The impact of complications on outcomes after resection for esophageal and gastroesophageal junction carcinoma.
BACKGROUND
Efforts to improve surgical outcomes have traditionally focused on improving preoperative patient selection and reducing the risk of postoperative medical complications. Strategies to optimize surgical technique have been less well studied. We sought to assess the relation between complications related to surgical technique and outcomes after esophagogastrectomy for cancer.


METHODS
Medical records of 510 consecutive patients undergoing esophagogastrectomy for invasive squamous cell carcinoma or adenocarcinoma at Memorial Sloan-Kettering Cancer Center from 1996 to 2001 were reviewed. Data on diagnosis, stage of disease, therapies received, surgical approach, patient comorbidities, technical complications, and postoperative medical complications and outcomes including length of stay and overall survival were determined by one reviewer of the medical records. The primary predictor was surgical complications and the primary outcome was survival.


RESULTS
Of the 150 patients studied 138 (27%) had complications directly attributable to surgical technique, such as an anastomotic leak, a paralyzed vocal cord, or chylothorax. At 3 years 43 of 138 patients (31%) with technical complications were alive, whereas 179 of 372 patients (48%) without technical complications were alive. Technical complications were associated with increased length of stay (median 23 days versus 11 days, p < 0.001), increased in-hospital mortality (12.3% versus 3.8%, p < 0.001), and a higher rate of medical complications (77.5% versus 47.3%, p < 0.001). After controlling for age, medical comorbidities, use of induction therapy, tumor stage, histology, and location, and completeness of resection the presence of a technical complication was highly predictive of poorer overall survival; the multivariable hazard ratio was 1.41 (1.22 to 1.63, p = 0.008).


CONCLUSIONS
Technical complications have a large negative impact on survival after esophagogastrectomy for cancer. Strategies to optimize surgical technique and minimize complications should improve outcomes in this cancer operation.
Rizk
Nabil P
NP
Thoracic Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
Bach
Peter B
PB
Schrag
Deborah
D
Bains
Manjit S
MS
Turnbull
Alan D
AD
Karpeh
Martin
M
Brennan
Murray F
MF
Rusch
Valerie W
VW
D000230:Adenocarcinoma / Q000401:mortality / Q000601:surgery*; D002294:Carcinoma, Squamous Cell / Q000401:mortality / Q000601:surgery*; D015897:Comorbidity; D004938:Esophageal Neoplasms / Q000401:mortality / Q000601:surgery*; D016629:Esophagectomy; D004943:Esophagogastric Junction; D005260:Female; D005743:Gastrectomy; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality; D012189:Retrospective Studies; D016019:Survival Analysis