Short and long term outcomes of oesophagectomy in a provincial New Zealand hospital

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%.3-7A 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.4,7,8The 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.15In 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.Methods PatientsAll 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 collectionRetrospective 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. StatisticsResults were tabulated and analysed using SPSS 00ae for Windows 00ae 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. Results PatientsSixty-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 Variables N (%) Age (Mean in years, SD) 63.6 (10.9) Sex Male Female 47 (69.1%) 21 (30.9%) BMI (Mean in kg/m2, SD) 25.9 (7.4) ASA score I II III 6 (8.8%) 43 (63.2%) 19 (27.9%) Previous major abdominal surgery 24 (35.3%) SD: Standard Deviation. Intraoperative dataFour 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 00b1 101.8 min and mean intraoperative blood loss was 934.5 00b1 790.2 ml (Table 2). Median intraoperative blood transfusion requirement was 2 units (0-8), and mean intravenous fluid requirement was 6.6 00b1 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 Variables N (%) Operation Ivor-Lewis oesophagectomy Oesophagectomy + splenectomy + pancreatectomy Oesophagectomy + oesophago-jejunal anastamosis Thoraco-abdominal oesophagectomy 65 (95.5%) 1 (1.5%) 1 (1.5%) 1 (1.5%) Operative intent Cure Palliation 64 (94.1%) 4 (5.9%) Operation time (Mean in min, SD) 438.7 (101.8) Blood loss (Mean in ml, SD) 934.5 (790.2) Blood transfused (Red cells, Median in units, Range) 2 (0-8) Intravenous fluids (Mean in L, SD) 6.6 (1.4) Intraoperative complications Splenic injury Liver injury Acute coronary syndrome Total (per patient) 5 (7.4%) 1 (1.5%) 2 (2.9%) 8 (11.8%) Postoperative dataMedian 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 00b1 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 Parameter Value Intravenous fluids 1st 24hours (Mean in L, SD) 10.4 (2.1) Days in ICU (Median, Range) 7 (1-29) Day extubated (Median, Range) 3 (0-23) Total days intubated (Median, Range) 4 (0-23) Tracheostomy required 20 (29.4%) Days on TPN (Median, Range) 7.5 (0-33) Days on enteric feed (Median, Range) 0.5 (0-47) Day oral fluids started (Median, Range) 8 (0-55) Day oral solid food started (Median, Range) 11 (0-57) Day stay (Median, Range) 17.5 (4-60) Major postoperative complication Anastomotic leak Chylothorax Other intra-abdominal Sub-phrenic abscess Stomach perforation Mesenteric ischaemia Cardiopulmonary Pneumonia ARDS Pulmonary embolism Congestive cardiac failure Myocardial infarction Cardiac Arrhythmia Cerebrovascular Event / Stroke Prolonged unexplained hypotension Acute renal failure Costal osteomyelitis Central line sepsis Total (per patient) 7 (10.3%) 6 (8.8%) 3 (4.4%) 1 1 1 34 (50.0%) 25 2 1 1 3 4 1 1 2 (2.9%) 2 (2.9%) 1 (1.5%) 39 (57.54%) Minor postoperative complication Atrial Fibrillation Wound infection Urinary tract infection DVT Early anastomotic stricture Foot drop Total (per patient) 20 3 2 1 4 1 25 (36.7%) Re-operation 6 (8.8%) Re-admission to ICU 10 (14.7%) 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%). PathologyFifty-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 2019s 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) Variables N (%) Differentiation Well Moderate Poor Not available 12 (18.8%) 32 (50.0%) 16 (25.0%) 4 (6.3%) Lymph nodes (Mean, SD) Total nodes Positive nodes 13.1 (8.7) 3.3 (5.9) T T1 T2 T3 T4 12 (18.8%) 11 (17.2%) 40 (62.5%) 1 (1.6%) N N0 N1 32 (50.0%) 32 (50.0%) M M0 M1 61 (95.3%) 3 (4.7%) Preoperative Chemotherapy / Radiotherapy Chemotherapy Radiotherapy Nil 17 (26.6%) 2 (3.1%) 45 (70.3%) Postoperative Chemotherapy / Radiotherapy Chemotherapy Radiotherapy Chemotherapy + Radiotherapy Nil 10 (15.6%) 19 (29.7%) 1 (1.6%) 34 (53.1%) SurvivalThere 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) Variables Percentage 30 days (n=64) 1 year (n=57) 2 years (n=50) 3 years (n=42) 4 years (n=40) 5 years (n=33) 98.4% 77.2% 56.0% 42.9% 32.5% 30.3% Figure 1. Kaplan-Meier survival graph for patients with invasive carcinoma (n=64) Discussion We 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 wh