Objective: To evaluate changes in treatment and outcomes of esophagogastric cancer surgery after introduction of the DUCA. In addition, the presence of risk-averse behavior was assessed. Summary of Background Data: Clinical auditing is seen as an important quality improvement tool; however, its long-term efficacy remains largely unknown. In addition, critics claim that enhancements result from risk-averse behavior rather than positive effects of auditing. Methods: DUCA data were used from registration start (1-1-2011) until 31-12-2018. Trends in patient, tumor, hospital and treatment characteristics were univariably assessed. Trends in short-term outcomes were investigated using multilevel multivariable logistic regression. Presence of risk aversion was described by the corrected proportion of patients undergoing surgery, using data from the Netherlands Cancer Registry. To evaluate the impact of centralization on time trends identified, the association between hospital volume and outcomes was investigated. Results: This study included 6172 patients with esophageal and 3,690 with gastric cancer who underwent surgery. Pathological outcomes (lymph node yield, radicality) improved and futile surgery decreased over the years. In-hospital/30-day mortality decreased for esophagectomy (4.2% to 2.5%) and for gastrectomy (7.1% to 4.3%). Reinterventions, (minor) complications and readmissions increased. Risk aversion appeared absent. Between 2011-2018, annual median hospital volumes increased from 38 to 53 for esophagectomy and from 14 to 29 for gastrectomy. Higher hospital volumes were associated with several improved outcomes measures. Conclusions: During 8 years of auditing, outcomes improved, with no signs of risk-averse behavior. These improvements occurred in parallel with centralization. Feedback on postoperative complications remains the focus of the DUCA.

Objective: In the pursuit of quality improvement, this study aimed to investigate volume-outcome trends in oncologic esophagectomy in the Netherlands. Summary of Background Data: Concentration of Dutch esophageal cancer care was dictated by introducing an institutional minimum of 20 resections/yr. Methods: This nationwide cohort study included all esophagectomy patients registered in the Dutch Upper Gastrointestinal Cancer Audit in 2016–2019 from hospitals currently still performing esophagectomies. Annual esophagectomy hospital volume was assigned to each patient and categorized into quartiles. Multivariable logistic regression investigated short-term surgical outcomes. Restricted cubic splines investigated if volume-outcome relationships eventually plateaued. Results: In 16 hospitals, 3135 esophagectomies were performed. First volume quartile hospitals performed 24–39 resections/yr; second, third, and fourth quartile hospitals performed 40–53, 54–69, and 70–101, respectively. Compared to quartile 1, in quartiles 2 to 4, overall/severe/technical complication, anastomotic leakage, and prolonged hospital/intensive care unit stay rates were significantly lower and textbook outcome and lymph node yield were higher. When raising the cut-off from the first to second quartile, higher-volume centers had less technical complications [Adjusted odds ratio (aOR): 0.82, 95% confidence interval (CI): 0.70–0.96], less anastomotic leakage (aOR: 0.80, 95% CI: 0.66–0.97), more textbook outcome (aOR: 1.25, 95% CI: 1.07–1.46), shorter intensive care unit stay (aOR: 0.80, 95% CI: 0.69–0.93), and higher lymph node yield (aOR: 3.56, 95% CI: 2.68–4.77). For most outcomes the volume-outcome trend plateaued at 50–60 annual resections, but lymph node yield and anastomotic leakage continued to improve. Conclusion: Although this study does not reflect on individual hospital quality, there appears to be a volume trend towards better outcomes in high-volume centers. Projects have been initiated to improve national quality of care by reducing hospital variation (irrespective of volume) in outcomes in The Netherlands.

Background: Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay after esophageal cancer surgery and its association with 30-day readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients with an uneventful recovery after esophagectomy. Methods: All patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) who underwent a potentially curative esophagectomy between 2015 and 2018 were considered for inclusion. Patients were excluded in case of an intraoperative/post-operative complication, readmission to the intensive care unit, or any re-intervention. Length of hospital stay was dichotomized around the national median into ‘short admissions’ and ‘long admissions’. Hospital variation was evaluated using a case-mix-corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with 30-day readmission rates was investigated using the χ2-statistic. Results: A total of 1007 patients was included. National median length of hospital stay was 9 days, ranging from 6.5 to 12.5 days among 17 hospitals. The percentage of ‘short admissions’ per hospital ranged from 7.7 to 93.5%. After correction for case-mix variables, 3 hospitals had significantly higher ‘short admission’ rates and 4 hospitals had significantly lower ‘short admission’ rates. Overall, 6.2% [hospital variation (0.0–13.2%)] of patients were readmitted. Hospital 30-day readmission rates were not significantly different between patients with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19). Conclusions: Based on these nationwide audit data, median length of hospital stay after an uncomplicated esophagectomy was 9 days ranging from 6.5 to 12.5 days among Dutch hospitals. There was no association between length of hospital stay and readmission rates. Nationwide improvement might lead to a substantial reduction of hospital costs.

The value of routine intensive care unit (ICU) admission after minimally invasive esophagectomy (MIE) has been questioned. This study aimed to investigate Dutch hospital variation regarding length of direct postoperative ICU stay, and the impact of this hospital variation on short-term surgical outcomes. Patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) undergoing curative MIE were included. Length of direct postoperative ICU stay was dichotomized around the national median into short ICU stay ( ≤ 1 day) and long ICU stay ( > 1 day). A case-mix corrected funnel plot based on multivariable logistic regression analyses investigated hospital variation. The impact of this hospital variation on short-term surgical outcomes was investigated using multilevel multivariable logistic regression analyses. Between 2017 and 2019, 2110 patients from 16 hospitals were included. Median length of postoperative ICU stay was 1 day [hospital variation: 0-4]. The percentage of short ICU stay ranged from 0 to 91% among hospitals. Corrected for case-mix, 7 hospitals had statistically significantly higher short ICU stay rates and 6 hospitals had lower rates. ICU readmission, in-hospital/30-day mortality, failure to rescue, postoperative pneumonia, cardiac complications and anastomotic leakage were not associated with hospital variation in length of ICU stay. Total length of hospital stay was significantly shorter in hospitals with relatively short ICU stay. This study showed significant hospital variation in postoperative length of ICU stay after MIE. Short ICU stay was associated with shorter overall hospital admission and did not negatively impact short-term surgical outcomes. More selected use of ICU resources could result in a national significant cost reduction.

Transthoracic esophagectomy is currently the predominant curative treatment option for resectable esophageal adenocarcinoma. The majority of carcinomas present as locally advanced tumors requiring multimodal strategies with either neoadjuvant chemoradiotherapy or perioperative chemotherapy alone. Minimally invasive, including robotic, techniques are increasingly applied with a broad spectrum of technical variations existing for the oncological resection as well as gastric reconstruction. At the present, intrathoracic esophagogastrostomy is the preferred technique of reconstruction (Ivor Lewis esophagectomy). With standardized surgical procedures, a complete resection of the primary tumor can be achieved in almost 95% of patients. Even in expert centers, postoperative morbidity remains high, with an overall complication rate of 50–60%, whereas 30- and 90-day mortality are reported to be <2% and <6%, respectively. Due to the complexity of transthoracic esophagetomy and its associated morbidity, esophageal surgery is recommended to be performed in specialized centers with an appropriate caseload yet to be defined. In order to reduce postoperative morbidity, the selection of patients, preoperative rehabilitation and postoperative fast-track concepts are feasible strategies of perioperative management. Future directives aim to further centralize esophageal services, to individualize surgical treatment for high-risk patients and to implement intraoperative imaging modalities modifying the oncological extent of resection and facilitating surgical reconstruction.

Background: The COVID-19 pandemic caused disruption of regular healthcare leading to reduced hospital attendances, repurposing of surgical facilities, and cancellation of cancer screening programmes. This study aimed to determine the impact of COVID-19 on surgical care in the Netherlands. Methods: A nationwide study was conducted in collaboration with the Dutch Institute for Clinical Auditing. Eight surgical audits were expanded with items regarding alterations in scheduling and treatment plans. Data on procedures performed in 2020 were compared with those from a historical cohort (2018–2019). Endpoints included total numbers of procedures performed and altered treatment plans. Secondary endpoints included complication, readmission, and mortality rates. Results: Some 12 154 procedures were performed in participating hospitals in 2020, representing a decrease of 13.6 per cent compared with 2018–2019. The largest reduction (29.2 per cent) was for non-cancer procedures during the first COVID-19 wave. Surgical treatment was postponed for 9.6 per cent of patients. Alterations in surgical treatment plans were observed in 1.7 per cent. Time from diagnosis to surgery decreased (to 28 days in 2020, from 34 days in 2019 and 36 days in 2018; P < 0.001). For cancer-related procedures, duration of hospital stay decreased (5 versus 6 days; P < 0.001). Audit-specific complications, readmission, and mortality rates were unchanged, but ICU admissions decreased (16.5 versus 16.8 per cent; P < 0.001). Conclusion: The reduction in the number of surgical operations was greatest for those without cancer. Where surgery was undertaken, it appeared to be delivered safely, with similar complication and mortality rates, fewer admissions to ICU, and a shorter hospital stay.