Background: In 2019, the Gastrectomy Complications Consensus Group (GCCG) published a standardized set of complications aiming toward uniform reporting of post-gastrectomy complications. This study aimed to report outcomes after gastrectomy in the Netherlands according to GCCG definitions and compare them to previously reported national results and the European database reported by the GCCG. Methods: This nationwide, population-based cohort study included all patients undergoing gastrectomy for gastric cancer registered in the DUCA in 2020–2021. Postoperative morbidity and 30-day/in-hospital mortality were analyzed according to the GCCG definitions. For all patients, baseline characteristics and outcomes were compared with the GCCG cohort consisting of 27 European expert centers (GASTRODATA; 2017–2018). Results: In 2020–2021, 782 patients underwent gastrectomy in the Netherlands. Variation was seen in baseline characteristics between the Dutch and the GCCG cohort (N = 1349), most notably in minimally invasive surgery (80.6% vs 19.6%, p < 0.001). In the Netherlands, 223 (28.5%) patients developed a total of 407 complications, the most frequent being non-surgical infections (28.5%) and anastomotic leakage (13.4%). The overall complication and 30-day mortality rates were similar between the Dutch and GCCG cohort (28.5% vs 29.8%, p = 0.563; 3.7% vs 3.6%, p = 0.953). Higher surgical and endoscopic/radiologic reintervention rates were observed in the Netherlands compared to the GCCG cohort (10.7% vs 7.8%, p = 0.025; 10.9% vs 2.9%, p < 0.001). Conclusion: Reporting outcomes according to the standardized GCCG definitions allows for international benchmarking. Postoperative outcomes were comparable between Dutch and GCCG cohorts, but both exceed the international benchmark for expert gastrectomy care, highlighting targets for national and international quality improvement.

Reasons for structural and outcome differences in esophageal cancer surgery in Western Europe remain unclear. This questionnaire study aimed to identify differences in the organization of esophageal cancer surgical care in Western Europe. A cross-sectional international questionnaire study was conducted among upper gastrointestinal (GI) surgeons from Western Europe. One surgeon per country was selected based on scientific output and active membership in the European Society for Diseases of the Esophagus or (inter)national upper GI committee. The questionnaire consisted of 51 structured questions on the structural organization of esophageal cancer surgery, surgical training, and clinical audit processes. Between October 2021 and October 2022, 16 surgeons from 16 European countries participated in this study. In 5 countries (31%), a volume threshold was present ranging from 10 to 26 annual esophagectomies, in 7 (44%) care was centralized in designated centers, and in 4 (25%) no centralizing regulations were present. The number of centers performing esophageal cancer surgery per country differed from 4 to 400, representing 0.5–4.9 centers per million inhabitants. In 4 countries (25%), esophageal cancer surgery was part of general surgical training and 8 (50%) reported the availability of upper GI surgery fellowships. A national audit for upper GI surgery was present in 8 (50%) countries. If available, all countries use the audit to monitor the quality of care. Substantial differences exist in the organization and centralization of esophageal cancer surgical care in Western Europe. The exchange of experience in the organizational aspects of care could further improve the results of esophageal cancer surgical care in Europe.

Objective: To examine the influence of the LOGICA RCT (randomized controlled trial) upon the practice and outcomes of laparoscopic gastrectomy within the Netherlands. Background: Following RCTs the dissemination of complex interventions has been poorly studied. The LOGICA RCT included 10 Dutch centers and compared laparoscopic to open gastrectomy. Methods: Data were obtained from the Dutch Upper Gastrointestinal Cancer Audit (DUCA) on all gastrectomies performed in the Netherlands (2012–2021), and the LOGICA RCT from 2015 to 2018. Multilevel multivariable logistic regression analyses were performed to assess the effect of laparoscopic versus open gastrectomy upon clinical outcomes before, during, and after the LOGICA RCT. Results: Two hundred eleven patients from the LOGICA RCT (105 open vs 106 laparoscopic) and 4131 patients from the DUCA data set (1884 open vs 2247 laparoscopic) were included. In 2012, laparoscopic gastrectomy was performed in 6% of patients, increasing to 82% in 2021. No significant effect of laparoscopic gastrectomy on postoperative clinical outcomes was observed within the LOGICA RCT. Nationally within DUCA, a shift toward a beneficial effect of laparoscopic gastrectomy upon complications was observed, reaching a significant reduction in overall [adjusted odds ratio (aOR):0.62; 95% CI: 0.46–0.82], severe (aOR: 0.64; 95% CI: 0.46–0.90) and cardiac complications (aOR: 0.51; 95% CI: 0.30–0.89) after the LOGICA trial. Conclusions: The wider benefits of the LOGICA trial included the safe dissemination of laparoscopic gastrectomy across the Netherlands. The robust surgical quality assurance program in the design of the LOGICA RCT was crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during surgeons learning curve.

Esophageal cancer surgery involves highly complex surgical procedures, which may be associated with substantial morbidity and even mortality. Over the last decades, incremental advancements have been made through minimally invasive techniques and early rehabilitation after surgery (ERAS) protocols. ^1–3 However, these improvements are not uniformly implemented across all European countries, and opportunities for further quality enhancement still exist. Two such opportunities are the centralization of esophageal cancer surgical care and quality control through national clinical audits. Although these initiatives face numerous organizational and structural obstacles and are entangled in political dynamics, both deserve further exploration in the pursuit of improving the outcome of esophageal cancer surgery throughout Europe. Currently, there are two main forms of centralization present in Europe: (i) centralization in dedicated centers, appointed by the government; and (ii) centralization through volume thresholds, to which centers must comply to perform esophageal cancer surgery. A recent study showed an uneven implementation of centralization across Europe. ⁴ Both centralization strategies offer control over the number of centers, and subsequently over the annual volume per center.

The purpose of this study was to investigate hospital variation in the placement, surgical techniques, and safety of feeding jejunostomies (FJ) during minimally invasive esophagectomy (MIE) in the Netherlands. This nationwide cohort study analyzed patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) that underwent MIE for cancer. Hospital variation in FJ placement rates were investigated using case-mix corrected funnel plots. Short-term outcomes were compared between patients with and without FJ using multilevel multivariable logistic regression analysis. The incidence of FJ-related complications was described and compared between hospitals performing routine and non-routine placement (≥90%–<90% of patients). Between 2018–2020, an FJ was placed in 1481/1811 (81.8%) patients. Rates ranged from 11–100% among hospitals. More patients were discharged within 10 days (median hospital stay) without FJ compared to patients with FJ (64.5% vs. 50.4%; OR: 0.62, 95% CI: 0.42–0.90). FJ-related complications occurred in 45 (3%) patients, of whom 23 (1.6%) experienced severe complications (≥Clavien–Dindo IIIa). The FJ-related complication rate was 13.7% in hospitals not routinely placing FJs vs. 1.7% in hospitals performing routine FJ placement (p < 0.001). Significant hospital variation in the use of FJs after MIE exists in the Netherlands. No effect of FJs on complications was observed. FJs can be placed safely, with lower FJ-related complication rates, in centers performing routine placement.

Clinical and pathological outcomes of oesophagogastric cancer surgery are used for benchmarking hospital performance. The extent to which case-mix adjustment is required for valid hospital comparisons is unknown. This study aimed to develop distinct case-mix adjustment models for multiple outcomes of oesophageal and gastric cancer surgery, and to assess the impact of case-mix adjustment on between-hospital comparisons. We included all patients who underwent oesophagogastric cancer resections in the Netherlands between 2017 and 2022. We developed distinct case-mix adjustment models for ten outcomes. Model performance was evaluated with the area-under-the-receiving-operator-curve (AUC) and pseudo-R-squared, representing how strongly case-mix factors predict the outcomes. We used the Wald χ² test to assess relative predictor importance per model. The impact of case-mix adjustment on between-hospital comparisons on outcome was quantified using unadjusted and adjusted observed/expected ratios. In total, 4354 oesophageal cancer patients and 2109 gastric cancer patients were included. The most informative predictors in the models for oesophageal cancer were ASA-score, salvage surgery, peripheral vascular disease/aortic aneurysm, chronic lung disease, and tumour histology. For gastric cancer these were age, preoperative weight loss, tumour location, and clinical M-category. All case-mix models showed low to moderate performance, with AUCs ranging between 0.58 and 0.73 and between 0.58 and 0.74 for oesophageal and gastric cancer, respectively. Overall, case-mix adjustment had a limited impact on between-hospital comparisons, but more pronounced for 30-day mortality, failure-to-cure and failure-to-rescue. Given low to moderate model performance and the limited impact on between-hospital comparisons, case-mix adjustment may not always be necessary for valid benchmarking on outcomes in oesophagogastric cancer surgery.