Surgery: Lessons from 1,200 Resections

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This paper waspresented at the t526 Congress of the ters with an interest in dealing with this condition, we Pan-Pacific Surgical Meeting embarked on a systematic approach to reduce this high rate. The first step was to collect reliable prospective, Introduction almost real-time data on all aspects of the patient Two decades ago, cancer of the in the episodes in hospital, including both operative and East and in the West was a squamous cell cancer of non-operative treatment, From this, starting in 1982 the intrathoracic esophagus, situated predominantly we could identify precisely what were the incidences in the middle third. Today, in the East, this remains of each cause of death. At around that time, the hospital largely unchanged. In the West, however, the disease mortality rate was 20%. has become a Barrett’s adenocarcinoma of the distal esophagus, as aconsequence of gastroesophageal reflux Medical Causes and dysplasia occurring in specialized intestinal meta The major causes were categorized as medical, surgi plastic epithelium.L Indeed, this condition is epidemic cal and malignant cachexia. The most common cause in the West2 and has, like obesity, become a major health (45%) was pulmonary, which was not surprising given issue. Furthermore, while the epidemiology in the the average age of the patients (65 years), a male John Wong MD East has remained unchanged, in the West, Barrett’s preponderance of 5: 1, their smoking habits and most cancer primarily affects the professional middle-age of whom underwent a transthoracic resection (72%). Caucasian, unlike the older blue-collar worker in the Identifying relevant predictive factors for pulmonary past who habituates cigarettes and alcohol. As aware complications was important to improve outcome. Our ness increases in the West, the disease is diagnosed strategy to reduce this single most important7 complica at an increasingly early stage and treatment instituted tion was to: (1) enlist a good anesthetist, (2) implement in a more timely manner. In the East, diagnosis still epidural analgesia and patient-controlled analgesia, relies on the symptoni of dysphagia which usually (3) use a smaller thoracotomy, (4) insert a9small (18 indicates advanced disease. Treatment is therefore in Fr) vacuum suction chest 9drain, (5) practise early many instances palliative, extubation in the operating room, (6) perform regular A combination of both the type of patients and the postoperative bronchoscopic sputum clearance,Lo(7) nature of the disease renders the option of treatment to ambulate the patient from the first postoperative day, Authors: be fundamentally which has an fluid Divisionof Esophageal different, then impact (8) maintain restriction and albumin level, (9) Surgery on the risks and results of the chosen therapy. By and perform a tracheostomy early to aid sputum suction DepartmentofSurgery large, treatment in the East for squamous cell carci when the coughing effort was inadequate, and (10) UniversityofHongKong MedicalCentre noma still mandates a thoracotomy, while in the West, institute vigorous chest physiotherapy. Although even QueenMaryHospital the procedure has increasingly become a transhiatal with all these and other supportive measures pulmonary HongKong(S.L.,JW approach. While it is expected that the mortality and complications were not eliminated, the incidence was morbidity rates should be lower in the West, this has lowered and, more importantly, the seriousness had not been shown to he so and the mortality rate remains been mitigated through early intervention. This is a at around 10-I 2%.30In the East, no data comparable to theme that is relevant in the management of all other the Veterans Affairs database is available but a survey complications of esophagectomy. Cardiac complica

Corre.spondenceto: of 13hospitals in Hong Kong also revealed a hospital tions (12%) were mostly atrial arrhythmia, and the JohnWongPhD mortality rate of about l0%, Thus esophagectomy is availability of effective drugs made for rapid restora DepartmentofSurgery still one of the highest risk procedures whether in the tion of sinus rhythm. UniversityofHongKong East or West. 0 MedicalCentre QueenMaryHo.spitai Surgical Causes HongKong Causes of Hospital Mortality As for surgical complications, technical aspects are Tel:(852)28554610 Fax:(8t2(28551897 Two decades ago, the mortality rate for esophageal most important in preventing this occurrence , Anasto Email:jwong@hkohk cancer worldwide was around 30%,’ Like other cen motic leak was and remains a complication that strikes

HAWALLMEOLCALJOURNAL. VOL.63. JULY2.004 203 fear in the heart of all esophageal surgeons, and has the same effect Changes in Management on us as anyone else. By examining the problem objectively and During the period of improvement, there have also been advances instituting solutions supported by randomized controlled trials, we in technology and drugs which are more effective and safer than have reduced leak rate that was in excess of 25% to now around previously. This allowed us to better select patients ftr appropriate 2% that are clinically in nature, and another 1% radiologically. treatment. Examples of such advances include the self-expanding Changes in technique were made from a hand-sewn two layers of metallic 2stents, improved radiation techniques, and effective che interrupted suture (before 1982), to the circular stapler,4 and in the motherapy’ and combinations of them. last 8 years to a single-layercontinuous suture using a4/0 absorbable Thus there has been a reduction of the proportion of patients who suture. H What is equally important is our willingness, indeed our underwent resection from about 70% to 55%. and, in particular, obsession, to re-explore a patient, even through a re-thoracotomy, introduction of chemoradiation has made this 22possible. On the when the patient is not progressing well and no other cause is obvi other hand, the referral pattern to our hospital has now included ous, or when there is the slightest suspicion of a leak. As all surgeons more patients with more advanced disease. Coincidentally, it was are aware, how well the anastomosis was constructed technically at noteworthy that the mortality rate was halved at a time when our operation usually forewarn the risk of an anastomotic leak, resection rate was at its’peak inthe early 1990s. Therefore, the virtual Other surgical complications are not common if care to detail elimination of postoperative death cannot he attributed to patient is exercised at the operation. Postoperative bleeding, gangrene of selection alone, but is more likely due to the practice that had been conduit, chylothorax, bowel herniation into the chest, gastric outlet adopted cited earlier. 78obstruction, and others should be recognized early and treated. Benefits of Reducing Mortality Progressive Malignancy What are the benefits of improving the operative results? First and Death from progressing malignancy after a prolonged stay in hos foremost is that survival is prolonged. In our cohort of patients, the pital following a successful operation is a situation specific to the reduction inmortality from 20% to 1%has increased median survival social environment in [long Kong and to our hospital. Previously, from 8.6 months to 17.9 months and 5-year survival rate from 18.5% because alternative treatments were ineffective and associated with to 24,5%. However, some of the gain may be in part due to the ef considerable risks, we were prepared to resect (orto bypass using the fectiveness of and radiotherapy because even when Kirschner 920operation)’ even in the face of very advanced disease hospital deaths were excluded from calculation of survival, there and operative risks. Although the majority of patients recovered from remains a significant improvement in survival in recent 22years. these procedures and were ambulant and eating normally, they were Second, as deaths usually follow complications, and these are not discharged from the convalescent hospital to which they were managed aggressively, there are the savings from reducing the transferred because of social problems such as poor family support, number of these ill patients who are usually in the ICU. Patients living in the upper floors or roofs of buildings without elevators and with anastomotic leak. forexample, would require repeated episodes sharing cooking and toilet facilities, and emotionally, physically of imaging, a variety of radiological and operative procedures. and financially unable to cope by themselves. We have therefore ventilatory support, parenteral nutrition, third or fourth generation always used hospital mortality rate as the end point of success of an antibiotics, and an immense amount of attention by surgeons. nurses operation and not the 30-day mortality rate, To include deaths as a and allied health personnel. direct result of a technical complication of the operative procedure, Third, the surgical community benefits because of the aura of as had been used in the past by those who wished to present good good if not excellent results which encourages referral for operative results, does not reflect the true burden carried by patients after an treatment. Most would agree that a successful operation still offers esophagectomy. As with the holistic view of a surgeon’s mission, we the best palliation in terms of quality of swallowing and the widest hold that success is only achieved when a patient can be discharged variety of food that can be consumed. Cure is now also a distinct to his previous environment to enjoy what has been possible prior possibility. The need for further treatment in hospital to relieve to the illness that sought our help, and, in the case of esophageal dysphagia from persistence or recurrence of the primary tumor, such cancer, this is the ability to eat. We recognize social circumstances as from radiation stricture, is virtually eliminated. An uneventful as a cause of hospital mortality may not be a universal problem, but surgical resection still offers the best chance of long-term survival, at least it is a consistently measurable end point. and is the most cost-effective. Over the years, using the approach outlined, the hospital mortal Fourth, the argument that non-operative treatment offers less risk ity rate has decreased from about 20% to 1%. From 1996 till 1999, of death and complications cannot be sustained if resection mortality we had no deaths for 169 consecutive resectkns. Since then, there and morbidity rates can be achieved at the same if not lower levels were three — the first was an elderly female patient who recovered than, say, chemoradiation. This is now a verifiable claim. fully from the operation and died from a myocardial infarction as Fifth, the morale and confidence of patients and relatives are lifted she was transferred to a medical ward on day 38. The second was knowing they are being managed by a team with an excellent track a gentleman who had undergone prior resection for his head and record. This in turn puts the responsibility on the surgical team to cancer. A successful esophagectomy was performed but he perform even better to ensure that trust has not been misplaced. died from fulminant recurrence of the head and neck cancer on Sixth and finally,the impact of superior results are not lost to the day 56. The third patient died from SARS-like illness on day 17 administration when formulating policy or distributing resources. postoperatively. It is hard to ignore or argue against success.

HAWAHMEDCAL JOURNAL. VOL 63, .JULY2004 204 Conclusion Editor’s Note: In conclusion, improvements are possible and achievable. However, This paper was presented at the 26th Congress of the Pan-Pacific progress is slow and so requires persistence. Improvements are also SurgicalAssociation, February 14-16, 2004, in Honolulu. The C’on incremental and therefore there is no single remedy that changes gress, chaired by TornKosasa Ml) was outstanding. Look forward outcome overnight. Advancement comes from a team and not just to the next Pan-Pacific Congress — world class researchers and the operating surgeon, as the assistants, residents and house staffs all practicers of the surgical specialties will again return to Hawaii in contribute to the minuteto-minute and day-to-day care these patients January 14-16. 2006. need. Progress also occurs through input from other disciplines, particularly anesthesiologists (epidural analgesia), intensive care specialists and nurses whose diligence helps detect complications earlier. Improvements are not more costly, and in fact the reduction of complications derives major cost savings. Improvements are also inevitable because in the current environment of surgical practice those who do not or cannot produce acceptable if not superior results will not be tolerated by their peers, the administration, or the community. To achieve improvement take vigilance, commitment and long hours, It will also require honest auditing, nourished by studies such as randomized controlled trials to advance knowledge. Finally, to reach the level of excellence aspired requires the will and determi nation to succeed. References 1 DevesaSS. BlotWJ,Fraumeni-JFJ. Changingpatternsinthe inctdenceofesophagealandgastric carcinomainthe UnitedStates.Cancer1998;83(t0i:2049-2053. 2. LagergrenJ. BergstromR,LindgrenA,Nyren0. Symptomaticgastroesophagealrefluxass risktactor toresophagealadenocarcinoma.NEngIJ Med1999:340(1t(:825-831

3. BirkmeyerJD,SiewersAE.FinlaysonE\ StukelTA,LucasFL,BatistaI et al.Hospitalvolumeand

surgicalmortalityin the UnitedStates.NEngIJ Med2002:3481t5i:t1281137. ANewResourceKitfromthe 4. BaileySH.BullDA.HarpoleDH,RentzJJ, NeumayerLA.PappasTNet al.Outcomesafteresopha’ gectomy:a ten-yearprospectivecohort,AnnThoracSurg2003:75(1):2t7’222. NationalCancerInstitute 5. HospitalAuthorityHongKong.Clinicalauditon esophagectomyand hepatectomyin HongKong. 2002.

6. EarlamR.Cunha-MeloJR.Oesophagealsquamouscellcarcinoma:IAcriticalreviewofsurgery.Br J Surg1980:67:381-390. 7. LawS.WongK,KwokK,ChuK,WongJ.Predictivefactorsforpostoperativepulmonarycomplications andmortalityafteresophagectomyforcancer.AnnSurg.Inpress. 8. Tsui5L,ChanCS,ChanASH,WongSJ,LamCS.JonesRDM.Postoperativeanalgesiaforoesophageal surgery:Acomparisonofthreeanalgesicregimens.AnaesthIntensCare1991:19:329-337. 9. LauH,LawS,WongJ.Prospectiveevaluationofvacuumpleuraldrainageafterthoracotomya patients withesophagealcarcinoma.ArchSurg1997:132(7):749’752, ( 11ICCI I{((”irC1I 10. WhooleyBPLawS,MurthySC,AlesandrouA,WongJ. Analysisofreduceddeathandcomplication BECAUSE LIVES DEPEND ON IT ratesafteresophagealresection.AnnSurg2001:233(3):338’344. 11. MurthySC,LawS,WhooleyBPAlexandrouA,ChuKM,WongJ.Atrialfibrillationafteresophagectomy isa markerforpostoperativemorbidityandmortahty.J ThoracCardiovascSurg2003:t26(4(:1162- (10(1 / 111.51(11(11 ,/i’i/I’ ff14’ %. 1167. ‘I’ll ‘/Ifl” .5, (lI11f I/u f//f, .5 12. LawSY.FokM,WongJ. Riskanalysisinresectionofsquamouscellcarcmomaofthe esophagus. ri’l WorldJ Surg1994:18(3(:339’346. 13. LorentzT FokM.WongJ. Arrastomohcleakageafterresectionand bypassforesophagealcancer: ( lessonslearnedfromthe past.WorldJ Surgt989;13(4i:472-477. ui,ri “/rf/(./1” 14, WhooleyBPLawS,AlexandrouA,MurthySC,WongJ.Criticalappraisalofthesignificanceofintra thoracicanastomoticleakageafteresopoagectomytor cancer. Am J Surg2001:181(3(:198’203. 15. LawS,FokM,ChuKM.WongJ.Comparisonofhand’sewnandstapledesophagogastricanastomosis lI( .‘ ‘to/i lou/ui/n” afteresophagealresectionforcancer:a prospectiverandomizedcontrolledtrial.AnnSurg 1997; 226(2(:169-173, 16. LawS,Wong1.Esophagogastrectomyforcarcinomaoftheesophagusandcardis,andtheesophageal ( liii,’ ‘ii ‘/ud,’.’ a as or-os Ir BakerRJ Dec e eoitrs Mcaurnt Su oert PA bpp ncottWd6ams&69lPns i,,’,,’ 2001:813-827. 17. FokM,ChengSW.WongJ.Pyloroplastvversusnodrainageingastricreplacementoftheesophagus. AmJ Sum1991:162(5l:447-452. 18, LawS,Ch,eungMC.FokM..ChuKM,WongJ.Pyloropiastyandpyloromyotomyingastricreplacement

ottheesophagusafteresophsgectomy:srandomizedcontroiledtriai.JAmCotSurg1997:184i6.i:630- I . I I

636. I I ‘ I ‘‘ I I it. OngGB.TheKirschneroperation--aforgottenprocedure.BrJ Surg1973;60(3(:221-227. 20. WhooleyBDLawS,MurthySC.AlevandrouA,ChuKM.WongJ.TheKirschneroperationinunresect ableea.opf.agealcancer:currentap.plicstion.ArchSurg2002;137(11(:1226-1232. 1-800-4-CANCER 21. LawS.TungPH,ChuKM.Wong1.Self-expandingmetallicstuntsforpailiatio•nofrecurrentmalignant esophagealobstructionaftersubtotalesophagectomyforcancer.G.astrointeatEndosc1999:50(3(:427- 436. I’,! I Ii’

22. LawS. Kw’ongDL,KwokKEWongKH,Chu69$,Sh,amIS et al,Improvementintreatmentresults I, I ‘‘iii . ‘‘ / andlong-termsurvivalofpatientswithesophagealcancer:impactofchemoradiationandchangein treatmentstrategy.AnnSurg20.03:238(3(:339-348,

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