary referral centre, performing over a 100 hiatal hernia repairs annually. The robotic adoption process included simulation-based training and a multi-day wet lab-based course, followed by robotic operations proctored by robotic upper GI experts. CUSUM analysis was performed to assess changes in operating time in sequential cases. RESULTS: Each surgeon (A, B, C and D) performed between 22 and 32 cases, including a total of 109 patients. Overall, 40 cases were identified as 'complex' (36.7%), including 16 revisional cases (16/109, 14.7%). With CUSUM analysis inflection points for operating time were seen after 7 (surgeon B) to 15 cases (surgeon B). CONCLUSION: The learning curve for robotic laparoscopic fundoplication may be as little as 7-15 cases in the setting of a clearly organized learning pathway with proctoring. By integrating these organized learning pathways learning curves may be shortened, ensuring patient safety, preventing detrimental outcomes due to longer learning curves, and accelerating adoption and integration of novel surgical techniques.

Systematic review: robot-assisted versus conventional laparoscopic multiport cholecystectomy.

Laparoscopic cholecystectomy has become the standard of care for the treatment of symptomatic gallstone disease. In the context of the increasing uptake of robotic surgery, robotic cholecystectomy has seen a substantial growth over the past decades. Despite this, a formal assessment of the evidence for this practice remains elusive and a randomised controlled trial is yet to be performed. This paper reviews the evidence to date for robotic multiport cholecystectomy compared to conventional multiport cholecystectomy. This systematic review was performed conducted using the Medline, Embase and Cochrane databases; in line with the PRISMA guideline. All articles that compared robotic and conventional laparoscopic cholecystectomy were included. The studies were assessed with regards to operative outcomes, postoperative recovery and complications. Fourteen studies were included, describing a total of 3002 patients. There was no difference in operative blood loss, complication rates, incidence of bile duct injury or length of hospital stay between the robotic and laparoscopic groups. The operative time for robotic cholecystectomy was longer, whereas the risk of conversion to open surgery was lower. There was marked variation in definitions of measured outcomes, and most studies lacked data on training and quality assessment, leading to substantial heterogeneity of the data. Available evidence on multiport robotic cholecystectomy compared to conventional laparoscopic cholecystectomy is scarce and the quality of the available studies is generally poor. Results suggest longer operating time for robotic cholecystectomy, although many studies included the learning curve period. Postoperative recovery and complications were similar in both groups.

Trends in emergency colorectal surgery: a 7-year retrospective single-centre cohort study.

BACKGROUND: Emergency colorectal resections carry a higher morbidity and mortality than elective surgery. The use of minimally invasive surgery has now become widespread in elective colorectal surgery, with improved patient outcomes. Laparoscopy is being increasingly used for emergency colorectal resections, but its role is still being defined. Our aim was to observe the uptake of laparoscopy for emergency colorectal surgery in our centre. METHOD: A retrospective single-centre cohort study was performed using local National Emergency Laparotomy Audit data from January 2014-December 2020. All patients who had a colorectal resection were included. Trends in the number and type of resections were recorded. Primary outcome was the proportion of cases started and completed laparoscopically. Secondary outcomes included rate of conversion to open, length of stay and 30-day mortality. RESULTS: A total 523 colorectal resections were performed. The number of cases attempted and completed laparoscopically steadily increased over the study period (28.3% to 63.3% and 16.3% to 35.4%, respectively). The mean rate of conversion to open was 43.8%. The greatest expansion in laparoscopy was for cases of intestinal obstruction, perforation and peritonitis, and for those undergoing Hartmann's procedure and right hemicolectomy. 30­day mortality for cases completed laparoscopically was much lower than those converted or started with open surgery (2.1% vs 11.7% and 17.5%, respectively). Laparoscopic approach was independently associated with reduced length of stay. CONCLUSION: Laparoscopy has been successfully adopted for emergency colorectal resections in our centre, with half of cases felt to be suitable for minimally invasive surgery.

Laparoscopy in high-risk emergency general surgery reduces intensive care stay, length of stay and mortality.

PURPOSE: Emergency general surgery patients undergoing laparoscopic surgery are at reduced risk of mortality and may require reduced length of critical care stay. This study investigated the effect of laparoscopy on high-risk patients' post-operative care requirements. METHODS: Data were retrieved for all patients entered into the NELA database between 2013 and 2018. Only high-risk surgical patients (P-POSSUM predicted mortality risk of ≥ 5%) were included. Patients undergoing laparoscopic and open emergency general surgical procedures were compared using a propensity score weighting approach. Outcome measures included total length of critical care (level 3) stay, overall length of stay and inpatient mortality. RESULTS: A total of 66,517 high-risk patients received emergency major abdominal surgery. A laparoscopic procedure was attempted in 6998 (10.5%); of these, the procedure was competed laparoscopically in 3492 (49.9%) and converted to open in 3506 (50.1%). Following inverse probability treatment weighting adjustment for patient disease and treatment characteristics, high-risk patients undergoing laparoscopic surgery had a shorter median ICU stay (1 day vs 2 days p < 0.001), overall hospital length of stay (11 days vs 14 days p < 0.001) and a lower inpatient mortality (16.0% vs 18.8%, p < 0.001). They were also less likely to have a prolonged ICU stay with an OR of 0.78 (95% CI 0.74-0.83, p < 0.001). CONCLUSION: The results of this study suggest that in patients at high risk of post-operative mortality, laparoscopic emergency bowel surgery leads to a reduced length of critical care stay, overall length of stay and inpatient mortality compared to traditional laparotomy.

Specialist-led urgent cholecystectomy for acute gallstone disease.

BACKGROUND: Despite overwhelming evidence of the clinical and financial benefit of urgent cholecystectomy, there is variable enthusiasm and uptake across the UK. In 2014, following the First National Emergency Laparotomy Audit Organisational Report, we implemented a specialist-led urgent surgery service, whereby all patients with gallstone-related pathologies were admitted under the direct care of specialist upper gastrointestinal surgeons. We have analysed 5 years of data to investigate the results of this service model. METHODS: Computerised operating theatre records were interrogated to identify all patients within a 5-year period undergoing cholecystectomy. Patient demographics, admission details, length of stay, duration of surgery, and complications were analysed. RESULTS: Between 01/01/2016 and 31/12/2020, a total of 4870 cholecystectomies were performed; 1793 (36.8%) were urgent cases and 3077 (63.2%) were elective cases. All cases were started laparoscopically; 25 (0.5%) were converted to open surgery-14 of 1793 (0.78%) urgent cases and 11 of 3077 (0.36%) elective cases. Urgent cholecystectomy took 20 min longer than elective surgery (median 74 versus 52 min). No relevant difference in conversion rate was observed when urgent cholecystectomy was performed within 2 days, between 2 and 4 days, or greater than 4 days from admission (P = 0.197). Median total hospital stay was 4 days. CONCLUSION: Urgent laparoscopic cholecystectomy is safe and feasible in most patients with acute gall bladder disease. Surgery under the direct care of upper gastrointestinal specialist surgeons is associated with a low conversion rate, low complication rate, and short hospital stay. Timing of surgery has no effect on conversion rate or complication rate.

Outcomes After Independent Trainee Versus Consultant-led Emergency Laparotomy: Inverse Propensity Score Population Dataset Analysis.

OBJECTIVE: We utilized a population dataset to compare outcomes for patients where surgery was independently performed by trainees to cases led by a consultant. SUMMARY OF BACKGROUND DATA: Emergency laparotomy is a common, high-risk, procedure. Although trainee involvement to improve future surgeons' experience and ability in the management of such cases is crucial, some studies have suggested this is to the detriment of patient outcomes. In the UK, appropriately skilled trainees may be entrusted to perform emergency laparotomy without supervision of a consultant (attending). METHODS: Patients who underwent emergency laparotomy between 2013 and 2018 were identified from the National Emergency Laparotomy Audit of England and Wales. To reduce selection and confounding bias, the inverse probability of treatment weighting approach was used, allowing robust comparison of trainee-led and consultant-led laparotomy cases accounting for eighteen variables, including details of patient, treatment, pathology, and preoperative mortality risk. Groups were compared for mortality and length of stay. RESULTS: A total of 111,583 patients were included in the study. The operating surgeon was a consultant in 103,462 cases (92.7%) and atrainee in 8121 cases (7.3%). Mortality at discharge was 11.6%. Trainees were less likely to operate on high-risk and colorectal cases. After weighting, mortality (12.2% vs 11.6%, P = 0.338) was equivalent between trainee- and consultant-led cases. Median length of stay was 11 (interquartile range 7, 19) versus 11 (7, 20) days ( P = 0.004), respectively. Trainee-led operations reported fewer cases of blood loss >500mL (9.1% vs 11.1%, P < 0.001). CONCLUSIONS: Major laparotomy maybe safely entrusted to appropriately skilled trainees without impacting patient outcomes.

Learning curve for adoption of robot-assisted minimally invasive esophagectomy: a systematic review of oncological, clinical, and efficiency outcomes.

BACKGROUND: Robot-assisted minimally invasive esophagectomy (RAMIE) is gaining increasing popularity as an operative approach. Learning curves to achieve surgical competency in robotic-assisted techniques have shown significant variation in learning curve lengths and outcomes. This study aimed to summarize the current literature on learning curves for RAMIE. METHODS: A systematic review was conducted in line with PRISMA guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles reporting on learning curves in RAMIE were identified and scrutinized. Studies were eligible if they reported changes in operative outcomes over time, or learning curves, for surgeons newly adopting RAMIE. RESULTS: Fifteen studies reporting on 1767 patients were included. Nine studies reported on surgeons with prior experience of robot-assisted surgery prior to adopting RAMIE, with only four studies outlining a specified RAMIE adoption pathway. Learning curves were most commonly analyzed using cumulative sum control chart (CUSUM) and were typically reported for lymph node yields and operative times, with significant variation in learning curve lengths (18-73 cases and 20-80 cases, respectively). Most studies reported adoption without significant impact on clinical outcomes such as anastomotic leak; significant learning curves were more likely in studies, which did not report a formal learning or adoption pathway. CONCLUSION: Reported RAMIE adoption phases are variable, with some authors suggesting significant impact to patients. With robust training through formal programmes or proctorship, however, others report RAMIE adoption without impact on clinical outcomes. A formalized adoption curriculum appears critical to prevent adverse effects on operative efficiency and patient care.

Emergency robotic colorectal surgery during COVID-19 pandemic: A retrospective case series study.

Objective: While interest in elective robotic surgery is growing, use in emergency setting remains limited due to challenges posed by sicker patients, advanced pathology and logistical issues. During the COVID-19 pandemic, robotic surgery could provide the benefit of having the surgeon away from the bedside and reducing the number of directly exposed medical staff. The objective of this study was to report patient outcomes and initial learning experience of emergency robotic colorectal surgery during the COVID-19 pandemic. Methods: A case series study was conducted, including patients undergoing emergency robotic colorectal surgery between February 2020 and February 2021 at Queen Alexandra Hospital in Portsmouth, UK. Patient data were collected from an ethics approved prospective database. Patient demographics, operative time, conversions and postoperative complications were recorded. In addition, readmissions, length of stay and short-term oncological outcomes were analyzed. Results: Ten patients with median age 64 y (range, 36-83 y) were included. Four patients had robotic complete mesocolic resection for obstructing cancers. Six had colorectal resections for benign disease in emergency setting. All were R0 with a mean lymph node harvest of 54 ± 13. Mean operative time was 249 ± 117 min, the median length of stay was 9.4 d (range, 5-22 d). Only one patient was given a temporary diverting ileostomy. There were no grade III/V complications and no 30-day mortality. Conclusions: Provided an experienced team and peri-operative planning, emergency robotic colorectal surgery can achieve favorable outcomes with benefits of radical lymph node dissection in oncological cases and avoidance of diverting stoma.

P-POSSUM and the NELA Score Overpredict Mortality for Laparoscopic Emergency Bowel Surgery: An Analysis of the NELA Database.

BACKGROUND: Risk stratification has become a key part of the care processes for patients having emergency bowel surgery. This study aimed to determine if operative approach influences risk-model performance, and risk-adjusted mortality rates in the United Kingdom. METHODS: A prospectively planned analysis was conducted using National Emergency Laparotomy Audit (NELA) data from December 2013 to November 2018. The risk-models investigated were P-POSSUM and the NELA Score, with model performance assessed in terms of discrimination and calibration. Risk-adjusted mortality was assessed using Standardised Mortality Ratios (SMR). Analysis was performed for the total cohort, and cases performed open, laparoscopically and converted to open. Sub-analysis was performed for cases with ≤ 20% predicted mortality. RESULTS: Data were available for 116 396 patients with P-POSSUM predicted mortality, and 46 935 patients with the NELA score. Both models displayed excellent discrimination with little variation between operative approaches (c-statistic: P-POSSUM 0.801-0.836; NELA Score 0.811-0.862). The NELA score was well calibrated across all deciles of risk, but P-POSSUM over-predicted risk beyond 20% mortality. Calibration plots for operative approach demonstrated that both models increasingly over-predicted mortality for laparoscopy, relative to open and converted to open surgery. SMRs calculated using both models consistently demonstrated that risk-adjusted mortality with laparoscopy was a third lower than open surgery. CONCLUSION: Risk-adjusted mortality for emergency bowel surgery is lower for laparoscopy than open surgery, with P-POSSUM and NELA score both over-predicting mortality for laparoscopy. Operative approach should be considered in the development of future risk-models that rely on operative data.

Feasibility of laparoscopy and factors associated with conversion to open in minimally invasive emergency major abdominal surgery: population database analysis.

BACKGROUND: There is limited evidence regarding the overall feasibility and success rates of the laparoscopic approach in major emergency surgery, despite its potential to improve outcomes. This study aims to investigate the association between patient, procedural, and surgical factors and likelihood of successful laparoscopic completion in emergency major surgery and derive a predictive model to aid clinical decision-making. METHOD: All patients recorded in the NELA emergency laparotomy database 1 December 2013-31 November 2018 who underwent laparoscopically attempted surgery were included. A retrospective cohort multivariable regression analysis was conducted for the outcome of conversion to open surgery. A predictive model was developed and internally validated. RESULTS: Of 118,355 patients, 17,040 (7.7%) underwent attempted laparoscopic surgery, of which 7.915 (46.4%) were converted to open surgery. Procedure type was the strongest predictor of conversion (compared to washout as reference, small bowel resection OR 25.93 (95% CI 20.42-32.94), right colectomy OR 6.92 (5.5-8.71)). Diagnostic [free pus, blood, or blood OR 3.67 (3.29-4.1)] and surgeon [subspecialist surgeon OR 0.56 (0.52-0.61)] factors were also significant, whereas age, gender, and pre-operative mortality risk were not. A derived predictive model had high internal validity, C-index 0.758 (95% CI 0.748-0.768), and is available for free-use online. CONCLUSION: Surgical, patient, and diagnostic variables can be used to predict likelihood of laparoscopic success with a high degree of accuracy. This information can be used to inform peri-operative decision-making and patient selection.

Technique of open and minimally invasive intrathoracic reconstruction following esophagectomy-an expert consensus based on a modified Delphi process.

BACKGROUND: In recent years, minimally invasive Ivor Lewis (IL) esophagectomy with high intrathoracic anastomosis has emerged as surgical standard of care for esophageal cancer in expert centers. Alongside this process, many divergent technical aspects of this procedure have been devised in different centers. This study aims at achieving international consensus on the surgical steps of IL reconstruction using Delphi methodology. METHODS: The expert panel consisted of specialized esophageal surgeons from 8 European countries. During a two-round Delphi process, a detailed analysis and consensus on key steps of intrathoracic gastric tube reconstruction (IL esophagectomy) was performed. RESULTS: Response rates in Delphi rounds 1 and 2 were 100% (22 of 22 experts) and 83.3% (20 of 24 experts), respectively. Three essential technical areas of intrathoracic gastric tube reconstruction were identified: first, vascularization of the gastric conduit, second, gastric mobilization, tube formation and pull-up, and third, anastomotic technique. In addition, 3 main techniques for minimally invasive intrathoracic anastomosis are currently practiced: (i) end-to-side circular stapled, (ii) end-to-side double stapling, and (iii) side-to-side linear stapled technique. The step-by-step procedural analysis unveiled common approaches but also different expert practice. CONCLUSION: This precise technical description may serve as a clinical guideline for intrathoracic reconstruction after esophagectomy. In addition, the results may aid to harmonize the technical evolution of this complex surgical procedure and thereby facilitate surgical training.

The Effect of Postoperative Complications After Minimally Invasive Esophagectomy on Long-term Survival: An International Multicenter Cohort Study.

BACKGROUND: Esophagectomy is a technically challenging procedure, associated with significant morbidity. The introduction of minimally invasive esophagectomy (MIE) has reduced postoperative morbidity. OBJECTIVE: Although the short-term effect on complications is increasingly being recognized, the impact on long-term survival remains unclear. This study aims to investigate the association between postoperative complications following MIE and long-term survival. METHODS: Data were collected from the EsoBenchmark Collaborative composed by 13 high-volume, expert centers routinely performing MIE. Patients operated between June 1, 2011 and May 31, 2016 were included. Complications were graded using the Clavien-Dindo (CD) classification. To correct for short-term effects of postoperative complications on mortality, patients who died within 90 days postoperative were excluded. Primary endpoint was 5-year overall survival. RESULTS: A total of 915 patients were included with a mean follow-up time of 30.8 months (standard deviation 17.9). Complications occurred in 542 patients (59.2%) of which 50.2% had a CD grade ≥III complication [ie, (re)intervention, organ dysfunction, or death]. The incidence of anastomotic leakage (AL) was 135 of 915 patients (14.8%) of which 84 patients were classified as a CD grade ≥III. Multivariable analysis showed a significantly deteriorated long-term survival in all patients with AL [hazard ratio (HR) 1.68, 95% confidence interval (CI) 1.25-2.24]. This inverse relation was most distinct when AL was scored as a CD grade ≥III (HR 1.83, 95% CI 1.30-2.58). For all other complications, no significant association with long-term survival was found. CONCLUSION: The occurrence and severity of AL, but not overall complications, after MIE negatively affect long-term survival of esophageal cancer patients.

Anastomotic Techniques and Associated Morbidity in Total Minimally Invasive Transthoracic Esophagectomy: Results From the EsoBenchmark Database.

OBJECTIVE: The aim of this study was to describe anastomotic techniques used for total minimally invasive transthoracic esophagectomy (ttMIE) and to analyze the associated morbidity. BACKGROUND: ttMIE faces increasing application in surgical treatment of esophageal cancer. For esophagogastric reconstruction, different anastomotic techniques are currently used, but their effect on postoperative anastomotic leakage and morbidity has not been investigated. PATIENTS AND METHODS: Patients were selected from a basic dataset, collected during a 5-year period from 13 international surgical high-volume centers. Endpoints were anastomotic leakage rate and postoperative morbidity in correlation to anastomotic techniques, measured by the Clavien-Dindo classification and the Comprehensive Complication Index (CCI). RESULTS: Five anastomotic techniques were identified in 966 patients after ttMIE: intrathoracic end-to-side circular-stapled technique in 427 patients (double-stapling n = 90, purse-string n = 337), intrathoracic (n = 109) or cervical (n = 255) side-to-side linear-stapled, and cervical end-to-side hand-sewn (n = 175). Leakage rates were similar in intrathoracic and cervical anastomoses (15.9% vs 17.2%, P = 0.601), but overall complications (56.7%% vs 63.7%, P = 0.029) and median 90-day CCI {21 [interquartile range (IQR) 0-36] vs 29 [IQR 0-40], P = 0.019} favored intrathoracic reconstructions. Leakage rates after intrathoracic end-to-side double-stapling (23.3%) and cervical end-to-side hand-sewn (25.1%) techniques were significantly higher compared with intrathoracic side-to-side linear (15.6%), end-to-side purse-string (13.9%), and cervical side-to-side linear-stapled esophagogastrostomies (11.8%) (P < 0.001). Multivariable analysis confirmed anastomotic technique as independent predictor of leakage after ttMIE. CONCLUSION: Results of this analysis present the current status of the technical evolution of ttMIE with anastomotic leakage as predominant surgical complication. However, technique-related morbidity requires cautious interpretation considering the long learning curve of this complex surgical procedure.

FA01.02: THE EFFECT OF POSTOPERATIVE COMPLICATIONS AFTER MIE ON LONG-TERM SURVIVAL: A RETROSPECTIVE, MULTI-CENTER COHORT STUDY.

BACKGROUND: Esophagectomy has a high incidence of postoperative morbidity. Complications lead to a decreased short-term survival, however the influence of those complications on long-term survival is still unclear. Most of the performed studies are small, single center cohort series with inconclusive or conflicting results. Minimally invasive esophagectomy (MIE) has been shown to be associated with a reduced postoperative morbidity. In this study, the influence of complications on long-term survival for patients with esophageal cancer undergoing a MIE were investigated. METHODS: Data was collected from the EsoBenchmark database, a collaboration of 13 high-volume centers routinely performing MIE. Patients were included in this database from June 1, 2011 until May 31, 2016. Complications were scored according to the Clavien-Dindo (CD) classification for surgical complications. Major complications were defined as a CD grade ≥ 3. The data were corrected for 90-day mortality to correct for the short-term effect of postoperative complications on mortality. Overall survival was analyzed using the Kaplan Meier, log rank- and (uni- and multivariable) Cox-regression analyses. RESULTS: A total of 926 patients were eligible for analysis. Mean follow-up time was 30.8 months (SD 17.9). Complications occurred in 543 patients (59.2%) of which 39.3% had a major complication. Anastomotic leakage (AL) occurred in 135 patients (14.5%) of which 9.2% needed an intervention (CD grade ≥ 3). A significant worse long-term survival was observed in patients with any AL (HR 1.73, 95% CI 1.29-2.32, P < 0.001) and for patients with AL CD grade ≥3 (HR 1.86, 95% CI 1.32-2.63, P < 0.001). Major cardiac complications occurred in 18 patients (1.9%) and were related to a decreased long-term survival (HR 2.72, 95% CI 1.38-5.35, p 0.004). For all other complications, no significant influence on long-term survival was found. CONCLUSION: The occurrence and severity of anastomotic leakage and cardiac complications after MIE negatively affect long-term survival of esophageal cancer patients. DISCLOSURE: All authors have declared no conflicts of interest.

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

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/m). 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.

Open and laparoscopically assisted oesophagectomy: a prospective comparative study.

OBJECTIVES: Although a number of studies have examined minimally invasive approaches for oesophagectomy, these procedures have typically been offered only to selected patients with the limited long-term follow-up data. The purpose of this prospective study was to assess the feasibility of performing laparoscopically assisted oesophagectomy (LAO) for all-comers and to compare the short- and long-term clinical outcomes of this surgical strategy with a matched cohort of patients who had undergone open surgery. METHODS: From November 2009, all patients referred for trans-thoracic resection of an oesophageal cancer underwent a two-stage laparoscopically assisted Ivor-Lewis oesophagectomy. This consisted of laparoscopic mobilization of the stomach and distal oesophagus, followed by open thoracotomy, thoracic lymphadectomy and intrathoracic anastomosis. The clinical and oncological outcomes of the first 39 consecutive LAO patients were compared with those of the preceding 31 consecutive patients who had undergone open surgery. RESULTS: Of the 39 LAO cases, 37 cases were completed laparoscopically and 2 were converted to an open surgery. LAO was associated with a decreased incidence of postoperative complications (specifically cardiac and infectious complications) when compared with open surgery (54 vs 77%, P = 0.04). In addition, the initial intensive care unit stay (2 vs 4 days; P = 0.04) and overall length of hospital stay (14 vs 18 days; P = 0.02) were shorter in the LAO group. In terms of pathological outcomes, the lymph node yield and R0 resection rate of the LAO and open groups were comparable, as were the 1-year survival rates (62 vs 61%, P = 0.97). CONCLUSIONS: LAO can be offered to an unselected cohort of all-comers with a reduced postoperative complication rate and comparable oncological and long-term survival outcomes when compared with open surgery.