Impact of postoperative morbidity on long-term survival after oesophagectomy

Department of Upper Gastrointestinal and Soft Tissue Tumour Surgery, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
British Journal of Surgery (Impact Factor: 5.21). 01/2013; 100(1). DOI: 10.1002/bjs.8973
Source: PubMed

ABSTRACT BACKGROUND: Oesophageal malignancy is a disease with a poor prognosis. Oesophagectomy is the mainstay of curative treatment but associated with substantial morbidity and mortality. Although mortality rates have improved, the incidence of perioperative morbidity remains high. This study assessed the impact of postoperative morbidity on long-term outcomes. METHODS: A prospective database was designed for patients undergoing oesophagectomy for malignancy from 1998 to 2011. An observational cohort study was performed with these data, assessing intraoperative technical complications, postoperative morbidity and effects on overall survival. RESULTS: Some 618 patients were included, with a median follow-up of 51 months for survivors. The overall complication rate was 64·6 per cent (399 of 618), with technical complications in 124 patients (20·1 per cent) and medical complications in 339 (54·9 per cent). Technical complications were associated with longer duration of surgery (308 min versus 293 min in those with no technical complications; P = 0·017), greater operative blood loss (448 versus 389 ml respectively; P = 0·035) and longer length of stay (22 versus 13 days; P < 0·001). Medical complications were associated with greater intraoperative blood loss (418 ml versus 380 ml in those with no medical complications; P = 0·013) and greater length of stay (16 versus 12 days respectively; P < 0·001). Median overall and disease-free survival were 41 and 43 months. After controlling for age, tumour stage, resection margin, length of tumour, adjuvant therapy, procedure type and co-morbidities, there was no effect of postoperative complications on disease-specific survival. CONCLUSION: Technical and medical complications following oesophagectomy were associated with greater intraoperative blood loss and a longer duration of inpatient stay, but did not predict disease-specific survival. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

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    ABSTRACT: The Ivor Lewis and Sweet approaches are the two most widely used open transthoracic esophagectomy techniques. We evaluated and compared the therapeutic efficacy of these two approaches to determine the appropriate method to treat middle or lower third esophageal carcinomas. We retrospectively reviewed patients who underwent esophagectomy with the Sweet (n = 748) and Ivor Lewis (n = 167) approaches at Zhongshan Hospital, Fudan University between January 2007 and December 2010. Patients with preoperatively identified superior mediastinal lymph node metastases, high-level lesions (above the carina), and benign tumors were excluded. Perioperative-related indicators and 5-year survival rates were compared between groups. Compared with the Ivor Lewis approach, the Sweet approach has a shorter operative time (181 ± 71 minutes versus 208 ± 63 minutes; p < 0.001), less blood loss (167 ± 71 mL versus 179 ± 87 mL; p = 0.043), and a lower incidence of transfusion (8.7% versus 13.8%; p = 0.044) and postoperative complications (12.3% versus 20.4%; p = 0.002). The Ivor Lewis approach was more likely to result in wound infection (3.2% versus 7.8%; p = 0.010) and delayed gastric emptying (1.7% versus 4.7%; p = 0.046). There was no significant difference between groups with regard to the number of lymph nodes harvested or total number of patients with lymph node metastases. There was no significant difference in locoregional recurrence, distant recurrence, or 5-year survival between approaches. The Sweet approach has many advantages for the treatment of middle or lower third esophageal carcinomas. It is a safe, effective, and worthwhile approach in modern thoracic surgery.
    The Annals of thoracic surgery 03/2014; 97(5). DOI:10.1016/j.athoracsur.2014.01.034 · 3.65 Impact Factor
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    ABSTRACT: Background Major surgery is associated with high rates of postoperative complications, many of which are deemed preventable. It has been suggested that these complications not only present a risk to patients in the short term, but may also reduce long-term survival. The aim of this review was to examine the effects of postoperative complications on long-term survival.MethodsMEDLINE, Web of Science and reference lists of relevant articles were searched up to July 2013. Studies assessing only procedure-specific, or technical failure-related, complications were excluded, as were studies of poor methodological quality. Meta-analysis was performed using a random-effects model. Risk of bias was assessed using funnel plots.ResultsEighteen eligible studies were included, comprising results for 134 785 patients with an overall complication rate of 22·6 (range 10·6–69) per cent. The studies included operations for both benign and malignant disease. Median follow-up was 43 (range 28–96) months. Meta-analysis demonstrated reduced overall survival after any postoperative complication for ten studies with eligible data (20 755 patients), with a hazard ratio (HR) of 1·28 (95 per cent confidence interval 1·21 to 1·34). Similar results were found for overall survival following infectious complications: HR 1·92 (1·50 to 2·35). In analyses of disease-free survival the HR was 1·26 (1·10 to 1·42) for all postoperative complications and 1·55 (1·12 to 1·99) for infectious complications. Inclusion of poor-quality studies in a sensitivity analysis had no effect on the results.Conclusion Postoperative complications have a negative effect on long-term survival. This relationship appears to be stronger for infectious complications.
    British Journal of Surgery 08/2014; 101(12). DOI:10.1002/bjs.9615 · 5.21 Impact Factor
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    ABSTRACT: To investigate the relationship between variability in surgical ward round (WR) quality and clinical outcomes. Evidence increasingly suggests that ward-based care plays a key role in surgical outcomes. The WR is the focal point of surgical inpatient care. Assimilating various sources of clinical information is necessary for thorough patient assessment during the WR; whether this relates to outcomes has not previously been examined. WRs were observed for patients on a surgical high-dependency unit in a tertiary academic surgical unit. All sources of clinical information (SCI) were considered. Thoroughness of assessment, defined as the percentage of SCI assessed by the clinician, was recorded as a marker of WR quality. Complications were recorded from patient records; preventability was based on Agency for Healthcare and Research Quality guidelines. The relationship between WR quality and incidence of preventable complications was analyzed. Sixty-nine WRs were observed over 37 days for 50 patients receiving care in the high-dependency unit. Observed morbidity rate was 60% (30/50). Seventy-four percent of all complications (35/46) occurred on the high-dependency unit. There was significant variability in WR quality: clinicians assessed 9% to 91% (mean = 55% ± 17%) of SCI (analysis of variance P = 0.025). Low-quality (% SCI assessed less than the mean) WRs resulted in a greater incidence of patients experiencing preventable complications [83% (10/12) vs 39% (7/18)] (P = 0.034), odds ratio = 6.43 (95% confidence interval = 1.05-39.3). Forty-one percent of complications (19/46) could have been diagnosed earlier or possibly prevented. Patient assessment during WRs is variable. Less thorough WRs result in delayed diagnoses and preventable complications, and they negatively affect outcomes. Focusing on WR quality and training may improve patient care.
    Annals of surgery 11/2013; 259(2). DOI:10.1097/SLA.0000000000000376 · 7.19 Impact Factor

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