Analysis of reduced death and complication rates after esophageal resection

Objective To identify factors that have contributed to reduced rates of dea th and complications after esophageal resection in a 17-year period at a te rtiary referral center. Summary Background Data There has been an evolving refinement in surgical t echnique and perioperative management of patients undergoing esophageal res ection at Queen Mary Hospital during the past two decades. As of the end of 1998, there had been no hospital deaths among the last 105 consecutive res ections peformed for esophageal squamous cancer. Methods The results of esophageal resection for squamous cell carcinoma wer e analyzed using a prospective esophageal database. A longitudinal study wa s performed to compare and analyze rates of death and complications for thr ee consecutive time periods. Results The study group comprised 710 patients who underwent one-stage esop hageal resection between 1982 and 1998. A transthoracic esophagectomy was t he preferred approach in 590 patients (83%). The overall hospital death rat e was 11%. The leading causes of hospital death were pulmonary complication s (45.5%) and progression of malignant disease (21.5%), anastomotic leakage accounted for 9% of deaths. During the study period, the hospital death ra te decreased from 16% to 3.2%, and the incidence of postoperative respirato ry failure decreased from 15.5% to 6.5%. Perioperative factors that correla ted with the decreased death rate over time were the increased postoperativ e use of epidural analgesia and bronchoscopy (for clearance of pulmonary se cretions), a decrease in history of smoking, and a decrease in surgical blo od loss of more than 1,000 mL. Conclusions In this series of predominantly transthoracic esophagectomies, there has been a decline in the hospital death rate to less than 5%. These results are largely attributable to factors aimed at reducing postoperative pulmonary complications.