Surgical performance of Minimally Invasive Esophagectomy is associated with patient outcome on a national level - A video assessment study

Abstract Background It is highly likely that suboptimal surgical performance is associated with less favorable patient outcomes in minimally invasive esophagectomy (MIE). Establishing this association can lead to programs that promote better surgical performance of MIE and improve patient outcomes. Methods In this nationwide cohort study, 7 blinded expert MIE surgeons assessed performance of surgical videos of MIE performed in 2022, using a previously developed and validated competency assessment tool (CAT), the MIE-CAT. Hospitals were divided into quartiles based on their MIE-CAT score. Patient outcomes of 2021-2022 registered in the Dutch Upper-GI Clinical Audit were compared between highest (top 25%) and lowest (bottom 25%) performing quartiles. Multilevel logistic regression, with clustering of patients within hospitals was used to analyze associations between performance and outcomes, and to correct for casemix. Primary outcome parameter was severe postoperative complications (Clavien-Dindo≥3) within 30 days after surgery. Results MIE-CAT scores ranged from range 93.9-118.8. In total, 970 patients were included. Severe postoperative complications occurred in 18.7% (n=41/219) in the highest performing quartile versus 39.2% (n=40/102) in the lowest performing quartile (RR=0.50, 95%CI 0.24-0.99). Moreover, there were less conversions (1.8% versus 8.9%, RR=0.21, 95%CI 0.21-0.21), less peroperative complications (2.7% versus 7.8%, RR=0.21, 95%CI 0.04-0.94) and overall less postoperative complications (46.1% versus 65.7%, RR=0.54, 95%CI 0.24-0.96). Oncological outcomes R0 resection and lymph node yield increased with oncologic specific-performance scores (e.g. hiatus dissection/thoracic esophagus dissection and abdominal/thoracic lymph node dissection respectively). ). A strong association between high anastomotic-phase score and a lower anastomotic leakage rate was observed (4.6% versus 17.7%, RR=0.14, 95%CI 0.06-0.31). Conclusions Better surgical performance was associated with decreased perioperative complications and better oncological outcome for esophageal cancer patients undergoing MIE. If surgical performance of MIE can be improved, significantly better patient outcomes may be possible.