Original scientific article
The impact of complications on outcomes after resection for esophageal and gastroesophageal junction carcinoma

https://doi.org/10.1016/j.jamcollsurg.2003.08.007Get rights and content

Abstract

Background

Efforts to improve surgical outcomes have traditionally focused on improving preoperative patient selection and reducing the risk of postoperative medical complications. Strategies to optimize surgical technique have been less well studied. We sought to assess the relation between complications related to surgical technique and outcomes after esophagogastrectomy for cancer.

Study design

Medical records of 510 consecutive patients undergoing esophagogastrectomy for invasive squamous cell carcinoma or adenocarcinoma at Memorial Sloan-Kettering Cancer Center from 1996 to 2001 were reviewed. Data on diagnosis, stage of disease, therapies received, surgical approach, patient comorbidities, technical complications, and postoperative medical complications and outcomes including length of stay and overall survival were determined by one reviewer of the medical records. The primary predictor was surgical complications and the primary outcome was survival.

Results

Of the 150 patients studied 138 (27%) had complications directly attributable to surgical technique, such as an anastomotic leak, a paralyzed vocal cord, or chylothorax. At 3 years 43 of 138 patients (31%) with technical complications were alive, whereas 179 of 372 patients (48%) without technical complications were alive. Technical complications were associated with increased length of stay (median 23 days versus 11 days, p < 0.001), increased in-hospital mortality (12.3% versus 3.8%, p < 0.001), and a higher rate of medical complications (77.5% versus 47.3%, p < 0.001). After controlling for age, medical comorbidities, use of induction therapy, tumor stage, histology, and location, and completeness of resection the presence of a technical complication was highly predictive of poorer overall survival; the multivariable hazard ratio was 1.41 (1.22 to 1.63, p = 0.008).

Conclusions

Technical complications have a large negative impact on survival after esophagogastrectomy for cancer. Strategies to optimize surgical technique and minimize complications should improve outcomes in this cancer operation.

Section snippets

Study overview

We performed a retrospective review of the medical records of patients who had an esophagogastrectomy for invasive adenocarcinoma or squamous cell carcinoma of the esophagus or the gastroesophageal junction at Memorial Sloan Kettering between January 1996 and December 2001. January 1996 was the point at which an institutional electronic medical record system with complete treatment data was initiated. The review was performed by a single investigator (NPR) and consisted of a complete

Patient characteristics

We sampled all patients who underwent an operation for invasive squamous cell carcinoma or adenocarcinoma (n = 531). We then used the Social Security Death Index to make certain that all deaths were captured. We excluded from analysis patients who did not have a social security number (n = 11) and whose date of death could not be confirmed. Of these 11 patients who were lost to followup 2 had operative complications and 9 did not. Because of the initiation of an institutional electronic medical

Discussion

For patients who are fit to undergo esophagogastrectomy for localized cancer, quality improvement initiatives may enhance outcome. In this study we observed that patients whose operations were not associated with technical complications had fewer shortterm complications, shorter lengths of stay, and substantially better overall survival than those whose operations had technical complications. Between the two groups, the absolute survival difference was 17% 3 years after operation. We found no

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    No competing interests declared.

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