Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy

Abstract

Objectives: To examine the safety of transthoracic esophagogastrectomy (TTE) in a multidisciplinary cancer center and to determine which clinical parameters influenced survival and the rates of death and complications.

Summary background data: Although the incidence of cancer at the gastroesophageal junction has been rising rapidly in the United States, controversy still exists about the safety of surgical procedures designed to remove the distal esophagus and proximal stomach. Alternatives to TTE have been proposed because of the reportedly high rates of death and complications associated with the procedure.

Methods: Data from 143 patients treated by TTE by one author (1989-1999) were entered into a computerized database. Preoperative clinical parameters were tested for effect on death, complications, and survival.

Results: The patient population consisted of 127 men and 16 women. One hundred twenty-one patients had a history of tobacco abuse, and 118 reported the regular ingestion of alcohol. One hundred fifteen patients had adenocarcinoma, 16 had squamous cell cancer, 6 had another form of esophageal tumor, and 6 had high-grade dysplasia associated with Barrett epithelia. Fifty-six patients had adenocarcinomas arising in Barrett epithelium. Twenty-eight patients were treated with neoadjuvant chemoradiation before surgery. Three patients died within 30 days of surgery (mortality rate 2.1%). Five patients (3.5%) had a documented anastomotic leak; three died). Overall, 42 patients had complications (29%). Twenty-six had pulmonary complications (19%). The mean length of stay in the intensive care unit was 3.35 days; the mean hospital length of stay was 13.54 days. The overall 3-year survival rate was 29.6%.

Conclusions: A high ASA score and the development of complications predicted an increased length of stay. The presence of diabetes predicted the development of complication and an increased length of stay. None of the other parameters tested predicted perioperative death or complications. Only disease stage, diabetes, and blood transfusion affected overall survival. From these results with a large series of patients with gastroesophageal junction cancers, TTE can be performed with a low death rate (2.1%), a low leak rate (3. 5%), and an acceptable complication rate (29%).

Figure 1. Survival by stage for patients with adenocarcinoma and squamous cell carcinoma. Patients with high-grade dysplasia only were excluded. Median survival was 1.60 years (stage I = 3.0 years, IIA = 3.08 years, IIB = 1.17 year, III = 1.51 years, and IV = 0.44 years). Mean survival was 2.02 years.