Surgical Quality of Care in Esophageal Malignancies
Surgical Quality of Care in Esophageal Malignancies
Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high.
Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: 'esophagectomy', 'esophagus', 'neoplasm' and 'cancer' to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care.
Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients.
Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons' practice.
Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvements have been made, the ceiling for improvement is still high. The complexity of the operation combined with the relative rarity of operable candidates has limited the rate that evidence can be gathered and has resulted in numerous controversies that still remain unanswered. Some of the most highly discussed topics include approach, anastomotic type, patient selection, oncologic sufficiency and application of minimally invasive techniques. However, there are countless other variables that have no definitive standard of care. Current practice is dependent on training, personal experience and available evidence. Owing to the relative ease of retrospective analysis, the majority of the evidence that is currently in use is based on level 2 evidence, namely cohort and case–control studies. Conclusions from these analyses primarily come in the form of risk analysis. While these data can have sufficient power to initiate changes in practice, these studies are ideally used as the foundation for a randomized clinical trial that better eliminates confounding factors. The following is a systematic review of randomized clinical trials from the surgical perspective of esophagectomy with regard to optimizing delivery of patient care. Each section lists studies divided by time relative to operation: preoperative (Table 1); intraoperative (Table 2); and postoperative (Table 3).
Abstract and Introduction
Abstract
Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high.
Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: 'esophagectomy', 'esophagus', 'neoplasm' and 'cancer' to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care.
Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients.
Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons' practice.
Introduction
Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvements have been made, the ceiling for improvement is still high. The complexity of the operation combined with the relative rarity of operable candidates has limited the rate that evidence can be gathered and has resulted in numerous controversies that still remain unanswered. Some of the most highly discussed topics include approach, anastomotic type, patient selection, oncologic sufficiency and application of minimally invasive techniques. However, there are countless other variables that have no definitive standard of care. Current practice is dependent on training, personal experience and available evidence. Owing to the relative ease of retrospective analysis, the majority of the evidence that is currently in use is based on level 2 evidence, namely cohort and case–control studies. Conclusions from these analyses primarily come in the form of risk analysis. While these data can have sufficient power to initiate changes in practice, these studies are ideally used as the foundation for a randomized clinical trial that better eliminates confounding factors. The following is a systematic review of randomized clinical trials from the surgical perspective of esophagectomy with regard to optimizing delivery of patient care. Each section lists studies divided by time relative to operation: preoperative (Table 1); intraoperative (Table 2); and postoperative (Table 3).
