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Oesophagectomy in the UK…Is it any better?
Rohan Gunasekera
Aims of Talk
Problems faced in UK
Reorganisation of Upper GI cancer services
Impact of AUGIS / NCIN / National dataset of histopathological reporting
AUGIS consensus on MIO in UK
& If there is time…
Post CCT Fellowships
How to get in from Australia/New Zealand given UK immigration rules etc
I am NOT going to look at the results of individual published series
Problems in the UK
NHS cuts – major financial challenge
Problems in the UK
Formation of Regional Specialist Centres –Politics!
Clear split between ‘benign upper GI’ and Resection Centre jobs
Trainees steering away from Upper GI / HPB as jobs in resection centres are scarce.
Problems in the UK
Increase in the number of obese, ‘unfit’ patients with GOJ adenocarcinomata
Reduction in the number of resections with PET picking up more non-resectable cancers; and alternative therapies for HGD
Reorganisation of UGI services
Centralisation of oesophageal resection (recommended in guidelines published by NHS Executive in 2001)
Gradual reorganisation of upper GI services since then
32 Cancer networks in England with a National Welsh Cancer Network
Regional Specialist Centres
1 - 3 regional specialist centres in each cancer network serving a population of approx one million people each
Surgeons are expected to perform at least 20 resections per year
All new consultant appointments need to be approved by the local cancer network.
Cancer Networks
Specialist MDT (video links)
Ensure standards
Log all cases on national database
Subject to external peer review
SMDT to ensure standards of
Staging & decision-making
Resection surgery
Histopathological Reporting
Follow-up
CQuins
Cancer services online peer review tool
For quality improvement of cancer care through self assessment
Available to each member of the MDT
Standardised Reporting
There is a national dataset for oesophageal carcinoma histopathology reports.
Current version to been amended to fit TNM 7th edition.
Major effort to standardise treatment across the cancer networks
Standardised staging pathways
(cf. Palser et al Audit of ICNARC data Critical Care 2009, 13(suppl2);1-10)
Staging Investigations
All patients are expected to have
– Endoscopy & biopsy,
– CT chest and abdomen,
– PETCT
– EUS(Many centres perform CPX routinely as part of
preoperative work up)
Neoadjuvant therapy
All patients with adenocarcinoma considered for ECX neoadjuvant chemotherapy.
Patients with SCC are offered chemoradiation +/- resection
(cf. NEJM May 2009: 360: 2277)
Early Oesophageal Cancer
NICE approval for local therapiesESD for SCC or squamous dysplasiaHALO- RF ablation for HGDEMR for HGD
Data presented at AUGIS 2010 - Bill Allum
NCRI & NCIN
National Cancer Research Institute launched in June 2008
National Cancer Intelligence Network - is a section of NCRI & has an Upper GI clinical reference group (chaired by Bill Allum)
Up to now the emphasis of the peer review body has been quantitative assessment
Data presented at AUGIS 2010 - Bill Allum
Key elements of the NCIN Oesophagogastric group
Registry data
Peer review – focusing on a clinical line of enquiry (qualitative)
National Audit – NHS uses HES
Procedure codes
Hospital Episode Statistic data
Focuses on cost/tariff for treatments
Based on ICD codes
Coding by clerks – retrospective, Notoriously unreliable, inaccurate
Aimed at ascribing cost to NHS.
Special word on HES data
All non training grade doctors (SMOs) in the UK have mandatory annual appraisals
As of 2012 will be required to take part in 3-5 yearly revalidation by the GMC
HES will also be used as part of this revalidation process
Data presented at AUGIS 2010 - Bill Allum
NCIN procedure codes
NCIN have proposed coding of upper GI resections according to site of disease.
4 coding options for oesophagectomy to simplify coding and increase accuracy of these data
Data presented at AUGIS 2010 - Bill Allum
Oesophagectomy procedure codes
OG with anastomosis of oesophagus to stomach
Total OG with anastomosis of cervical oesophagus to stomach
Total OG with colonic interposition
Extended TG, omentectomy and anastomosis of oesophagus to jejunum
Data presented at AUGIS 2010 - Bill Allum
Aim of Procedure Codes
Simplify
Surgeon ownership (improved accuracy of data recorded)
To be used as coding for tariff; so that trusts are paid for correct procedure
OPCS data will be more accurate
MIO Consensus by Mr RH Hardwick Sept 2009
AUGIS consensus on MIO Published September 2009
Minimally invasive surgery is a techniquefor resection, not a new treatment.
Even if it is shown to benefit some patients, it will join open resection in the surgeons’ armamentarium and not replace it in the foreseeable future
MIO Consensus by Mr RH Hardwick Sept 2009
MIO consensus
Patients for MIO should be deemed fit for open as well
No good evidence at the time of consensus re. reduced overall complication rates, or peri-operative mortality.
learning curve of between 20-50 operations, with variation from surgeon to surgeon
MIO Consensus by Mr RH Hardwick Sept 2009
MIO consensus
All surgeons should monitor outcomes prospectively & submit data to the national audit on every patient.
MIO confined to recognised cancer centres, by teams confident in open equivalent
MIO Consensus by Mr RH Hardwick Sept 2009
General Advice on patient selection
Fitness same as for open & suitability for MIOT discussed at specialist MDT
Avoid pts with BMI>30, full-thickness tumours (with perceived risk of invasion into adjacent structures, patients with high burden of lymph nodes on EUS/CT) UNTIL surgical team feels confident to progress to these more difficult pt groups
MIO Consensus by Mr RH Hardwick Sept 2009
Recommendations on the introduction of MIO
Process- Formal training, recognition by local trusts
Team working & mentoring – Operate in pairs during learning curve, visit centre experienced with MIO together with theatre team prior, mentorship by AUGIS recognised mentor (5+5 cases)
MIO Consensus by Mr RH Hardwick Sept 2009
Technical & ethical aspects
Fully informed consent
Confidence that oncological standard of minimal access procedure no different to open
Step-wise progression to MIO (LAO or TAO first)
Lazzarino et al Annals of Surgery: Aug 2010: 252; 292-298
“Open versus Minimally Invasive Esophagectomy: Trends of Utilization and Associated Outcomes in England”
Lazzarino et al Annals of Surgery: Aug 2010: 252; 292-298
Total of 18 673 OGs over 12 years
Minimal Access surgery increased exponentially in time
0.6% in 1996/1997; 16% in 2007/2008
Lazzarino et al Annals of Surgery: Aug 2010: 252; 292-298
“Open versus Minimally Invasive Esophagectomy: Trends of Utilization and Associated Outcomes in England”
Suggestion of better 1-year survival rates (OR=0.68, CI=0.46-1.01, p=0.058)
Patients selected for MIE had similar mortality, LOS outcomes compared to open
Herbella FA & Patti MG, World J Gast: Aug 2010:16;3811
“Minimally invasive esophagectomy”
Herbella FA & Patti MG, World J Gast: Aug 2010:16;3811
(Non systematic) review of literature
Conclude no current evidence that MIE brings clear benefit over open approach
Quick word on post CCT fellowships…
Application via RCS website 74 post CCT fellowships in total (about 9 UGI)
PLAB may be required (I agree it is crazy!)
Once a job has been sorted out-
visa can be arranged via Overseas Drs Training Scheme (ODTS) / Medical Training Initiative (MTI)
In Conclusion
There has been a considerable effort to limit oesophageal resections to regional specialist centres and to standardise staging & histological assessment.
MIO is gradually gaining favour but is not the standard operation in most units
The population in the UK is generally less fit & comorbidities are a limitation to reducing mortality rates
So is oesophagectomy in the UK better?
Questions?
