Robotic Transthoracic Esophagectomy in High-Volume Centers: Improving Outcome and Extending Indications

There is vast evidence that high-volume centers perform better in highly complex oncological surgical procedures such as esophagectomy. This translates into a better outcome, lower postoperative mortality, and improved long-term survival. A population-based study from the Netherlands showed that short- and long-term survival after surgery for esophageal cancer is best in hospitals that perform at least 50 to 60 of these operations per year.[1] An important new outcome measure is “failure to rescue.” This term indicates the percentage at which a center is capable of preventing a complication from becoming fatal.[2] It appears that high-volume centers are much better able to treat complications adequately and thus prevent a fatal outcome.[2]

In the United Kingdom, the government made agreements in 2001 to concentrate on upper gastrointestinal units caring for a population of at least 1 to 2 million inhabitants. In addition, these centers should have at least four to six specialized surgeons who perform at least 20 resections per year and provide continuous care (24/7) for these patients.[3] In the United Kingdom, the 30-day mortality decreased from 7.3 to 4.1% in 2004 to 2008.[4] In 2013, a further reduction was achieved to 1.7% (95% confidence interval: 1.0–2.5) for esophageal resections.

So far, most studies focused on surgery, but there is increasing evidence that other parts of the pathway, such as the neoadjuvant therapy and rehabilitation, as well as postoperative management and follow-up, are better in high-volume centers.[5] This seems logical, but is still a subject of debate especially in countries were centralization is in a developing phase. The expertise of the whole team and treatment chain is important to achieve this improved outcome. Recent studies show that the triage and decision-making are important factors for survival of patients with esophageal cancer. Survival was found to be directly dependent on the referral hospital in a western country with a high incidence of esophageal cancer.[6]

For surgery, minimally invasive techniques, such as robotic transthoracic esophagectomy (RAMIE), will probably become the new standard of care. This high-end thoracolaparoscopic procedure requires highly specialized surgical skills and training. An analysis of the learning curve of this procedure showed that without proctoring, this exceeds 70 procedures, whereas with a structured proctoring program, this can be reduced to 20.[7] This is, however, only possible in centers that have a sufficient caseload to provide for weekly exposure to these procedures.[8]

Minimally invasive resection leads to a better outcome in all domains with comparable oncologic results.[9] However, this was mainly demonstrated in specialized high-volume centers. In population-based studies in various countries, it was shown that these results cannot be generally reproduced.[10] [11] [12] Results are probably highly influenced by the centers performing in their learning curve. In the United Kingdom, various centers even stopped the minimally invasive esophagectomy program due to increased complications. A structured proctoring program, starting with a hands-on course, case observation, specialized cadaver course, and on-site proctored cases, has been shown to be highly successful. Within this program we have trained RAMIE in several centers in Europe with excellent results.[13]

In high-volume centers, indications for surgical resection can be extended by close collaboration with oncologists and radiation oncologists. Those patients with locally advanced tumors invading the adjacent organs can be downstaged by chemoradiotherapy followed by surgical resection using robotic techniques.[14]

Finally, further concentration of care will also lead to less variation in the treatment of cancer.[6] [15] In addition to the curative treatment, palliative treatment will also gain quality by applying the latest treatment insights by a multidisciplinary team of specialists skilled in the diagnosis and treatment of esophageal cancer.

• References

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• 3 Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS). Guidance on minimum surgeon volumes (2010). http://www.augis.org/augis-guidelines/ . Accessed July 2018
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