Pattern of Postoperative Mortality After Esophageal Cancer Resection According to Center Volume: Results from a Large European Multicenter Study

Abstract

Background

High center procedural volume has been shown to reduce postoperative mortality (POM); however, the cause of POM has been poorly studied previously. The aim of this study was to define the pattern of POM and major morbidity in relation to center procedural volume.

Methods

Data from 2,944 consecutive adult patients undergoing esophagectomy for esophageal cancer in 30 centers between 2000 and 2010 were retrospectively collected. Data between patients who suffered 30-day POM were compared with those who did not. Factors associated with POM were identified using binary logistic regression, with propensity matching to compare low- (LV) and high-volume (HV) centers.

Results

The 30-day and in-hospital POM rates were 5.0 and 7.3 %, respectively. Pulmonary complications were the most common, affecting 38.1 % of patients, followed by surgical site infection (15.5 %), cardiovascular complications (11.2 %), and anastomotic leak (10.2 %). Factors that were independently associated with 30-day POM included American Society of Anesthesiologists grade IV, LV center, anastomotic leak, pulmonary, cardiovascular and neurological complications, and R2 resection margin status. Surgical complications preceded POM in approximately 30 % of patients compared to medically-related causes in 68 %. Propensity-matched analysis demonstrated LV centers were significantly associated with increased 30-day POM, and POM secondary to anastomotic leak, and pulmonary- and cardiac-related causes.

Conclusions

The results of this large, multicenter study provide further evidence to support the centralization of esophagectomy to HV centers, with a lower rate of morbidity and better infrastructure to deal with complications following major surgery preventing further mortality.

Appendices

Appendix 1

Surgical Complications

Anastomotic leak was defined as any esophagogastric anastomosis dehiscence that was clinically symptomatic (abscess, mediastinitis, digestive liquid externalizing drainage) or asymptomatic detected by contrast study. In case of doubt, the diagnosis was confirmed by gastroscopy without insufflation performed by an experienced physician.

Surgical site infection was defined as superficial pus expressed from the abdominal, thoracic, or drains incision sites, requiring surgical debridement and antibiotic treatment.

Chylothorax was suspected when a major pleural effusion was seen in the first postoperative week upon resumption of feeding, and was defined by the presence of pleural or abdominal fluid, rich in chylomicrons and lymphocytes.

Postoperative hemorrhage was defined as blood loss requiring endoscopic or surgical intervention.

Gastroparesis was defined as the occurrence of vomiting after removal of the nasogastric tube or distension of the gastric conduit on plain radiograph after day 5 postoperatively, requiring repositioning of the nasogastric tube despite prokinetic treatment.

Medical Complications

Pulmonary complications included bronchial congestion, disorders of ventilation, atelectasis, pneumonia, respiratory failure, and acute respiratory distress syndrome.

Cardiovascular complications included angina, myocardial infarction, arrhythmia, and cardiac insufficiency.

Thromboembolic complications included deep venous thrombosis and pulmonary embolism.

Neurological complications included temporospatial disorientation, transient ischemic attack, and cerebrovascular accident.

Appendix 2

List of Collaborators

Abdennahceur Dhahri, MD, PhD, Delphine Lignier, MD, Cyril Cossé, MD, Jean-Marc Regimbeau, MD, PhD, Department of Digestive Surgery Amiens, France; Denis Collet, MD, Department of Digestive Surgery, Bordeaux, France; Magalie Cabau, MD, Jacques Jougon, MD, PhD, Department of Thoracic Surgery, Bordeaux, France; Patrick Lozach, MD, Jean Pierre Bail, MD, Department of Digestive Surgery, Brest, France; Serge Cappeliez, MD, PhD, Issam El Nakadi, MD, PhD, Department of Digestive Surgery, Brussel ULB Erasme Bordet University, Brussel, Belgium; Gil Lebreton, MD, Arnaud Alves, MD, PhD, Department of Digestive Surgery, Caen, France; Renaud Flamein, MD, Denis Pezet, MD, PhD, Department of Digestive Surgery, Clermont-Ferrand, France; Federica Pipitone, MD, Bogdan Stan-Iuga, MD, Nicolas Contival, MD, Eric Pappalardo, MD, Simon Msika, MD, PhD, Department of Digestive Surgery, Louis Mourier University Hospital, Colombes, France; Styliani Mantziari, MD, Nicolas Demartines, Department of Digestive Surgery, Lausanne University Hospital, Lausanne, Switzerland; Flora Hec, MD, Marguerite Vanderbeken, MD, Williams Tessier, MD, Nicolas Briez, MD, Department of Digestive Surgery, Lille, France; Fabien Fredon, MD, Alain Gainant, MD, Muriel Mathonnet, MD, PhD, Department of Digestive Surgery, Limoges, France; Salim Mezoughi, MD, Christian Ducerf, MD, Jacques Baulieux, MD, Jean-Yves Mabrut, MD, PhD, Department of Digestive Surgery, Croix Rousse University Hospital, Lyon, France; Arnaud Pasquer, MD, Oussama Baraket, MD, Gilles Poncet, MD, Mustapha Adam, MD, PhD, Department of Digestive Surgery, Edouard Herriot University Hospital, Lyon, France; Delphine Vaudoyer, MD, Peggy Jourdan Enfer, MD, Laurent Villeneuve, MD, Olivier Glehen, MD, PhD, Department of Digestive Surgery, Lyon Sud University Hospital, Lyon, France; Thibault Coste, MD, Jean-Michel Fabre, MD, Department of Digestive Surgery, Montpellier, France; Frédéric Marchal, MD, Department of Digestive Surgery, Institut de cancérologie de Lorraine, Nancy, France; Romain Frisoni, MD, Ahmet Ayav, MD, PhD, Laurent Brunaud, MD, PhD, Laurent Bresler, MD, Department of Digestive Surgery, Nancy, France; Charlotte Cohen, MD, Olivier Aze, MD, Nicolas Venissac, MD, Daniel Pop, MD, Jérôme Mouroux, MD, Department of Thoracic Surgery, Nice, France; Ion Donici, MD, Michel Prudhomme, MD, PhD, Department of Digestive Surgery, Nîmes, France; Emanuele Felli, MD, Stéphanie Lisunfui, MD, Marie Seman, MD, Gaelle Godiris Petit, MD, Mehdi Karoui, MD, PhD, Christophe Tresallet, MD, PhD, Fabrice Ménégaux, MD, PhD, Jean-Christophe Vaillant, MD, Laurent Hannoun, MD, Department of Digestive Surgery, Pitié-Salpétrière University Hospital, Paris, France; Brice Malgras, MD, Denis Lantuas, MD, Karine Pautrat, MD, Marc Pocard, MD, PhD, Patrice Valleur, MD, Department of Digestive Surgery, Lariboisière University Hospital, Paris, France; Najim Chafai, MD, Pierre Balladur, MD, Magalie Lefrançois, MD, Yann Parc, MD, PhD, François Paye, MD, PhD, Emmanuel Tiret, MD, Department of Digestive Surgery, Saint-Antoine University Hospital, Paris, France; Marius Nedelcu, MD, Letizia Laface, MD, Thierry Perniceni, MD, Brice Gayet, MD, Department of Digestive Surgery, Institut Mutualiste Montsouris, Paris, France; Bernard Meunier, MD, Department of Digestive Surgery, Rennes, France; Alexandre Filipello, MD, Jack Porcheron, MD, Olivier Tiffet, MD, PhD, Department of Digestive Surgery, Saint-Etienne, France; Noémie Kamlet, MD, Rodrigue Chemaly, MD, Amandine Klipfel, MD, Patrick Pessaux, MD, PhD, Cecile Brigand, MD, PhD, Serge Rohr, MD, Department of Digestive Surgery, Strasbourg, France; Nicolas Carrère, MD, PhD, Department of Digestive Surgery, Toulouse, France; Chiara Da Re, MD, Frédéric Dumont, MD, Diane Goéré, MD, PhD, Dominique Elias, MD, Department of Digestive Surgery Institut Gustave-Roussy,Villejuif, France; Claude Bertrand, MD, Mont-Godinne University Hospital, Yvoir, Belgium.