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01-06-2012 | Original Article

Risk Assessment Using a Novel Score to Predict Anastomotic Leak and Major Complications after Oesophageal Resection

Authors: Fergus Noble, Nathan Curtis, Scott Harris, Jamie J. Kelly, Ian S. Bailey, James P. Byrne, Timothy J. Underwood, on behalf of the South Coast Cancer Collaboration–Oesophago-Gastric (SC-OG)

Published in: Journal of Gastrointestinal Surgery | Issue 6/2012

Abstract

Background

Oesophagectomy is associated with significant morbidity and mortality. A simple score to define a patient's risk of developing major complications would be beneficial.

Methods

Patients who underwent upper gastrointestinal resections with an oesophageal anastomosis between 2005 and 2010 were reviewed and formed the development dataset with resections performed in 2011 forming a prospective validation dataset. The association between post-operative C-reactive protein (CRP), white cell count (WCC) and albumin levels with anastomotic leak (AL) or major complication including death using the Clavien–Dindo (CD) classification were analysed by receiver operating characteristic curves. After multivariate analysis, from the development dataset, these factors were combined to create a novel score which was subsequently tested on the validation dataset.

Results

Two hundred fifty-eight patients were assessed to develop the score. Sixty-three patients (25%) developed a major complication, and there were seven (2.7%) in-patient deaths. Twenty-six (10%) patients were diagnosed with AL at median post-operative day 7 (range: 5–15). CRP (p = 0.002), WCC (p < 0.0001) and albumin (p = 0.001) were predictors of AL. Combining these markers improved prediction of AL (NUn score > 10: sensitivity 95%, specificity 49%, diagnostic accuracy 0.801 (95% confidence interval: 0.692–0.909, p < 0.0001)). The validation dataset confirmed these findings (NUn score > 10: sensitivity 100%, specificity 57%, diagnostic accuracy 0.879 (95% CI 0.763–0.994, p = 0.014)) and a major complication or death (NUn > 10: sensitivity 89%, specificity 63%, diagnostic accuracy 0.856 (95% CI 0.709–1, p = 0.001)).

Conclusions

Blood-borne markers of the systemic inflammatory response are predictors of AL and major complications after oesophageal resection. When combined they may categorise a patient's risk of developing a serious complication with higher sensitivity and specificity.

Lepage C, Rachet B, Jooste V, Faivre J, Coleman MP. Continuing rapid increase in esophageal adenocarcinoma in England and Wales. Am J Gastroenterol 2008; 103(11): 2694-9.PubMedCrossRef

Allum WH, Blazeby JM, Griffin SM, Cunningham D, Jankowski JA, Wong R. Guidelines for the management of oesophageal and gastric cancer. Gut 2011; 60(11): 1449-72.PubMedCrossRef

Noble F, Bailey D, Tung K, Byrne JP. Impact of integrated PET/CT in the staging of oesophageal cancer: a UK population-based cohort study. Clin Radiol 2009; 64(7): 699-705.PubMedCrossRef

Stein HJ, Sendler A, Fink U, Siewert JR. Multidisciplinary approach to esophageal and gastric cancer. Surg Clin North Am 2000; 80(2): 659-82; discussions 83-6PubMedCrossRef

Bachmann MO, Alderson D, Edwards D, et al. Cohort study in South and West England of the influence of specialization on the management and outcome of patients with oesophageal and gastric cancers. Br J Surg 2002; 89(7): 914-22.PubMedCrossRef

Lauder CI, Marlow NE, Maddern GJ, et al. Systematic review of the impact of volume of oesophagectomy on patient outcome. ANZ J Surg 2010; 80(5): 317-23.PubMedCrossRef

Kim RH, Takabe K. Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review. J Surg Oncol 2010; 101(6): 527-33.PubMedCrossRef

Low DE, Kunz S, Schembre D, et al. Esophagectomy—it's not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007; 11(11): 1395-402; discussion 402

Park DP, Welch CA, Harrison DA, et al. Outcomes following oesophagectomy in patients with oesophageal cancer: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care 2009; 13 Suppl 2: S1PubMedCrossRef

10.

Traverso LW, Shinchi H, Low DE. Useful benchmarks to evaluate outcomes after esophagectomy and pancreaticoduodenectomy. Am J Surg 2004; 187(5): 604-8.PubMedCrossRef

11.

Griffin SM, Lamb PJ, Dresner SM, Richardson DL, Hayes N. Diagnosis and management of a mediastinal leak following radical oesophagectomy. Br J Surg 2001; 88(10): 1346-51.PubMedCrossRef

12.

Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg 2011; 253(5): 890-9.PubMedCrossRef

13.

Takeuchi H, Saikawa Y, Oyama T, et al. Factors influencing the long-term survival in patients with esophageal cancer who underwent esophagectomy after chemoradiotherapy. World J Surg 2010; 34(2): 277-84.PubMedCrossRef

14.

Ohtsuka T, Kitajima Y, Takahashi T, et al. Infectious complications after gastric cancer surgery accelerate a rapid hepatic recurrence. Hepatogastroenterology 2009; 56(94-95): 1277-80.PubMed

15.

Escofet X, Manjunath A, Twine C, Havard TJ, Clark GW, Lewis WG. Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network. Dis Esophagus 2010; 23(2): 112-6.PubMedCrossRef

16.

Sierzega M, Kolodziejczyk P, Kulig J. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg 2010; 97(7): 1035-42.PubMedCrossRef

17.

Bartels H, Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer. Br J Surg 1998; 85(6): 840-4.PubMedCrossRef

18.

Steyerberg EW, Neville BA, Koppert LB, et al. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol 2006; 24(26): 4277-84.PubMedCrossRef

19.

Finlayson EV, Birkmeyer JD. Operative mortality with elective surgery in older adults. Eff Clin Pract 2001; 4(4): 172-7.PubMed

20.

Piccirillo JF, Tierney RM, Costas I, Grove L, Spitznagel EL, Jr. Prognostic importance of comorbidity in a hospital-based cancer registry. JAMA 2004; 291(20): 2441-7.PubMedCrossRef

21.

Ferguson MK, Martin TR, Reeder LB, Olak J. Mortality after esophagectomy: risk factor analysis. World J Surg 1997; 21(6): 599-603; discussion -4PubMedCrossRef

22.

Charnley RM, Paterson-Brown S. Surgeon volumes in oesophagogastric and hepatopancreatobiliary resectional surgery. Br J Surg 2011; 98(7): 891-3.PubMedCrossRef

23.

Tekkis PP, McCulloch P, Poloniecki JD, Prytherch DR, Kessaris N, Steger AC. Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM. Br J Surg 2004; 91(3): 288-95.PubMedCrossRef

24.

Lagarde SM, Maris AK, de Castro SM, Busch OR, Obertop H, van Lanschot JJ. Evaluation of O-POSSUM in predicting in-hospital mortality after resection for oesophageal cancer. Br J Surg 2007; 94(12): 1521-6.PubMedCrossRef

25.

Raja SG, Dreyfus GD. Modulation of systemic inflammatory response after cardiac surgery. Asian Cardiovasc Thorac Ann 2005; 13(4): 382-95.PubMed

26.

Talmor M, Hydo L, Barie PS. Relationship of systemic inflammatory response syndrome to organ dysfunction, length of stay, and mortality in critical surgical illness: effect of intensive care unit resuscitation. Arch Surg 1999; 134(1): 81-7.PubMedCrossRef

27.

Ryan AM, Hearty A, Prichard RS, Cunningham A, Rowley SP, Reynolds JV. Association of hypoalbuminemia on the first postoperative day and complications following esophagectomy. J Gastrointest Surg 2007; 11(10): 1355-60.PubMedCrossRef

28.

Korner H, Nielsen HJ, Soreide JA, Nedrebo BS, Soreide K, Knapp JC. Diagnostic accuracy of C-reactive protein for intraabdominal infections after colorectal resections. J Gastrointest Surg 2009; 13(9): 1599-606.PubMedCrossRef

29.

Welsch T, Muller SA, Ulrich A, et al. C-reactive protein as early predictor for infectious postoperative complications in rectal surgery. Int J Colorectal Dis 2007; 22(12): 1499-507.PubMedCrossRef

30.

MacKay GJ, Molloy RG, O'Dwyer PJ. C-reactive protein as a predictor of postoperative infective complications following elective colorectal resection. Colorectal Dis 2011; 13(5): 583-7.PubMedCrossRef

31.

Ortega-Deballon P, Radais F, Facy O, et al. C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World J Surg 2010; 34(4): 808-14.PubMedCrossRef

32.

Dutta S, Fullarton GM, Forshaw MJ, Horgan PG, McMillan DC. Persistent elevation of C-reactive protein following esophagogastric cancer resection as a predictor of postoperative surgical site infectious complications. World J Surg 2011; 35(5): 1017-25.PubMedCrossRef

33.

Deitmar S, Anthoni C, Palmes D, Haier J, Senninger N, Bruwer M. [Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection?]. Zentralbl Chir 2009; 134(1): 83-9.PubMedCrossRef

34.

Hardwick RH. A Consensus View and Recommendations on the Development and Practice of Minimally Invasive Oesophagectomy AUGIS/ALSGBI 2008.

35.

UICC. TNM Classification of malignant tumours Seventh edition. Wiley:New York 2009; Seventh Edition.

36.

Clavien PA, Barkun J, de Oliveira ML, et al. The Clavien–Dindo classification of surgical complications: five-year experience. Ann Surg 2009; 250(2): 187-96.PubMedCrossRef

37.

Schrecengost JE, LeGallo RD, Boyd JC, et al. Comparison of diagnostic accuracies in outpatients and hospitalized patients of D-dimer testing for the evaluation of suspected pulmonary embolism. Clin Chem 2003; 49(9): 1483-90.PubMedCrossRef

38.

Clinical Effectiveness Unit RCSEng A, BSG, NCASP. National Oesophago-Gastric Cancer Audit. The NHS Information Centre, 2010.

39.

Wang X, Pan L, Zhang P, et al. Enteral nutrition improves clinical outcome and shortens hospital stay after cancer surgery. J Invest Surg 2010; 23(6): 309-13.PubMedCrossRef

40.

Schroeder D, Gillanders L, Mahr K, Hill GL. Effects of immediate postoperative enteral nutrition on body composition, muscle function, and wound healing. JPEN J Parenter Enteral Nutr 1991; 15(4): 376-83.PubMedCrossRef

Title: Risk Assessment Using a Novel Score to Predict Anastomotic Leak and Major Complications after Oesophageal Resection
Authors: Fergus Noble
Nathan Curtis
Scott Harris
Jamie J. Kelly
Ian S. Bailey
James P. Byrne
Timothy J. Underwood
on behalf of the South Coast Cancer Collaboration–Oesophago-Gastric (SC-OG)
Publication date: 01-06-2012
Publisher: Springer-Verlag
Published in: Journal of Gastrointestinal Surgery / Issue 6/2012
Print ISSN: 1091-255X
Electronic ISSN: 1873-4626
DOI: https://doi.org/10.1007/s11605-012-1867-9

At a glance: The STEP trials

Springer Medicine

Risk Assessment Using a Novel Score to Predict Anastomotic Leak and Major Complications after Oesophageal Resection

Abstract

Background

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

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