Trends in Distal Esophageal and Gastroesophageal Junction Cancer Care: The Dutch Nationwide Ivory Study.

OBJECTIVE: This study evaluated the nationwide trends in care and accompanied postoperative outcomes for patients with distal esophageal and gastro-esophageal junction cancer. SUMMARY OF BACKGROUND DATA: The introduction of transthoracic esophagectomy, minimally invasive surgery, and neo-adjuvant chemo(radio)therapy changed care for patients with esophageal cancer. METHODS: Patients after elective transthoracic and transhiatal esophagectomy for distal esophageal or gastroesophageal junction carcinoma in the Netherlands between 2007-2016 were included. The primary aim was to evaluate trends in both care and postoperative outcomes for the included patients. Additionally, postoperative outcomes after transthoracic and tran-shiatal esophagectomy were compared, stratified by time periods. RESULTS: Among 4712 patients included, 74% had distal esophageal tumors and 87% had adenocarcinomas. Between 2007 and 2016, the proportion of transthoracic esophagectomy increased from 41% to 81%, and neo-adjuvant treatment and minimally invasive esophagectomy increased from 31% to 96%, and from 7% to 80%, respectively. Over this 10-year period, postoperative outcomes improved: postoperative morbidity decreased from 66.6% to 61.8% ( P = 0.001), R0 resection rate increased from 90.0% to 96.5% (P <0.001), median lymph node harvest increased from 15 to 19 ( P <0.001), and median survival increased from 35 to 41 months ( P = 0.027). CONCLUSION: In this nationwide cohort, a transition towards more neo-adju-vant treatment, transthoracic esophagectomy and minimally invasive surgery was observed over a 10-year period, accompanied by decreased postoperative morbidity, improved surgical radicality and lymph node harvest, and improved survival.

Recurrent Disease After Esophageal Cancer Surgery: A Substudy of The Dutch Nationwide Ivory Study.

OBJECTIVE: This study investigated the patterns, predictors, and survival of recurrent disease following esophageal cancer surgery. BACKGROUND: Survival of recurrent esophageal cancer is usually poor, with limited prospects of remission. METHODS: This nationwide cohort study included patients with distal esophageal and gastroesophageal junction adenocarcinoma and squamous cell carcinoma after curatively intended esophagectomy in 2007 to 2016 (follow-up until January 2020). Patients with distant metastases detected during surgery were excluded. Univariable and multivariable logistic regression were used to identify predictors of recurrent disease. Multivariable Cox regression was used to determine the association of recurrence site and treatment intent with postrecurrence survival. RESULTS: Among 4626 patients, 45.1% developed recurrent disease a median of 11 months postoperative, of whom most had solely distant metastases (59.8%). Disease recurrences were most frequently hepatic (26.2%) or pulmonary (25.1%). Factors significantly associated with disease recurrence included young age (≤65 y), male sex, adenocarcinoma, open surgery, transthoracic esophagectomy, nonradical resection, higher T-stage, and tumor positive lymph nodes. Overall, median postrecurrence survival was 4 months [95% confidence interval (95% CI): 3.6-4.4]. After curatively intended recurrence treatment, median survival was 20 months (95% CI: 16.4-23.7). Survival was more favorable after locoregional compared with distant recurrence (hazard ratio: 0.74, 95% CI: 0.65-0.84). CONCLUSIONS: This study provides important prognostic information assisting in the surveillance and counseling of patients after curatively intended esophageal cancer surgery. Nearly half the patients developed recurrent disease, with limited prospects of survival. The risk of recurrence was higher in patients with a higher tumor stage, nonradical resection and positive lymph node harvest.

Efforts, rewards and professional autonomy determine residents' experienced well-being.

The well-being of residents, our future medical specialists, is not only beneficial to the individual physician but also conditional for delivering high-quality patient care. Therefore, the authors further explored how residents experience their own well-being in relation to their professional and personal life. The authors conducted a qualitative study based on a phenomenological approach. From June to October 2013, 13 in-depth interviews were conducted with residents in various training programs using a semi-structured interview guide to explore participants' experience of their well-being in relation to their professional life. The data were collected and analyzed through an iterative process using the thematic network approach. Effort-reward balance and perceived autonomy were dominant overarching experiences in influencing residents' well-being. Experiencing sufficient autonomy was important in residents' roles as caregivers, as learners and in their personal lives. The experienced effort-reward balance could both positively and negatively influence well-being. We found two categories of ways that influence residents' experience of well-being; (1) professional lives: delivering patient care, participating in teamwork, learning at the workplace and dealing with the organization and (2) personal lives: dealing with personal characteristics and balancing work-life. In residents' well-being experiences, the effort-reward balance and perceived autonomy are crucial. Additionally, ways that influence residents' well-being are identified in both their professional and personal lives. These dominant experiences and ways that influence well-being could be key factors for interventions and residency training adaptations for enhancing residents' well-being.

Evaluating Mind Fitness Training and Its Potential Effects on Surgical Residents' Well-Being: A Mixed Methods Pilot Study.

BACKGROUND: Residents' well-being is essential for both the individual physician and the quality of patient care they deliver. Therefore, it is important to maintain or possibly enhance residents' well-being. We investigated (i) the influence of mind fitness training (MFT) on quality of care-related well-being characteristics: work engagement, empathy, work satisfaction and stress perception and explored (ii) residents' perceptions of MFT. METHODS: A multicenter study was conducted in eight Dutch teaching hospitals, from September 2012 to February 2014, using mixed methods­that is, quantitative and qualitative approaches to data collection and analysis. Eighty-nine surgical residents were invited to participate in pre- and post-intervention questionnaire surveys. Twenty-two residents participated in MFT and were additionally invited to evaluate the training by post-intervention interviews including open questions. RESULTS: At baseline 22 (100%) residents in intervention group and 47 (70.2%) residents in control group, and postintervention 20 (90.9 %) residents in intervention group and 41 (66.1%) residents in control group completed the questionnaires. In intervention-group, residents' specialty satisfaction increased by 0.23 point on 5-point Likert scale (95% CI 0.23­0.24, P < 0.001) while stress scores decreased by -0.94 point on 10-point scale (95% CI -1.77 to -0.12, P = 0.026). No substantial changes were observed in control group. Participation in MFT was positively associated with residents' empathy (b = 7.22; 95% CI 4.33­10.11; P < 0.001) and specialty satisfaction scores (b = 0.42; 95% CI 0.18­0.65; P = 0.001). Residents positively evaluated MFT with median scores of 6.80 for training design and 7.21 for outcome (10-point scale). Residents perceived improvement in focusing skills and reported being more aware of their own state of mind and feeling calmer and more in control. CONCLUSION: Mind fitness training could improve residents' empathy, specialty satisfaction, stress perception, and focusing skills, and was positively received by surgical residents.

[Healing with art?]. / Beter met kunst?

Music and other forms of art are increasingly being integrated into hospitals. As well as the aesthetic value of art, more and more attention is being paid to its contribution to the healing of the patient. Scientific research indicates the possible benefits of specific art in healthcare facilities. Using this knowledge of the role and employability of surroundings and art in the healing of patients may be complementary to the high quality of care in the Netherlands. By means of proper, methodologically correct research, it is possible to investigate the use of different aspects of the patient's environment as simple, safe and low-cost measures in improving health and well-being of patients.

Short-term results of a randomized controlled trial comparing primary suture with primary glued mesh augmentation to prevent incisional hernia.

BACKGROUND: Incisional hernia is one of the most frequent postoperative complications after abdominal surgery. Patients with an abdominal aortic aneurysm and patients with a body mass index of 27 or higher have an increased risk to develop incisional hernia. Primary mesh augmentation is a method in which the abdominal wall is strengthened to reduce incisional hernia incidence. This study focused on the short-term results of the PRImary Mesh Closure of Abdominal Midline Wounds trial, a multicenter double blind randomized controlled trial. METHODS: Between 2009 and 2012 patients were included if they were operated via midline laparotomy, and had an abdominal aortic aneurysm or a body mass index of 27 or higher. Patients were randomly assigned to either receive primary suture, onlay mesh augmentation (OMA), or sublay mesh augmentation. RESULTS: Outcomes represent results after 1-month follow-up. A total of 480 patients were randomized. During analysis, significantly (P = 0.002) more seromas were detected after OMA (n = 34, 18.1%) compared with primary suture (n = 5, 4.7%) and sublay mesh augmentation (n = 13, 7%). No differences were discovered in any of the other outcomes such as surgical site infection, hematoma, reintervention, or readmission. Multivariable analysis revealed an increase in seroma formation after OMA with an odds ratio of 4.3 (P = 0.004) compared with primary suture and an odds ratio of 2.9 (P = 0.003) compared with sublay mesh augmentation. CONCLUSIONS: On the basis of these short-term results, primary mesh augmentation can be considered a safe procedure with only an increase in seroma formation after OMA, but without an increased risk of surgical site infection.

Residents' engagement and empathy associated with their perception of faculty's teaching performance.

BACKGROUND: Faculty members rely on residents' feedback about their teaching performance. The influence of residents' characteristics on evaluations of faculty is relatively unexplored. We aimed to evaluate the levels of work engagement and empathy among residents and the association of both characteristics with their evaluation of the faculty's teaching performance. METHODS: A multicenter questionnaire study among 271 surgery and gynecology residents was performed from September 2012 to February 2013. Residents' ratings of the faculty's teaching performance were collected using the system for evaluation of teaching quality (SETQ). Residents were also invited to fill out standardized measures of work engagement and empathy using the short Utrecht Work Engagement Scale and the Jefferson Scale of Physician Empathy, respectively. Linear regression analysis using generalized estimating equations to evaluate the association of residents' engagement and empathy with residents' evaluations of teaching performance. RESULTS: Overall, 204 (75.3 %) residents completed 1814 SETQ evaluations of 302 faculty, and 143 (52.8 %) and 140 (51.7 %) residents, respectively, completed the engagement and empathy measurements. The median scores of residents' engagement and empathy were 4.56 (scale 0-6) and 5.55 (scale 1-7), respectively. Higher levels of residents' engagement (regression coefficient b = 0.128; 95 % confidence interval (CI) 0.072-0.184; p < 0.001) and empathy (b = 0.113; 95 % CI 0.063-0.164; p < 0.001) were associated with higher faculty teaching performance scores. CONCLUSIONS: Residents' engagement and empathy appear to be positively associated with their evaluation of the faculty's performance. A possible explanation is that residents who are more engaged and can understand and share others' perspectives stimulate and experience faculty's teaching better than others.

[Clinical research in surgery departments: back to the past]. / Klinisch wetenschappelijk onderzoek in de chirurgie; terug naar 'de operette'?

In recent decades, numerous prospective randomized surgical trials have been performed in the Netherlands. Due to the unexpected high mortality rate in the PROPATRIA-trial, legislation pertaining to research involving human subjects has recently been changed. The resulting considerable legal and administrative burdens and financial consequences now necessitate a different way of organising clinical research in non-academic hospitals.

Long-term outcomes following laparoscopically assisted versus open ileocolic resection for Crohn's disease.

BACKGROUND: Long-term results of laparoscopically assisted versus open ileocolic resection for Crohn's disease were evaluated in a randomized trial. METHODS: Sixty patients who underwent ileocolic resection between 1999 and 2003 were followed prospectively. Primary outcomes were reoperation, readmission and repeat resection rates for recurrent Crohn's disease. Secondary outcomes were quality of life (QOL), body image and cosmesis. RESULTS: Five patients were lost to follow-up. Median follow-up was 6.7 (interquartile range 5.7-7.9) years. Sixteen of 29 and 16 of 26 patients remained relapse free after ileocolic resection in the laparoscopic and open groups respectively (risk difference 6 (95 per cent confidence interval - 20 to 32) per cent). Resection of recurrent Crohn's disease was necessary in two of 29 versus three of 26 patients (risk difference 5 (-11 to 20) per cent). Overall reoperation rates for recurrent Crohn's disease, incisional hernia and adhesion-related problems were two of 29 versus six of 26 (risk difference 16 (-3 to 35) per cent). QOL was similar, whereas body image and cosmesis scores were significantly higher after laparoscopy (P = 0.029 and P < 0.001 respectively). CONCLUSION: Laparoscopically assisted ileocolic resection results in better body image and cosmesis, whereas open surgery is more likely to produce incisional hernia and obstruction.

[A master's exam in surgical training]. / De meesterproef in de chirurgijnsopleiding. Een historisch concept als voorbeeld voor nu?

AN EXAMPLE FOR THE PRESENT DAY: The current requirement for explicit quality standards and examination of surgeons is an opportunity to contemplate surgical training from a historical perspective by looking at the regulations of the Amsterdam Surgeons' Guild (1461-1736). At that time Amsterdam surgeons usually trained for five years in a master-apprentice relationship under the guidance of a master surgeon in a surgeon's shop. An important part of the surgical training took place in the botanical gardens and anatomical theatre, where, during the weekly lessons, the praelector anatomiae would also demonstrate anatomy on the bodies of the deceased. Surgical training was complete after the trainee had passed the 'meesterproef' (master's exam), in which the manufacturing of lancets, blood-letting and performing a trepanation on a skull played a major part. However, over the course of time the final master's exam as the ultimate test of capability at the end of surgical training has disappeared. From the perspective of renewed interest in explicit quality standards and examination of surgeons, the reintroduction of a modern master's exam should perhaps be considered.

Geographic origin of publications in surgical journals.

BACKGROUND: Publications in peer-reviewed journals are the main determinants of research rating and funding. The present study assesses worldwide scientific contributions in the field of surgical research. METHODS: Fifteen major surgical journals were selected for a bibliometric search in Medline/PubMed over a 6-year period (2000-2005). All articles with abstracts were totalled according to country of corresponding author. Publications (total and corrected for population size) and journal impact factor were assessed according to country. RESULTS: A total of 18,717 articles were identified. Fifteen countries generated 88.8 per cent of these: the USA produced 42.1 per cent, Japan 9.1 per cent and the UK 7.6 per cent. When corrected for population size, the Netherlands, Sweden and Switzerland topped the ranking; the USA was sixth. Ireland and Switzerland scored the highest mean impact factor. CONCLUSION: The USA is the most productive country in terms of absolute number of surgical publications in the selected journals. However, when population size is taken into consideration, certain smaller European countries were more prolific.

Conversion rate of laparoscopic cholecystectomy after endoscopic retrograde cholangiography in the treatment of choledocholithiasis: does the time interval matter?

BACKGROUND: Preceding endoscopic retrograde cholangiography (ERC) in patients with choledochocystolithiasis impedes laparoscopic cholecystectomy (LC) and increases risk of conversion. We studied the influence of time interval between ERC and LC on the course of LC. METHODS: All patients treated for choledochocystolithiasis with ERC and LC during 1996-2001 were studied retrospectively, comparing the course of LC in three time interval groups; LC < 2, 2-6, and > 6 weeks after ERC. PRIMARY OUTCOMES: adhesions, bile duct injury, operating time, and conversion-rate. RESULTS: Eighty-three patients were studied (group 1, n = 23; group 2, n = 15; group 3, n = 45). Adhesions, operation time, and bile duct damage did not significantly differ between the groups. The conversion rate in group 2 is significantly higher compared to group 1 (p = 0.027, OR 11 (1.13-106.8)) CONCLUSIONS: A higher conversion rate of LC is found 2-6 weeks after ERC compared to LC within 2 weeks. However, further research is needed to gain more reliable data on whether this is caused by timing.

Randomized study of the effectiveness of closing laparoscopic trocar wounds with octylcyanoacrylate, adhesive papertape or poliglecaprone.

BACKGROUND: Several methods for skin closure are used, i.e. sutures, adhesive papertape and tissue adhesives. Little is known about the efficacy of these techniques in laparoscopic surgery. This study was performed to analyse the efficacy of octylcyanoacrylate, a new tissue adhesive, adhesive papertape and poliglecaprone for wound closure in laparoscopy. METHODS: From May 2000 to September 2001, 140 patients were included in a prospective randomized trial. Wounds were closed with octylcyanoacrylate (n = 48), adhesive papertape (n = 42) or poliglecaprone (n = 50). Closing time, wound infection, cosmetic results and costs were evaluated. A time-motion analysis was also performed. RESULTS: The patients in the three groups were well matched for age, gender and body mass index. Closing times per wound were 26, 33 and 65 s respectively for adhesive papertape, octylcyanoacrylate and poliglecaprone (P < 0.001). Cosmetic results, as scored by the patients, were no different. The number of actions required to close each wound was 5.7, 8.3 and 21.0 for octylcyanoacrylate, adhesive papertape (P = 0.05 versus octylcyanoacrylate) and poliglecaprone (P < 0.01 versus octylcyanoacrylate and adhesive papertape) respectively. Octylcyanoacrylate was significantly more expensive than poliglecaprone and adhesive papertape. CONCLUSION: Closure with adhesive papertape was the fastest method. The smallest number of actions required to close a wound was with octylcyanoacrylate. Adhesive papertape was the most cost-effective.