Introducing robotic oesophagectomy into an Australian practice: an assessment of the early procedural outcomes and learning curve.

BACKGROUND: Robotic oesophagectomy (RAMIO) is a novel procedure in Australia and New Zealand. We aimed to report the early operative and clinical outcomes achieved during the introduction of RAMIO into the practice of a single Australian surgeon and benchmark these against outcomes of patients receiving conventional minimally invasive oesophagectomy (MIO) by the same surgeon. METHODS: Data on all patients undergoing RAMIO, performed by a single high-volume Australian surgeon, were collected from a prospectively maintained database. Operative, clinical and surgical quality outcomes were benchmarked on a univariable basis against those of patients receiving MIO. Learning curves were computed using quadratic and linear regression of operating times on case-numbers and compared using Cox regression modelling. RESULTS: 290 patients (237 MIO, 53 RAMIO (47% Ivor-Lewis, 53% McKeon oesophagectomy)) were included. Compared with MIO, the median thoracic operating time was 20 min longer for RAMIO (P = 0.03). Following RAMIO, there was less blood loss (P < 0.01) and a shorter length of stay (P < 0.01).There were no differences in morbidity and quality of surgery following RAMIO compared with MIO. There were no deaths following RAMIO. Having progressed from MIO, the operating times for RAMIO improved after 22 cases compared with MIO (110 cases) (HR 0.70 (0.51-0.93), P = 0.01). CONCLUSION: With careful implementation, RAMIO may be safely performed within the Australian setting and is associated with a modest increase in procedure duration, but less blood loss and shorter length of stay compared with conventional MIO.

Procedure-specific outcomes following gastrectomy for cancer compared by hospital volume and service capability.

BACKGROUND: International literature recommends centralising gastric cancer surgery, however, with volumes that define 'high-volume resection' being higher than those in most major centres in Australia and New Zealand. These reports rarely focus on the difference between total (TG) and partial gastrectomy (PG). We assessed the impact of resection volume and service capability on operative mortality, morbidity and surgical quality in patients who had a PG and TG. METHODS: Patients who had gastrectomy for adenocarcinoma, between 2001 and 2015, were collected from the Queensland Oncology Repository. Hospitals were characterised by cases-per-annum (high-volume [HV] ≥ 5 and low-volume [LV] < 5) and hospital service capability as (high-service [HS] and low-service [LS]), giving three hospital groups: HVHS, LVHS and LVLS. Chi-squared tests were used to compare post-operative mortality, morbidity, failure to rescue (FTR) from complications and surgical quality between these three groups. RESULTS: There were 426 patients who had a TG and 827 having PG. HVHS centres performed 59% of PG with high surgical quality rates of: HVHS = 53%, LVHS = 34% and LVLS = 46% (p < 0.01). Surgical complications were highest in LVLS (LVLS = 19%, LVHS = 11%, HVHS = 11%; p = 0.02). There was no difference in 30-day mortality nor in FTR. For TG, HVHS performed 67% of these procedures, with lower 30-day mortality (2%) and FTR rates (5%) compared with LVHS (7%, 22%) and LVLS (12%, 28%; p < 0.01). There was no difference in operative morbidity and surgical quality between hospital groups. CONCLUSION: Despite the 'high-volume' threshold for gastrectomy being the lowest described in the literature, we have shown that centralisation to HVHS centres was associated with lower operative mortality for TG and improved quality of surgery for PG.

Hospital characteristics associated with better 'quality of surgery' and survival following oesophagogastric cancer surgery in Queensland: a population-level study.

BACKGROUND: The impact of hospital characteristics on the quality of surgery and survival following oesophagogastric cancer surgery has not been well established in Australia. We assessed the interaction between hospital volume, service capability and surgical outcomes, with the hypothesis that both the quality of surgery and survival are better following treatment in high-volume, high service capability hospitals. METHODS: All patients undergoing oesophagectomy and gastrectomy for cancer in Queensland, between 2001 and 2015, were included. Demographic, pathology and outcome data were collected. Hospitals were categorized into high (HV) (≥5 gastrectomies; ≥6 oesophagectomies) and low volume (LV). Hospital service capability was defined as high (HS) and low (LS), and then linked to hospital volume: HVHS, LVHS and LVLS. Higher quality surgery was defined using six perioperative parameters. Univariable comparisons of quality of surgery between hospital groups used chi-squared tests. The 5-year overall survival was compared using log-rank tests and Cox proportional hazard models. RESULTS: For both gastrectomy and oesophagectomy, higher quality surgery occurred more frequently in HVHS hospitals (gastrectomy: HVHS = 44.2%, LVHS = 23.1%, LVLS = 29.1% (P < 0.01); oesophagectomy: HVHS = 34.5%, LVHS = 24.4%, LVLS = 21.7% (P = 0.01)). Following oesophagectomy, the 3- and 5-year overall survival was better following treatment in HVHS (P < 0.01). There was no difference between the groups following gastrectomy. CONCLUSION: In Queensland, the quality of surgery was higher in HVHS hospitals performing gastrectomy and oesophagectomy; however, the impact on cancer survival was only seen following oesophagectomy.

Pancreaticoduodenectomy in a low-resection volume region: a population-level study examining the impact of hospital-volume on surgical quality and longer-term survival.

BACKGROUND: An association between higher hospital-volume and better "quality of surgery" and long-term survival has not been reported following pancreatic cancer surgery in low resection-volume regions such as in Australia. Using a population-level study, we compare "quality of surgery" and two-year survival following pancreaticoduodenectomy between Australian hospitals grouped by resection-volume. METHODS: Data on all patients undergoing pancreaticoduodenectomy for adenocarcinoma in the Australian state of Queensland, between 2001 and 2015, were obtained from the Queensland Oncology Repository. Hospitals were grouped into high (≥6 resections annually) and low (<6) volume centres. Following adjustment for case-mix, "quality-of-treatment" indicators were compared between hospital groups using multivariate logistic regression and Poisson regression analysis; and two-year cancer-specific and overall survival were compared using multivariate Cox proportional hazard models. RESULTS: Compared with high-volume centres, low-volume centres had worse two-year cancer-specific survival (Adjusted HR = 1.31; 95% CI:1.03-1.68), higher 30-day mortality (Adjusted IRR = 3.81; 95% CI: 1.36-10.62) and fewer patients received "high-quality surgery" (Adjusted OR = 0.55; 95% CI: 0.33-0.90). Differences in 30-day mortality, or "quality-of-treatment" indicators did not entirely explain the observed survival difference between hospital-volume groups. CONCLUSION: In an Australian environment, a "high" hospital-volume was significantly associated with better quality surgery and two-year survival following pancreaticoduodenectomy.

Impact of hospital resection volume and service capability on post-operative mortality following gastrectomy.

BACKGROUND: Improved post-operative mortality following gastrectomy for cancer in hospitals with higher resection volumes has not been reported in Australia. Using a population-based study in Queensland, we aimed to compare post-operative mortality following gastrectomy between high- and low-volume hospitals stratified by their service capability. METHODS: All patients undergoing gastrectomy for adenocarcinoma in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into 'high-volume (≥5 gastrectomies annually), high service capability' (HVHS); 'low-volume (<5), high service capability'; and 'low-volume, low service capability' (LVLS). Negative binomial regression models were used to compare 30- and 90-day mortality rates between hospital groups adjusting for age, sex, socio-economic status, Charlson and American Society of Anesthesiologists scores, treatment regimen, stage and time-period. Potential mediation of mortality differences between hospital groups due to differences in the type of gastrectomy performed was also examined. RESULTS: LVLS hospitals have higher adjusted 30-day (incidence rate ratio (IRR) 2.97, 95% confidence interval (CI) 1.65-5.35) and 90-day (IRR 1.95, 95% CI 1.23-3.09) mortality rates compared with HVHS hospitals. There is no significant difference in adjusted 30-day (IRR 1.16, 95% CI 0.48-2.79) and 90-day (IRR 1.12, 95% CI 0.59-2.13) mortality rates comparing low-volume, high service capability hospitals with HVHS hospitals. The type of gastrectomy performed did not significantly influence differences in mortality compared between hospital groups. CONCLUSION: In the Australian environment, post-operative mortality following gastric cancer surgery may be optimized by centralizing gastrectomy away from hospitals characterized by LVLS.

Assessment of hospital characteristics associated with improved mortality following complex upper gastrointestinal cancer surgery in Queensland.

BACKGROUND: High hospital-volume and service capability are associated with improved mortality following complex cancer surgery. Using a population-based study in Queensland, we assessed differences in mortality following oesophagectomy and pancreaticoduodenectomy, comparing high- and low-volume hospitals stratified by service capability. METHODS: Data on all patients undergoing oesophagectomy and pancreaticoduodenectomy for cancer in Queensland between 2001 and 2015 were obtained from the Queensland Oncology Repository. Hospital service capability was defined using the 2015 Australian Institute of Health and Welfare hospital peer groupings. Hospitals were grouped into 'high-volume (≥6 oesophagectomies or pancreaticoduodenectomies annually) with high service capability'; 'low-volume (<6) with high service capability' and 'low-volume with low service capability'. Multivariate Poisson models were used to estimate differences in 30- and 90-day mortality between hospital groups adjusting for age, sex, socioeconomic status, Charlson and American Society of Anesthesiologists scores, chemotherapy, radiotherapy, stage and time-period. RESULTS: For oesophagectomy, adjusted 90-day mortality was higher in low-volume compared with high-volume hospitals, regardless of service capability (low-volume, high service: incident rate ratio (IRR) 3.86, 95% confidence interval (CI) 1.74-8.57; low-volume, low service: IRR 3.40, 95% CI 1.16-10.00). For pancreaticoduodenectomy, mortality was higher in low-volume compared with high-volume centres regardless of service capability: 30-day mortality (low-volume, high service: IRR 2.32, 95% CI 1.07-5.03; low-volume, low service: IRR 3.92, 95% CI 1.45-10.61); 90-day mortality (low-volume, high service: IRR 2.36, 95% CI 1.29-4.30; low-volume, low service: IRR 3.32, 95% CI 1.64-6.71). CONCLUSION: High hospital resection volumes are associated with lower post-operative mortality following oesophagectomy and pancreaticoduodenectomy regardless of hospital service capability. This data supports centralization of these procedures to high-volume centres.

Single-access laparoscopic surgery for ileal disease.

Aim. Single-access laparoscopic surgery (SALS) can be effective for benign and malignant diseases of the ileum in both the elective and urgent setting. Methods. Ten consecutive, nonselected patients with ileal disease requiring surgery over a twelve month period were included. All had a preoperative abdominopelvic computerized tomogram. Peritoneal access was achieved via a single transumbilical incision and a "surgical glove port" utilized as our preferred access device. With the pneumoperitoneum established, the relevant ileal loop was located using standard rigid instruments. For ileal resection, anastomosis, or enterotomy, the site of pathology was delivered and addressed extracorporeally. Result. The median (range) age of the patients was 42.5 (22-78) years, and the median body mass index was 22 (20.2-28) kg/m(2). Procedures included tru-cut biopsy of an ileal mesenteric mass, loop ileostomy and ileotomy for impacted gallstone extraction as well as ileal (n = 3) and ileocaecal resection (n = 4). Mean (range) incision length was 2.5 (2-5) cm. All convalescences were uncomplicated. Conclusions. These preliminary results show that SALS is an efficient and safe modality for the surgical management of ileal disease with all the advantages of minimal access surgery and without requiring a significant increase in theatre resource or cost or incurring extra patient morbidity.