The effect of surgical complications on long-term prognosis following oesophagectomy

Association between ERAS protocol and major postoperative complications and reasons for non-compliance in patients with esophageal cancer

INTRODUCTION

The association between each Enhanced Recovery After Surgery (ERAS) component and the incidence of major postoperative complications following Ivor Lewis or McKeown surgery is understudied. Therefore, we wanted to determine the association between ERAS components, major postoperative complications, and the reasons for non-compliance with the ERAS program.

METHODS

Data were extracted from the prospective ERAS Registry managed by the University of Verona, Italy. We searched and compared the data for postoperative major complications (Clavien-Dindo Classification ≥3B) and reasons for non-compliance with 15 ERAS items in patients undergoing Ivor Lewis or McKeown surgery with radical intent for esophageal or esophagogastric junction cancer.

RESULTS

The study sample was 346 patients: 43 (12.4 %) experienced one or more postoperative major complications. When stratified by type of surgery, complications were more frequent after McKeown surgery than after Ivor Lewis surgery (15.5 % and 11.5 %, respectively). Organizational setbacks were the most common reason for non-compliance with the ERAS program. We identified several associations between clinical and patient demographic characteristics and 90-day postsurgical complications. The multivariate model indicated an association between fewer major postoperative complications after Ivor Lewis surgery and adherence to the protocol items "soft diet intake" (adjusted odds ratio [OR], 0.23; 95 % confidence interval [CI], 0.08-0.63) and "urinary catheter removal" (adjusted OR, 0.26; 95 % CI, 0.10-0.63).

DISCUSSION/CONCLUSIONS

Major complications are relatively frequent, especially after McKeown surgery. What remains uncertain is whether ERAS items can predict the occurrence of postoperative complications. Adherence to the protocol may be influenced by the co-occurrence of complications, comorbidities, and organizational setbacks.

Impact of postoperative infectious complications on long-term prognosis after esophagectomy

BACKGROUND

Postoperative complications have been reported to be a risk factor for worse oncologic outcomes in patients with esophageal cancer. However, the impact of postoperative complications on prognosis after esophagectomy remains controversial. We aimed to investigate the factors that influence the prognosis of postoperative complications in patients who underwent oncological esophagectomy, focusing on chronic obstructive pulmonary disease (COPD).

METHODS

In total, 254 consecutive patients who underwent esophagectomy for esophageal cancer between 2009 and 2021 were eligible. We examined the association between postoperative complications and long-term outcomes.

RESULTS

Focusing on infectious complications (IC: a combination of postoperative pneumonia and anastomotic leakage), overall survival (OS) and relapse-free survival (RFS) rates were significantly worse in patients with IC than those without (p < 0.01, and <0.01, respectively), whereas the presence of other complications demonstrated no survival impact. No clinicopathological variables have changed the influence of IC on long-term outcomes. Meanwhile, patients with postoperative pneumonia exhibited significantly lower OS and RFS rates compared to those without in non-COPD group, however, the presence of postoperative pneumonia demonstrated no prognostic impact in COPD group. Also, interaction analysis revealed that the effect of postoperative pneumonia on poor RFS differed based on the presence of COPD (p for interaction = 0.09).

CONCLUSIONS

IC influenced the long-term outcomes in patients with esophageal cancer, however no clinicopathological variables have changed the effect of the presence of IC on prognosis. Meanwhile, the effect of postoperative pneumonia on poor survival differed based on the presence of COPD.

Essential updates 2022/2023: Recent advances in perioperative management of esophagectomy to improve operative outcomes

In the era of minimally invasive surgery, esophagectomy remains a highly invasive procedure with a high rate of postoperative complications. Preoperative risk assessment is essential for planning esophagectomy in patients with esophageal cancer, and it is crucial to implement evidence-based perioperative management to mitigate these risks. Perioperative support from multidisciplinary teams has recently been reported to improve the perioperative nutritional status and long-term survival of patients undergoing esophagectomy. Intraoperative management of anesthesia and fluid therapy also significantly affects short-term outcomes after esophagectomy. In this narrative review, we outline the recent updates in the perioperative management of esophagectomy, focusing on preoperative risk assessment, intraoperative management, and perioperative support by multidisciplinary teams to improve operative outcomes.

The Prognostic Impact of Minimally Invasive Esophagectomy on Survival After Esophagectomy Following a Delayed Interval After Chemoradiotherapy: A Secondary Analysis of the DICE Study

OBJECTIVE

To evaluate prognostic differences between minimally invasive esophagectomy (MIE) and open esophagectomy (OE) in patients with surgery after a prolonged interval (>12 wk) following chemoradiotherapy (CRT).

BACKGROUND

Previously, we established that a prolonged interval after CRT before esophagectomy was associated with poorer long-term survival.

METHODS

This was an international multicenter cohort study involving 17 tertiary centers, including patients who received CRT followed by surgery between 2010 and 2020. Patients undergoing MIE were defined as thoracoscopic and laparoscopic approaches.

RESULTS

A total of 428 patients (145 MIE and 283 OE) had surgery between 12 weeks and 2 years after CRT. Significant differences were observed in American Society of Anesthesiologists grade, radiation dose, clinical T stage, and histologic subtype. There were no significant differences between the groups in age, sex, body mass index, pathologic T or N stage, resection margin status, tumor location, surgical technique, or 90-day mortality. Survival analysis showed MIE was associated with improved survival in univariate ( P =0.014), multivariate analysis after adjustment for smoking, T and N stage, and histology (HR=1.69; 95% CI: 1.14-2.5) and propensity-matched analysis ( P =0.02). Further subgroup analyses by radiation dose and interval after CRT showed survival advantage for MIE in 40 to 50 Gy dose groups (HR=1.9; 95% CI: 1.2-3.0) and in patients having surgery within 6 months of CRT (HR=1.6; 95% CI: 1.1-2.2).

CONCLUSIONS

MIE was associated with improved overall survival compared with OE in patients with a prolonged interval from CRT to surgery. The mechanism for this observed improvement in survival remains unknown, with potential hypotheses including a reduction in complications and improved functional recovery after MIE.

An audit of perioperative speech pathology intervention on improving enhanced recovery after surgery in oesophagectomy patients

PURPOSE

To evaluate the impact of a speech-language pathology (SLP) pathway on recovery following oesophagectomy.

METHOD

An audit was conducted at a single metropolitan public hospital in Sydney, Australia. Patients between 2014-2021 undergoing a three-stage oesophagectomy (n = 41) were included in the study. The sample was divided into two groups, those who received usual care (2014-2019) and those who received perioperative SLP assessment and intervention (2020-2021), with data collected across swallowing and health outcomes. Patient demographics and outcomes between the two groups were compared.

RESULT

Patients who received perioperative SLP intervention commenced oral intake faster postoperatively (SLP intervention group Mdn = 6.50 days, IQR = 6.00-7.00; usual care group Mdn = 9.00 days, IQR = 7.00-13.25; p = 0.001). There was no statistically significant difference between groups in rates of aspiration on the postoperative leak test (p = 0.32). No statistically significant differences were found between the two groups in length of hospital stay or number of swallowing-related medical images completed during their admission.

CONCLUSION

Perioperative SLP intervention has a positive impact on commencing oral intake following a three-stage oesophagectomy, however, it does not have a significant impact on rates of aspiration postoperatively. This pathway may contribute to enhanced recovery after oesophagectomy.

Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis

BACKGROUND

Severe postoperative complications (SPCs) may occur after curative esophagectomy for cancer and are associated with prolonged hospital stay, augmented costs, and increased in-hospital mortality. However, the effect of SPCs on survival after esophagectomy is uncertain.

AIM

To assess the impact of severe postoperative complications (SPCs) on long-term survival following curative esophagectomy for cancer, we conducted a systematic search of PubMed, MEDLINE, Scopus, and Web of Science databases up to December 2023. The included studies examined the relationship between SPCs and survival outcomes, defining SPCs as Clavien-Dindo grade > 3. The primary outcome measure was long-term overall survival (OS). We used restricted mean survival time difference (RMSTD) and 95% confidence intervals (CIs) to calculate pooled effect sizes. Additionally, we applied the GRADE methodology to evaluate the certainty of the evidence.

RESULTS

Ten studies (2181 patients) were included. SPCs were reported in 651 (29.8%) patients. The RMSTD overall survival analysis shows that at 60-month follow-up, patients experiencing SPCs lived for 8.6 months (95% Cis -12.5, -4.7; p < 0.001) less, on average, compared with no-SPC patients. No differences were found for 60-month follow-up disease-free survival (-4.6 months, 95% CIs -11.9, 1.9; p = 0.17) and cancer-specific survival (-6.8 months, 95% CIs -11.9, 1.7; p = 0.21). The GRADE certainty of this evidence ranged from low to very low.

CONCLUSIONS

This study suggests a statistically significant detrimental effect of SPCs on OS in patients undergoing curative esophagectomy for cancer. Also, a clinical trend toward reduced CSS and DFS was perceived.

The influence of postoperative outcomes on survival after esophageal cancer surgery: validation of a consensus-based updated textbook outcome parameter

BACKGROUND

Esophagectomy in combination with perioperative multimodal therapy is the cornerstone of modern curative treatment for esophageal adenocarcinoma. The primary aim of this study was to assess the influence of textbook outcome (TO) as a composite quality performance indicator (QPI) and its perioperative parameters on survival in patients who underwent esophagectomy with curative intent.

METHODS

Consecutive patients who underwent an esophagectomy between January 2014 and December 2022 at Christchurch Hospital were identified from a prospectively maintained hospital database. Univariable and multivariable analyses were performed to assess prognostic factors for each composite and individual postoperative outcome. Survival analysis was performed to evaluate the influence of these outcomes on overall survival.

RESULTS

A total of 108 patients underwent an esophagectomy during the study period. The overall and Clavien-Dindo (CD) grade ≥ 3 postoperative complication rates were 62% and 26%, respectively. The anastomotic leak rate was 6.5% (n = 7). The TO rate, 30-day readmission rate, and 30-day mortality rate were 20%, 13%, and 1%, respectively. Resection margin and nodal disease were found to be independent prognostic factors for reduced survival.

CONCLUSION

TO as originally defined and its postoperative parameters of 30-day postoperative complications and 30-day readmission are validated QPIs of esophageal cancer surgery. Updating the postoperative complication parameter to include CD grade ≥ 3 complications resulted in a positive association between achieving TO and increased survival. Our findings support the call to redefine TO based on an update to this parameter, making it a more precise QPI of esophageal cancer surgery.