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| Journal of the New Zealand Medical Association,
20-April-2012, Vol 125 No 1353
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Oesophagectomy is a potentially curative treatment for
patients with resectable oesophageal cancer, and is the mainstay of treatment
for adenocarcinoma in patients without metastatic
disease.1 The procedure is, however, associated
with considerable morbidity,2 and despite
advances in surgical technique and adjuvant therapy, 5-year survival rates in
all published series remain at or below
40%.3–7
A multitude of factors influence survival rates after
curative oesophageal resection. These include: patient selection criteria,
tumour location, surgical technique, perioperative care practices, adjuvant
therapy protocols, and various population
factors.4,7,8
The impact of hospital and surgeon volume on operative
mortality has also been well
reported.9–11 As a result of this,
referral of patients suitable for oesophagectomy to dedicated specialised
centres has been advocated, in keeping with international trends towards
centralisation and specialisation of low-volume complex
surgery.12–14 However, there is currently
no evidence that volume has any influence on long-term survival or improvement
in quality of life after oesophagectomy.15 In
addition, it has been noted that volume alone is insufficient to define centres
of excellence, and that a lowest recommended annual volume has not actually been
defined.15
In New Zealand, geographical and population barriers to
centralisation have meant that oesophagectomy continues to be performed in some
non-tertiary centres. A single case series published from a tertiary centre has
demonstrated equivalent outcomes for oesophagectomy in New Zealand compared with
international data;16 however, there is
currently no published data from a non-tertiary hospital.
Palmerston North Hospital (PNH) is a level II provincial
hospital servicing the city of Palmerston North (population 75,000) and the
Manawatu province of the lower central North Island of New Zealand (population
160,000). It is the only secondary level hospital in the Manawatu region, and
one of six national Regional Cancer Treatment Service centres, providing
specialist intensive care, medical and surgical subspecialty services for a
larger population of up to 500,000.
The aim of this study is to evaluate the outcome of
oesophagectomy at PNH.
MethodsPatients—All patients who
underwent an oesophagectomy at PNH between 1st January 1993 and July 2010 were
included in this study (clinical records prior to 1993 are not available, as a
significant number, particularly of deceased patients, have been deliberately
destroyed in accordance with national clinical records guidelines). There were
no exclusion criteria.
Data collection—Retrospective
review of patient clinical records, the Otago Audit System electronic
database21 (prospectively maintained by the
Department of General Surgery since 1993), as well as Operating Theatre and
Department of Pathology electronic records was performed by two investigators
(F.A., D.H.). Data collected included demographic data, intraoperative
parameters, postoperative outcomes, pathological / histological data, details of
adjuvant and neo-adjuvant therapy, and survival data.
Statistics—Results were
tabulated and analysed using SPSS® for Windows® version 17.0 (Lead
Technologies Inc, Chicago, Illinois, USA). Continuous variables were tested
using the Shapiro-Wilk test for normality and the results presented as Mean
(Standard Deviation) for parametric data and Median (Range) for non-parametric
data.
ResultsPatients—Sixty-eight patients
underwent surgery for oesophagectomy between January 1993 and July 2010 in PNH.
Mean patient age was 63.3 years, and 69.1% of the patients were male (Table 1).
Fifty-two patients (76.5%) presented with pathology sited in
the distal third of the oesophagus, and the remaining with pathology in the
middle third of the oesophagus. Sixty-five patients underwent an Ivor-Lewis
oesophagectomy; 1 underwent Ivor-Lewis oesophagectomy with pancreatectomy; 1
underwent oesophagectomy via abdominal and right thoracotomy with
oesophago-jejunal anastomosis (because of previous total gastrectomy), and 1
underwent left thoraco-abdominal oesophagestrectomy.
Table 1. Baseline patient
parameters
SD: Standard Deviation.
Intraoperative data—Four surgeons
performed all the operations, with one surgeon (M.Y.) performing 35 operations,
and another (B.R.) performing 31 operations. The other two surgeons performed
one oesophagectomy each during this period. Mean operating time was 438.4 ±
101.8 min and mean intraoperative blood loss was 934.5 ± 790.2 ml (Table
2).
Median intraoperative blood transfusion requirement was 2
units (0–8), and mean intravenous fluid requirement was 6.6 ± 1.4 L.
Eight patients had intraoperative complications: 5 patients had a splenic injury
(all requiring splenectomy), 1 patient had a liver injury (treated
conservatively with packing and a re-look laparotomy on day 1, and 2 patients
developed an intraoperative acute coronary syndrome.
Table 2. Intraoperative
parameters
Postoperative data—Median intensive
care unit stay was 7 days (1–29), and median time to extubation was 3 days
(0–23, Table 3). Twenty (29.4%) patients required tracheostomy. Mean
intravenous fluid infusion in the first 24 hours was 10.4 ± 2.1 L, median
time of total parenteral nutrition administration was 7.5 days (0–33), and
median time of jejunal or nasogastric enteric feeding administration was 0.5
days (0–47). The median total hospital stay was 17.5 (4–60)
days.
Table 3. Postoperative recovery
parameters
ICU=Intensive Care Unit; SD=Standard Deviation.
An anastomotic leak occurred in seven patients (10.3%),
chylothorax in six patients (8.8%) and cardiopulmonary complications in
thirty-four patients (50.0%, Table 3). Six patients (8.8%) required reoperation
to resolve major postoperative complications, and ten patients (14.7%) required
re-admission to ICU after they had been discharged to the general surgical ward.
Minor early / inpatient postoperative complications occurred in 25 patients
(36.7%).
Pathology—Fifty-one patients (75.0%)
had adenocarcinoma diagnosed on histology, 11 (16.2%) had squamous carcinoma, 2
patients (2.9%) had adeno-squamous carcinoma, 2 patients (2.9%) had
Barrett’s disease with high grade dysplasia but no invasive cancer, 1
(1.5%) had a gastrointestinal stromal tumour, and 1 (1.5%) had a non-invasive
neuroendocrine tumour. Further details on staging and adjuvant/ neoadjuvant
therapy for the 64 patients with confirmed invasive cancer are presented in
Table 4.
Table 4: Pathology and adjuvant/neoadjuvant
therapy for patients with invasive carcinoma (n=64)
Survival—There were 3 postoperative
in-hospital deaths. One patient died secondary to systemic sepsis after a
clinical anastomotic leak, 1 patient had a global mesenteric embolic event on
day 4, and 1 patient died after a myocardial infarction on day 31. Thus the
total in-hospital survival rate was 95.6%.
For patients with a confirmed diagnosis of invasive
carcinoma on the resection specimen, the 1-year survival rate was 77.2% and the
5 year survival rate was 30.3% (Table 5). A Kaplan-Meier survival curve is shown
in Figure 1. The survival rate for the entire patient cohort (including patients
with non-invasive disease) was marginally higher.
Table 5. Survival for patients with invasive
carcinoma (n=64)
Figure 1. Kaplan-Meier survival graph for
patients with invasive carcinoma (n=64)
 DiscussionWe have conducted a retrospective study looking at the short
and long-term outcomes of oesophagectomy in a secondary level provincial New
Zealand hospital. The results demonstrate outcomes that are generally comparable
with current national and international
data.2,5,6,9–11,15–20
The 5-year overall survival rate in this study was 30%,
which compares favourably with the published 5 year rate of 23% by Omundsen et
al (the only published oesophagectomy case series from a tertiary New Zealand
hospital).16 The trend is similar for survival
at 1 year (77.2% vs 54.5%); and 3 years (42.9% vs 35%) as
well.16
The apparent differences in survival rate could be explained
by a number of factors. In our series only 1 patient (1.6%) was diagnosed with a
stage T4 tumour, versus 12 patients (18%) in the Omundsen
study.16 It is unclear whether this difference
is due to patient selection or earlier detection. In addition, a higher
percentage of patients in our series were given neo-adjuvant chemotherapy
compared with the relatively low rates in the Omundsen
series.16 This is probably because their data
set pre-dates publication of the MAGIC trial of neo-adjuvant therapy for
oesophago-gastric adenocarcinoma.21
Since publication of the MAGIC trial recommendations, use of
neo-adjuvant chemotherapy has probably increased in New
Zealand.22 Certainly, since early 2007,
Palmerston North Hospital’s Regional Cancer Treatment Service has adopted
the MAGIC protocol for neoadjuvant therapy for bulky stage II and III
oesophageal or gastric adenocarcinoma (as evident on preoperative imaging) in
otherwise fit patients.21.
The postoperative complication rate in our study is
relatively high. Although the anastomotic leak rate of 10.3% is within the
accepted range for this procedure, a relatively high proportion of patients
developed postoperative cardiopulmonary complications (50.0%) compared to other
published series.9, 11, 15, 16, 20, 23 One
possible explanation for this finding is the relatively prolonged intubation
time experienced by these patients (3 days).
Indeed, the long intensive care unit stay (7 days) is not
only a reflection of the lack of a dedicated high dependency unit in PNH, but
also the high rate of utilisation of a tracheostomy for ventilation (which
anecdotally is a practice peculiar to the PNH intensive care unit). However, it
has been previously shown that early extubation may significantly reduce the
rate of postoperative cardiovascular complications, and from a resource
utilisation perspective it is clear that an early extubation policy should be
advocated.24-26
Another possible reason for the high cardiopulmonary
complication rate is the highly positive intraoperative and postoperative fluid
balance. Patients received on average 2 units of blood and 6.6 L intravenous
fluids intraoperatively, despite an estimated blood loss of less than 1 L. In
addition, the total volume of intravenous fluids administered in the first 24
hours was 10.4 L.
There is now clear evidence that a policy of relative fluid
restriction is advantageous in terms of cardiopulmonary complications after
major abdominal surgery, and specifically after
oesophagectomy.17, 27, 28 Taking these
practices one step further, a recent case-control study by Munitiz et al
demonstrates significant advantages using a clearly defined enhanced recovery
perioperative protocol in the management of patients undergoing
oesophagectomy.17
As part of this protocol, all patients were extubated in the
operating theatre or immediately on arrival in the intensive care unit, and a
policy of negative fluid balance over the first 4 days was adhered to. As a
result, pulmonary complications were significantly reduced from 23% to 14%
(P=0·025).17 These modifications in
perioperative management are being discussed at PNH, with view to
implementation, at the time of writing of this manuscript.
Despite the relatively higher postoperative cardiopulmonary
complication rate in our study, it should be noted that the in hospital
mortality rate in our series was relatively low at
4.4%.9,11,15,16,20,23 Thus, the impact of
hospital volume on short and long term survival was not readily apparent.
The major limitation of the current study is the
retrospective nature of the data collection. In addition, mortality data was
derived from the Palmerston North Hospital Clinical Records Department rather
than the New Zealand Births and Deaths Registry. Nonetheless, all deaths
notified by the New Zealand Births and Deaths registry are cross-referenced
automatically with the Palmerston North Hospital Clinical Records Department,
and therefore we can assume that survival data is accurate. Another weakness of
this study is that disease-specific mortality and cancer recurrence rates could
not be established.
ConclusionOutcomes of oesophagectomy in this provincial New Zealand
hospital are comparable to published series from national and international
tertiary centres.
Competing interests: None
declared.
Author information: Fadhel Al-Herz,
Surgical Registrar, Department of Surgery, Palmerston North Hospital, Palmerston
North; David Healey, Surgical Registrar Department of Surgery, Palmerston North
Hospital, Palmerston North; Tarik Sammour, Research Fellow, Department of
Surgery, South Auckland Clinical School, Faculty of Medical and Health Sciences,
University of Auckland; Josese Turagava, Surgical Registrar Department of
Surgery, Palmerston North Hospital, Palmerston North; Bruce Rhind, General
Surgeon Department of Surgery, Palmerston North Hospital, Palmerston North; Mike
Young, General Surgeon, Department of Surgery, Palmerston North Hospital,
Palmerston North
Acknowledgements: The authors thank Dr
Bruce Lockett (Pathologist, Department of Pathology/ MedLab Central, Palmerston
North Hospital), and the Clinical Records Department staff of Palmerston North
Hospital.
Correspondence and reprint requests: Dr
Tarik Sammour, Research Fellow, Department of Surgery, South Auckland Clinical
School, Private Bag 93311, Middlemore Hospital, Otahuhu, Auckland, New Zealand.
Fax: + 64 (0)9 6264558; email: sammour@xtra.co.nz
References:
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