Buscar en
Cirugía Española (English Edition)
Toda la web
Inicio Cirugía Española (English Edition) Standardizing the Treatment of Esophagogastric Junction Tumors: Centralization, ...
Journal Information
Vol. 97. Issue 10.
Pages 609-611 (December 2019)
Vol. 97. Issue 10.
Pages 609-611 (December 2019)
Letter to the Editor
DOI: 10.1016/j.cireng.2019.11.012
Full text access
Standardizing the Treatment of Esophagogastric Junction Tumors: Centralization, Registries and Surgical Training
Puntualizaciones a los proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación
Roberto de la Plaza Llamas
Corresponding author

Corresponding author.
, José Manuel García Gil, José Manuel Ramia Ángel
Servicio de Cirugía General y del Aparato Digestivo, Hospital Universitario de Guadalajara, Guadalajara, Spain
Related content
Cir Esp. 2019;97:470-610.1016/j.cireng.2019.03.021
Javier Osorio, Joaquín Rodríguez-Santiago, Josep Roig, Manuel Pera
Article information
Full Text
Download PDF
Full Text
Dear Editor

We have read with interest the article published by Osorio et al.1 We congratulate the authors for their review, but we wanted to share our comments.

We agree that centralization of certain complex procedures could improve results. However, as the authors point out, when choosing hospitals, other structure and result requirements should be met in addition to volume.2 We believe that the basic factors for centralization should be the 90-day morbidity and mortality results and 3- or 5-year survival results, as externally audited by impartial authorities with no conflicts of interests, such as the National Healthcare Administration. However, these results are not known for any service and, therefore, the basic principles of quality are overlooked.3 These hospitals should offer a structure that provides permanent access to interventional radiology and endoscopy teams, critical care units and, of course, trained surgeons. Only then will failure-to-rescue rates decrease. If we do not know what the actual results are, there is no ‘textbook outcome’.4

No one questions the need for multidisciplinary cancer committees. But these should be based on scientific evidence and demonstrated protocols, and not be a ‘committee of experts’. Practices with no evidence to support them should be integrated into randomized clinical trials. Without results and structure, volume is of no interest.

The auditing process should be permanent so that results improve or at least remain the same. You cannot talk about benchmarks in results —as frequently published— or ‘service benchmarking’ without impartial auditing.

Filling the registries with patient complications and communicating them does not imply that the results are objective.5 National or multiregional cancer registries are objective only if their reliability is validated.6 Therefore, it does not seem coherent that the audit to verify the veracity of the registry data is conducted by professionals who are connected to it. The registries should have 2 sources, the surgical service itself and the auditors, which should be compared and any discrepancies resolved. A postoperative complication is any negative event.7 All morbidities should be noted on specific forms in the medical record. Simultaneously in the registry, morbidity forms should be used, as well as the medical and nursing progress notes, particularly the latter. Surgical societies insist on publishing endless lists of complications that are not valid for comparison.8 In addition, these listings do not include minor complications, which also affect patient quality of life, clinical results and economic costs.9,10 We believe that all complications should be compiled, classified according to the Clavien Dindo Classification7 and with calculated scores like the Comprehensive Complication Index,11 in order to compare the results.9,10 Obviously, important and specific results from each intervention should also be used, such as the percentage of fistulae, their location and reoperations.3 In addition, if we compare results, the complexity of the patient should be considered, using scales like the Charlson index.12 Otherwise, it could lead us to reject patients with severe comorbidities who are at risk for worse results.

Long-term cancer outcomes are more complex to follow, but necessary. They are the only results that summarize the global and multidisciplinary care received by the patient throughout their process. In this case, it is possible that the infrastructure necessary for its analysis is somewhat more expensive.

We are surprised by the high number of minimally invasive gastrectomies (MIG) of the Spanish EURECCA group: 37%. We believe that the use of MIG in western countries is well above what randomized clinical trials (RCT) conducted by experienced groups currently allow: early distal gastric cancer (EDGC),13,14 although in advanced gastric cancer (AGC) it has shown some benefit15 in very experienced groups. It should be borne in mind that, to participate in these trials, for instance, surgeons must have an experience of more than 50 MIG and 50 laparotomic procedures with D2 lymphadenectomy, the hospitals should perform at least 300 gastrectomies/year, and the qualification of surgeons is determined by videos of their surgeries.16 These figures are far from the caseload and experience in Spain and Europe.

RCT are underway in long-term EDGC17 and in short-term18–20 and long-term21,22 AGC. There are short-term results in EGC of total MIG,23 but no long-term results.

Currently, MIG should be reserved for EDGC, or RCT. Total MIG should not be practiced outside the RCT setting. Patients admitted for MIG should be reserved for experienced surgeons at hospitals with high volumes.24

Training should be led by those who have the best 90-day results and long-term oncological results, as demonstrated by audit.

Unfortunately, there is no real evidence from audited results of national or international services. Aside from that, everything else is conjecture. In a society that defends and requires transparency and quality, we cannot defend the accreditation of units and the centralization of complex processes without previously auditing short- and long-term results in a prospective, impartial manner. Only then will we be able to improve and determine benchmarking services. The cost-efficiency analysis should come afterwards. The cost of audits is insignificant compared to the health and economic benefits. The biggest problem will be to mitigate the fear of surgery services. The Health Administration should take the lead and audit these results, since, together with patients, they will be the true beneficiaries of this healthcare policy.


This manuscript has not been funded.

J. Osorio, J. Rodríguez-Santiago, J. Roig, M. Pera.
Proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación.
Cirugía Española., 97 (2019), pp. 470-476
R. Vonlanthen, P. Lodge, J.S. Barkun, O. Farges, X. Rogiers, K. Soreide, et al.
Toward a consensus on centralization in surgery.
Ann Surg., 268 (2018), pp. 712-724
R. de la Plaza Llamas, J.M. Ramia.
Postoperative complications in gastrointestinal surgery: A “hidden” basic quality indicator.
World J Gastroenterol, 25 (2019), pp. 2833-2838
L.A.D. Busweiler, M.G. Schouwenburg, M.I. van Berge Henegouwen, N.E. Kolfschoten, P.C. de Jong, T. Rozema, et al.
Textbook outcome as a composite measure in oesophagogastric cancer surgery.
Br J Surg., 104 (2017), pp. 742-750
R. de la Plaza Llamas, J. Ramia Ángel, J. García Gil, V. Arteaga Peralta, C. García Amador, A. López Marcano, et al.
Registro prospectivo de todas las complicaciones postoperatorias en un servicio de cirugía general. ¿Como hacerlo?.
Cir Esp., 96 (2018), pp. S7
G. Linder, M. Lindblad, P. Djerf, P. Elbe, J. Johansson, L. Lundell, et al.
Validation of data quality in the Swedish National Register for Oesophageal and Gastric Cancer.
Br J Surg., 103 (2016), pp. 1326-1335
D. Dindo, N. Demartines, P.-A. Clavien.
Classification of surgical complications.
G.L. Baiocchi, S. Giacopuzzi, D. Marrelli, D. Reim, G. Piessen, P. Matos da Costa, et al.
International consensus on a complications list after gastrectomy for cancer.
Gastric Cancer., 22 (2019), pp. 172-189
R. de la Plaza Llamas, J.M. Ramia Ángel, J.M. Bellón, V. Arteaga Peralta, C. García Amador, A.J. López Marcano, et al.
Clinical validation of the comprehensive complication index as a measure of postoperative morbidity at a surgical department: a prospective study.
Ann Surg., 268 (2018), pp. 838-844
R. de la Plaza Llamas, Á Hidalgo Vega, R.A. Latorre Fragua, A.J. López Marcano, A.A. Medina Velasco, D.A. Díaz Candelas, et al.
the cost of postoperative complications and economic validation of the comprehensive complication index.
K. Slankamenac, R. Graf, J. Barkun, M.A. Puhan, P.-A. Clavien.
The comprehensive complication index: a novel continuous scale to measure surgical morbidity.
M.E. Charlson, P. Pompei, K.L. Ales, C.R. MacKenzie.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
J Chronic Dis, 40 (1987), pp. 373-383
W. Kim, H.-H. Kim, S.-U. Han, M.-C. Kim, W.J. Hyung, S.W. Ryu, et al.
Decreased morbidity of laparoscopic distal gastrectomy compared with open distal gastrectomy for stage I gastric cancer: short-term outcomes from a multicenter randomized controlled trial (KLASS-01).
Ann Surg., 263 (2016), pp. 28-35
H. Katai, J. Mizusawa, H. Katayama, M. Takagi, T. Yoshikawa, T. Fukagawa, et al.
Short-term surgical outcomes from a phase III study of laparoscopy-assisted versus open distal gastrectomy with nodal dissection for clinical stage IA/IB gastric cancer: Japan Clinical Oncology Group Study JCOG0912.
Gastric Cancer., 20 (2017), pp. 699-708
H.-J. Lee, W.J. Hyung, H.-K. Yang, S.U. Han, Y.-K. Park, J.Y. An, et al.
Short-term outcomes of a multicenter randomized controlled trial comparing laparoscopic distal gastrectomy with D2 lymphadenectomy to open distal gastrectomy for locally advanced gastric cancer (KLASS-02-RCT).
Y. Hu, C. Huang, Y. Sun, X. Su, H. Cao, J. Hu, et al.
Morbidity and mortality of laparoscopic versus open D2 distal gastrectomy for advanced gastric cancer: a randomized controlled trial.
J Clin Oncol., 34 (2016), pp. 1350-1357
H.-H. Kim, S.-U. Han, M.-C. Kim, W. Kim, H.-J. Lee, S.W. Ryu, et al.
Effect of laparoscopic distal gastrectomy vs open distal gastrectomy on long-term survival among patients with stage I gastric cancer: The KLASS-01 randomized clinical trial.
J. Straatman, N. van der Wielen, M.A. Cuesta, S.S. Gisbertz, K.J. Hartemink, A. Alonso Poza, et al.
Surgical techniques, open versus minimally invasive gastrectomy after chemotherapy (STOMACH trial): study protocol for a randomized controlled trial.
L. Haverkamp, H.J.F. Brenkman, M.F.J. Seesing, S.S. Gisbertz, M.I. van Berge Henegouwen, M.D.P. Luyer, et al.
Laparoscopic versus open gastrectomy for gastric cancer, a multicenter prospectively randomized controlled trial (LOGICA-trial).
BMC Cancer., 15 (2015), pp. 556
J. Luo, Y. Zhu, H. Liu, Y.-F. Hu, T.-J. Li, T. Lin, et al.
Morbidity and mortality of elderly patients with advanced gastric cancer after laparoscopy-assisted or open distal gastrectomy: a randomized-controlled trial.
Gastroenterol Rep., 6 (2018), pp. 317-319
T. Yoshikawa, T. Fukunaga, M. Taguri, C. Kunisaki, S. Sakuramoto, S. Ito, et al.
Laparoscopic or open distal gastrectomy after neoadjuvant chemotherapy for operable gastric cancer, a randomized Phase II trial (LANDSCOPE trial).
Jpn J Clin Oncol., 42 (2012), pp. 654-657
H. Hur, H.Y. Lee, H.-J. Lee, M.C. Kim, W.J. Hyung, Y.K. Park, et al.
Efficacy of laparoscopic subtotal gastrectomy with D2 lymphadenectomy for locally advanced gastric cancer: the protocol of the KLASS-02 multicenter randomized controlled clinical trial.
BMC Cancer., 15 (2015), pp. 355
H. He, H. Li, X. Su, Z. Li, P. Yu, H. Huang, et al.
Study on safety of laparoscopic total gastrectomy for clinical stage I gastric cancer: the protocol of the CLASS02-01 multicenter randomized controlled clinical trial.
BMC Cancer., 18 (2018), pp. 944
C.-D. Zhang, H. Yamashita, S. Zhang, Y. Seto.
Reevaluation of laparoscopic versus open distal gastrectomy for early gastric cancer in Asia: a meta-analysis of randomized controlled trials.
Int J Surg., 56 (2018), pp. 31-43

Please cite this article as: de la Plaza Llamas R, García Gil JM, Ramia Ángel JM. Puntualizaciones a los proyectos de estandarización del tratamiento del cáncer de la unión esofagogástrica: centralización, registros y formación. Cir Esp. 2019;97:609–611.

Copyright © 2019. AEC
Article options
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos