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Rapid Responses: Rapid Responses published:
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Anesthesia and outcome from surgery
- William J Fawcett (14 December 2003)
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Surgery of oesophageal cancer
- Tom Treasure, Richard Page, Wyn Parry, John Duffy (17 December 2003)
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Re: Surgery of oesophageal cancer
- Matthew Forshaw, James Gossage, Robert Mason (6 February 2004)
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William J Fawcett, Consultant anaesthetist Royal Surrey County Hospital, Guildford, Surrey, GU2 7XX, UK
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Editor – The ASCOT group make no mention of the role of anaesthesia and perioperative care in their study of mortality and morbidity following gastro-oesophageal cancer surgery [1]. This is important as there are several areas where anaesthestists and intensivists may have a considerable impact on mortality on this patient population. These include epidural anaesthesia and perioperative optimisation of oxygen delivery. Properly conducted epidural anaesthesia has a number of beneficial effects such as a reduction in deep vein thrombosis by 44%, pulmonary embolism by 55%, transfusion requirements by 50%, pneumonia by 39%, and respiratory depression by 59% and smaller reduction in the incidence of myocardial infarction and renal failure, with an overall reduction in mortality by about one third in patients who received neuraxial blockade [2]. In addition, the use of preoperative fluids and inotropes to increase oxygen delivery may reduce mortality in high risk patient groups into which the patients in this study fall, by 75-82% [3,4] The omission of crucial perioperative data of this sort ignores the fact that surgical outcome is related to a number of factors, of which the patient and the surgeon are only two. Excellence in anaesthesia and intensive care may have a dramatic effect on mortality in patients who are otherwise well matched. References. 1. McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastro- oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ 2003; 327: 1192-6 2. Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1493. 3. Boyd O. Grounds RM. Bennett ED. A randomized clinical trial of the effect of deliberate perioperative increase of oxygen delivery on mortality in high-risk surgical patients. JAMA 1993;270:2699-707 4. Wilson J, Woods I, Fawcett J, Whall R, Dibb W, Morris C, McManus E. Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery. BMJ 1999; 318: 1099 - 1103. Competing interests: None declared |
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Tom Treasure, Consultant Thoracic Surgeon Guy's Hospital SE1 9RT, Richard Page, Wyn Parry, John Duffy
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ASCOT (Assessment of Stomach and Oesophageal Cancer Outcomes) reports on 229 oesophageal cancers over four years (1999-2002) with 50 hospital deaths and a 14% mortality[1] in a paper of enviable quality. The UK Thoracic Register in 2001-2 included 568 resections for oesophageal carcinoma with a mortality of under 5% (27 deaths). A difference as large as this deserves critical evaluation of the pattern of service for oesophageal cancer surgery, with a move towards lower risk. In fact the reverse has occurred. During the time frame of the ASCOT data the number of cases reported from the thoracic units has been steadily declining from 751 in 1998 to 568 in 2002. This cannot have been driven by published outcomes (there were none) but is we believe due to the double effect of referral through local gastroenterological multidisciplinary meetings to on-site upper GI surgeon coupled with a serious national under provision of specialist thoracic surgeons[2]. Taken at face value, surgical treatment of oesophageal cancer is moving away from a specialty with mortality figures of under 5% to surgeons with a mortality nearly three times that. We know that self reporting underestimates deaths and the Society of Cardiothoracic Surgeons (SCTS) has been party to an exercise making that point[3]. The Thoracic Register of the SCTS consists of self-reported returns of case numbers and mortality and it is clear to us that it comes nowhere close to the quality of the data in ASCOT. We are at present improving the quality of our data acquisition. This is being made ever more difficult by issues of confidentiality and privacy which are obstacles to both verification and linkage to death certification[4], both necessary components of a high quality data base from which to judge outcome. Nevertheless, this threefold difference is so great that it merits analysis by whatever means are at our disposal. There is the further important question of volume and mortality. Oesophageal cancer resection is generally regarded as an operation with a marked effect of surgeon volume[5] on hospital survival. In a large study in the USA 40% of oesophageal resections were performed in units doing fewer than 5 cases per annum[6]. ASCOT does not report an institutional volume effect for oesophageal cancer, nor is it revealed in the SCTS data but this is statistically difficult because simple comparisons of death rates in small data sets cannot distinguish bad luck from bad practice[7]. Irrespective of a provable effect on hospital survival, there are cogent arguments against this exacting work being spread too thinly. Although oesophageal cancer is more and more managed by upper GI surgeons we know that our Society members are called upon to help with predictably difficult cases and to help when complications have occurred. There is an impression that thoracic surgeons get not only fewer but worse cases – a contention unproven and unprovable on present evidence. However, the next generation of thoracic surgeons cannot be trained on this basis and the present surgeons are at risk of becoming progressively deskilled. In our view the way ahead is not a turf war but for joint care of these cases in units big enough to maintain institutional volumes at operationally reasonable levels and to combine the skills of thoracic and upper GI surgeons in this challenging area of surgery. This approach has the support of the Royal Colleges’ Specialist Advisory Committees (SACs) through approval of joint training but instances of this being taken up are few so far. Reference List 1. McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ 2003;327:1192-7. 2. Partridge MR. Thoracic surgery in a crisis. BMJ 2002;324:376-7. 3. Fine LG, Keogh BE, Cretin S, Orlando M, Gould MM. How to evaluate and improve the quality and credibility of an outcomes database: validation and feedback study on the UK Cardiac Surgery Experience. BMJ 2003;326:25-8. 4. Black N. Secondary use of personal data for health and health services research: why identifiable data are essential. J.Health Serv.Res.Policy 2003;8 Suppl 1:S1-40. 5. Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FL. Surgeon volume and operative mortality in the United States. N.Engl.J.Med. 2003;349:2117-27. 6. Birkmeyer JD, Siewers AE, Finlayson EV, Stukel TA, Lucas FL, Batista I et al. Hospital volume and surgical mortality in the United States. N.Engl J Med 2002;346:1128-37. 7. Treasure T. Rational decision-making about paediatric cardiac surgery. Lancet 2000;355:948. Competing interests: None declared |
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Matthew Forshaw, Specialist Registrar St Thomas' Hospital, London, SE1 7EH, James Gossage, Robert Mason
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McCulloch et al(1) have provided an overview of current surgical outcomes following oesophagectomy and gastrectomy in a sample of UK hospitals. Two further points need to be addressed. Firstly, the authors highlighted the disappointingly high rates of in hospital mortality, especially for oesophagectomy. Although this is in keeping with the results from other large multi-centre audits identified by the authors, recent guidelines(2) suggest that mortality rates should be less than 10%. Evidence does exist that surgical outcomes correlate with case volume(3). With only 15 out of 32 hospitals contributing oesophagectomy cases towards the ASCOT database, this equates to approximately 6 cases per annum per hospital. We have audited the surgical outcomes of 168 oesophagectomies (57% transhiatal and 43% transthoracic) with an annual volume of approximately 50 cases between January 2000 and May 2003 with the following results: in hospital mortality =1.8%, median length of hospital stay =14 days, ITU admissions =15.5%, reoperations =7.7%, anastomotic leak =7.7% respiratory complications =34.5%, cardiovascular complications =20.8% and septic complications =20.8%. We consider that low in hospital mortality rates are achievable. With recent efforts to centralise oesophago-gastric cancer surgery to units with sizeable catchment populations(4), we believe that McCulloch et al have provided important evidence for a more rationalised service in the UK. Secondly, it is increasingly commonplace to treat locally advanced oesophageal and junctional tumours with preoperative (or neoadjuvant) chemotherapy or chemoradiotherapy. A theoretical concern is that this neoadjuvant therapy may worsen preoperative nutritional and performance status baselines prior to surgery, leading to increases in treatment- related mortality(5). It would be interesting to know whether the use of radiochemotherapy (26.3% of oesophagectomy patients)in the ASCOT database adversely affected the surgical outcomes. We have used neoadjuvant therapy (predominantly 3 cycles of combination chemotherapy) in locally advanced carcinoma of the oesophagus and cardia (46.7% of the patients in our audit) and found no evidence to suggest any worsening of surgical outcomes. References 1 McCulloch P, Ward J, Tekkis P. Mortality and morbidity in gastro- oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ 2003;327:1192-7. 2 Allum WH, Griffin SM, Watson A, Colin-Jones D. Guidelines for the management of oesophageal and gastric cancer. Gut 2002;50(Suppl V):v1-v23. 3 Van Lanschot JJ, Hulscher JB, Buskens CJ, Tilanus HW, ten Kate FJ, Obertop H. Hospital volume and hospital mortality for esophagectomy. Cancer 2001;91:1574-8 4 Clinical Outcomes Group, NHS Executive. Guidance on commissioning cancer services. Improving the outcomes in upper gastro-intestinal cancers: the research evidence. London: Department of Health 2001. 5 Kaklamanos IG, Walker GR, Ferry K, Franceshi D, Livingstone AS. Neoadjuvant treatment for respectable cancer of the esophagus and the gastroesophageal junction: a meta-analysis of randomised clinical trials. Ann Surg Oncol 2003;10(7):754-761. Competing interests: None declared |
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