DISCUSSION
learning or proficiency gain, cancer, tumor, upper gastrointestinal Dutch
TUMOR, POSTOPERATIVE COMPLICATIONS, CANCER, PULMONARY COMPLICATIONS, GASTRIC CANCER
The results of the LOGICA randomized controlled trial across 10 experienced upper gastrointestinal Dutch centers showed that laparoscopic gastrectomy was associated with no significant improvements in length of hospital stay or postoperative complications when compared with open gastrectomy.When considering the external validity of a RCT concerning surgical interventions in surgical oncology, it is essential to remain acutely aware of the complexity of the intervention under investigation and the mechanism for its implementation within and following the RCT. Our research group previously examined the external validity of the TIME trial, which showed a substantial reduction in pulmonary complications associated with totally minimally invasive compared with open esophagectomy.There are important differences between this present study concerning the LOGICA trial and the previously conducted study concerning the TIME trial.The learning or proficiency gain curve is well described in the surgical literature and describes adverse patient outcomes as surgeon gain proficiency in performing a surgical technique.Given the importance of the findings of this present study it is crucial to consider the strengths and limitations in terms of study design. First, this study is novel in that it has shown the importance of a well-conducted RCT with a robust SQA program in facilitating the dissemination of a challenging surgical procedure nationally. Second, the data analyzed were collated from 2 well-validated sources, a well-designed RCT and a large well-validated national data set concerning surgery for gastric cancer. Third, given the underlying differences in patient and tumor characteristics between the study groups, the analysis conducted was appropriate with adjustment for known and measured confounding factors. The main limitations of the study include the potential effect of unmeasured confounding factors that evolved during the study period, including the introduction of enhanced recovery protocols and the ongoing centralization of cancer surgical services to high-volume centers within the Netherlands. Specific improvements in perioperative care and intraoperative and postoperative technology may also have contributed to improvements in clinical outcomes over the study period observed in the laparoscopic gastrectomy group. However, given the lack of improvement in postoperative morbidity seen from open gastrectomy over the study period (Fig. In conclusion, the result of this study suggests the wider benefits of the LOGICA trial include safe dissemination of laparoscopic gastrectomy across the Netherlands, and further ongoing progression through the surgical learning curve may lead to the true benefit of a technique being observed only after the evaluating trial. The importance of a robust SQA program in the design of the RCT is crucial to facilitate the national dissemination of the technique following the trial and reducing potential patient harm during the surgeons learning curve.