Evidence for the Positive Impact of Centralization in Esophageal Cancer Surgery.

IF 7.5 1区 医学 Q1 SURGERY Annals of surgery Pub Date : 2024-11-01 Epub Date: 2024-08-13 DOI:10.1097/SLA.0000000000006487
Noel E Donlon, Brendan Moran, Maria Davern, Matthew G Davey, Czara Kennedy, Roisin Leahy, Jenny Moore, Sinead King, Maeve Lowery, Moya Cunningham, Claire L Donohoe, Dermot O'Toole, Narayanasamy Ravi, John V Reynolds
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Abstract

Objective: To analyze the impact of centralization on key metrics, outcomes, and patterns of care at the Irish National Center.

Background: Overall survival rates for esophageal cancer in the West have doubled in the last 25 years. An international trend towards centralization may be relevant; however, this model remains controversial, with Ireland centralizing esophageal cancer surgery in 2011.

Methods: All patients (n=1245) with adenocarcinoma of the esophagus or junction treated with curative intent involving surgery, including endoscopic surgery, were included (n=461 from 2000 to 2011, and 784 from 2012 to 2022). All data entry was prospectively recorded. Overall survival was measured (1) for the entire cohort, (2) for patients with locally advanced disease (cT 2-3 N 0-3 ), and (3) for patients undergoing neoadjuvant therapy. All complications were recorded as per Esophageal Complication Consensus Group definitions, and the Clavien-Dindo severity classification. Data were analyzed using GraphPad Prism (v.6.0) for Windows and SPSS (v.23.0) software (SPSS) R Studio (R version 4.2.2). Survival times were calculated using a log-rank test and Cox regression analysis, and Kaplan-Meier curves were generated.

Results: Endotherapy for cT1a/intramucosal cancer adenocarcinoma increased from 40 (9% total) to 245 (31% total) procedures between the pre-centralization and post-centralization (post-C) periods. A significantly ( P < 0.001) higher proportion of patients with cT 2-3 N 0-3 disease in the post-C period underwent neoadjuvant therapy (66% vs 53%). Operative mortality was lower ( P =0.02) post-C, at 2% versus 4.5%, and ≥IIIa Clavien-Dindo major complications decreased from 33% to 25% ( P < 0.01). Recurrence rates were lower post-C (38% vs 53%, P < 0.01). Median overall survival was 73.83 versus 47.23 months in the 2012 to 2022 and 2000 to 2011 cohorts, respectively ( P < 0.001). For those who received neoadjuvant therapy, the median survival was 28.5 months pre-centralization and 42.5 months post-C ( P < 0.001).

Conclusions: These data highlight improvements in both operative outcomes and survival from the time of centralization, and a major expansion of endoscopic surgery. Although not providing proof, the study suggests a positive impact of formal centralization with governance on key quality metrics and an evolution in patterns of care.

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食管癌手术集中化的积极影响证据。
目的在这项研究中,我们分析了集中化对爱尔兰国家中心的关键指标、结果和护理模式的影响:过去 25 年中,西方国家食管癌患者的总生存率翻了一番。集中化的国际趋势可能与此有关,但这种模式仍存在争议,爱尔兰于2011年实现了食管癌手术的集中化:研究设计:纳入所有经手术(包括内窥镜手术)治愈的食管或交界处腺癌患者(n=1245)(2000-2011年461例,2012-2022年784例)。所有数据录入均为前瞻性记录。总生存率的测量对象包括:(i) 整组患者;(ii) 局部晚期疾病(cT2-3N0-3)患者;(iii) 接受新辅助治疗的患者。所有并发症均按照食管并发症共识小组(ECCG)的定义和克拉维恩-丁多(CD)严重程度分类进行记录:数据采用 Windows 版 GraphPad Prism(v.6.0)和 SPSS(v.23.0)软件(SPSS,Chicago,IL)RStudio(Rversion4.2.2)进行分析。采用对数秩检验和 Cox 回归分析计算生存时间,并生成 Kaplan-Meier 曲线:结果:在集中化前(pre-C)和集中化后(post-C)期间,针对 cT1a/IMC 腺癌的腔内治疗从 40 例(占总数的 9%)增加到 245 例(占总数的 31%)。主要并发症从 33% 明显降低到 25%:这些数据凸显了集中化后手术效果和存活率的提高,以及内窥镜手术的大幅扩展。虽然没有提供证据,但这项研究表明,正式的集中管理对关键质量指标有积极影响,并促进了护理模式的演变。
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来源期刊
Annals of surgery
Annals of surgery 医学-外科
CiteScore
14.40
自引率
4.40%
发文量
687
审稿时长
4 months
期刊介绍: The Annals of Surgery is a renowned surgery journal, recognized globally for its extensive scholarly references. It serves as a valuable resource for the international medical community by disseminating knowledge regarding important developments in surgical science and practice. Surgeons regularly turn to the Annals of Surgery to stay updated on innovative practices and techniques. The journal also offers special editorial features such as "Advances in Surgical Technique," offering timely coverage of ongoing clinical issues. Additionally, the journal publishes monthly review articles that address the latest concerns in surgical practice.
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