An Audit of Retrospective Database on Esophagectomy Surgeries at a Tertiary Care Cancer Hospital in India.

Esophageal cancers account for the seventh most common type of cancer worldwide. ¹Esophagectomy is the modality of treatment for locally-advanced esophageal cancers in many patients. The ERAS guidelines strongly recommend smoking and alcohol abstinence, and low level of recommendation for investigations such as CPET. Nutrition is an important aspect in esophagectomy surgeries as many patients are malnourished, often requiring additional support. 2 There is moderate evidence that minimally invasive surgeries are associated with less blood loss, shorter hospital stay and reduced pain. ERAS guidelines also comment on optimum fluid administration and maintenance of normothermia. Intraoperatively, one-lung ventilation with permissible hypercapnia is strongly recommended. They also strongly recommend optimum pain management with thoracic epidural, paravertebral block and co-analgesics such as NSAID’s and acetaminophen.2

The Esophageal Complications Consensus group (ECCG) has provided a list of the most common complications occurring in esophagectomy surgeries that categorizes a wide range of potential complications, organized by the specific body system affected. These complications, which include issues like pneumonia and pleural effusions in the pulmonary system, cardiac arrest and dysrhythmias, gastrointestinal leaks and infections, and various other systemic problems, often require further medical intervention, prolonged hospital stays, or specialized management. 3 They also obtained prospective data for over 2700 patients across 24 centres in 14 countries over 2 years. 56.2% surgeries were performed in the distal esophagus with more than half of them receiving some form of treatment prior to surgery. The incidence of complications was found to be 59%, with pneumonia contributing 14.6% and anastomotic leak 14.5% The readmission rates were 11.2% and 30 and 90-day mortality rates were 2.4% and 4.5%, respectively. 4

Studies conducted across the globe aim at estimating the incidence of complications based on ECCG. Netherlands reported 65% of patients (1046 of 1617) with postoperative complications, with 29% (468 patients) experiencing a major complication. The most prevalent complications observed were pneumonia (21%), esophago-enteric leak from the anastomosis, staple line, or localized conduit necrosis (19%), and atrial dysrhythmia (15%). The associated 30-day mortality rate was 1.7%. 5 The Dutch Upper Gastrointestinal Cancer Audit also analysed 4096 patients and concluded that pulmonary complications and anastomotic leakage are the most impactful adverse events following surgery, significantly contributing to postoperative mortality (44.1% and 30.4% attributable risk, respectively), prolonged hospital stays (31.4% and 30.9% attributable risk) and hospital readmissions (7.3% and 14.7% attributable risk). Additionally, anastomotic leakage is the primary driver for reoperations, accounting for 47.1% of such instances. Other complications have a comparatively minor effect on these outcomes. 6 The main complications identified in a study in New Zealand spanning 25 years include POPC’s and anastomotic leaks. 7

Hence, we wanted conduct and audit based on the data at our centre as we conduct over 150 esophageal surgeries per year. This would help in improving the quality of treatment in such complex surgeries in India. This will be a single-centre audit of over 1000 patients who underwent elective esophagectomy from 2017-2024.