Department of Anaesthesia, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UKUnited Kingdom
Department of Upper Gastrointestinal Surgery, Regional Oesophagogastric Unit, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, England, UKUnited Kingdom
Also available as PDF (figures and tables appear in the PDF).
National figures for oesophagectomy mortality in the United Kingdom have been steadily dropping (12% to 9%) since the late 1990’s.1 More recently, these figures have improved significantly as shown in the 2016 annual report of the UK National Oesophago-Gastric Cancer Audit (NOGCA), revealing a post-oesophagectomy 90-day mortality rate of 3.2%.
Open Journal Editorial The Role of Pre-Assessment in Oesophageal Cancer Surgery 1 2* Niven Akotia, MBBS, BSc, MSc, FRCA1; Alexandros Charalabopoulos, MD, MSc, PhD, MRCS, FRCS2* 1Department of Anaesthesia, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, UK 2Department of Upper Gastrointestinal Surgery, Regional Oesophagogastric Unit, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, England, UK * *Corresponding author Alexandros Charalabopoulos, MD, MSc, PhD, MRCS, FRCS Department of Upper Gastrointestinal Surgery, Regional Oesophagogastric Unit, Broomfield Hospital, Mid Essex Hospital Services NHS Trust, Chelmsford, Essex, England, UK; E-mail: acharalabopoulos@yahoo.com Article information th th th Received: September 11 , 2017; Accepted: September 18 , 2017; Published: September 18 , 2017 Cite this article Akotia N, Charalabopoulos A.The role of pre-assessment in oesophageal cancer surgery. Gastro Open J. 2017; 3(1): e1-e3. doi: 10.17140/GOJ-3-e004 ational figures for oesophagectomy mortality in the United morbidities and physiological reserve in patients. All have limita- Kingdom have been steadily dropping (12% to 9%) since tions and relatively poor specificity but by combining scores, evalu- N 1 the late 1990’s. More recently, these figures have improved sig- ation could be improved. The most commonly used scoring system nificantly as shown in the 2016 annual report of the UK National worldwide is the American Society of Anaesthesiologists (ASA) Oesophago-Gastric Cancer Audit (NOGCA), revealing a post-oe- Physical Status. Its limitations include lack of specificity and a large 2 6 sophagectomy 90-day mortality rate of 3.2%.2 Despite this, surgical inter-assessor variability.6 Others are Lee’s Revised Cardiac Index treatment for oesophageal cancer still carries significant morbidity, and POSSUM score.7 Another well-known system is the Charlson often quoted up to 64%.3 While centres of excellence maintain Comorbidity Index, which determines increased risk based on the high standards of surgery and improved surgical techniques, with number and severity of each of the co-morbidities the patient has. minimally invasive techniques potentially reducing physiological This has been validated both in gastric and oesophageal cancer as stresses on patients, we are perhaps being less conservative in our a predictor of mortality.8 Repeatedly, age has not been shown to be selection of patients for surgery; all having varying influences on a predictor of morbidity and mortality; rather, the co-morbidities the overall risks.
and the overall fitness of the patient need to be weighed to deter- mine the overall risk.9 Pre-assessment of patients over the last 2 decades has dramatically changed. We have moved from pre-assessment being Frailty is therefore becoming one of the strongest pre- performed by the most junior members of the surgical team in the dictors of outcome in oesophagectomy patients. Associated with past, to the current system with dedicated consultants and nurse frailty is sarcopenia, which is recognised as a global quantitative specialists, specializing in peri-operative medicine. This has been marker of frailty, and could potentially be used to assist with as- shown to decrease cancellations of surgery, reduce length of stay sessment. Here sarcopenia, which is age-related muscle mass and in a number of surgical specialities and potentially improve the strength loss, should be differentiated from cachexia, which may 4,5 outcome.
be due to malignancy or its treatment with chemotherapy. The primary aim is to balance the impact of the stress Cardiopulmonary exercise testing (CPET) is increasingly of surgery and the overall physiological reserve of the patient, to being used to risk stratify patients undergoing complex gastroin- provide some idea of the individual’s risk of morbidity and mor- testinal surgery. Anaerobic threshold (AT) has been extensively tality. Based on this initial assessment, any specific risks would be associated with cardiovascular risk stratification in many surgi- highlighted and strategies to mitigate these would be implemented, cal subspecialties. In oesophageal cancer resections, an AT of thus, attempting to tip the balance to lower those risks. less than 11 ml/kg/min has been shown to be an indicator of increased cardiopulmonary complications as well as predicting a RISK ASSESSMENT higher rate of unplanned intensive care unit admissions.11 More recently another marker that is considered to perhaps be an even Currently, a number of scoring systems are used to evaluate the co- more accurate predictor of cardiopulmonary complications is the cc Copyright 2017 by Charalabopoulos A. This is an open-access article distributed under Creative Commons Attribution 4.0 International License (CC BY 4.0), Gastro Open J. 2017; 3(1): e1-e3. doi: 10.17140/GOJ-3-e004 maximum oxygen uptake (VO2 max). In a Japanese study of 91 pa- ternet]. 2016. Web site. http://www.augis.org/national-oesopha- tients who had undergone radical oesophagectomy for cancer with go-gastric-cancer-audit/. Accessed September 8, 2017. 3-field lymph node dissection, VO2 max was found to correlate with cardiopulmonary complication rate, with a minimum cut-off 3. Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital -1 -2 12 at 800 ml.min .m . Patients with VO2 max above that had a low morbidity and mortality following esophagectomy. Ann Thor Surg. cardiopulmonary complication rate and it was recommended that 2004; 78(4): 1170-1176. doi: 10.1016/j.athoracsur.2004.02.034 radical oesophagectomy was safe within that patient cohort. On -1 -2 the contrary, with a VO2 max between 700 to 799 ml.min-1.m-2 , a 4. Cantlay KL, Baker S, Parry A, Danjoux G. The impact of a con- cardiopulmonary complication rate of 44% was shown, whereas sultant anaesthetist led pre-operative assessment clinic on patients -1 -2 when the VO2 max was dropping below 699 ml.min-1.m-2, cardio- undergoing major vascular surgery. Anaesthesia. 2006; 61(3): 234- pulmonary complication rate was in the area of 86%. Certainly, 239. doi: 10.1111/j.1365-2044.2005.04514.x further work in this area is sorely needed to exploit this useful mode of assessment.
5. Hocking G, Shaikh L. Anaesthetic pre-assessment clinics to identify patients at risk. Anaesthesia. 2000; 55(8): 812-812. doi: PRE-HABILITATION 10.1046/j.1365-2044.2000.01629-3.x CPET has been used successfully in orthopaedics and more re- 6. Tegels JJ. Improving the outcomes in gastric cancer surgery. 13,14 cently in colorectal cancer to improve post-operative recovery. World J Gastroenterol. 2014; 20(38): 13692-13704. doi: 10.3748/wjg. Ongoing clinical trials are underway looking at the effect of pre- v20.i38.13692 habilitation in patients undergoing treatment for oesophageal cancer.15 The approach is of a trimodal one to improve a patients 7. Bhagwat M, Paramesh K. Cardio-pulmonary exercise testing: overall well-being through exercise, nutrition (protein supplemen- An objective approach to pre-operative assessment to define level tation), and psychological support (anxiety reduction). This is be- of perioperative care. Indian J Anaesth. 2010; 54(4): 286-291. doi: lieved to have a greater impact on patients through improved com- 10.4103/0019-5049.68369 13,16,17 pliance and marginal gains.
8. Ra J, Paulson EC, Kucharczuk J, et al. Postoperative mortality OPTIMISATION after esophagectomy for cancer: Development of a preoperative risk prediction model. Ann Surg Oncol. 2008; 15(6): 1577-1584. doi: As the patient’s journey prior to surgery often involves investiga- 10.1245/s10434-008-9867-4 tions and possible treatment with neo-adjuvant chemotherapy, there is an opportunity to improve the co-morbidities to further re- 9. Markar SR, Low DE. Physiology, not chronology, dictates out- duce peri-operative risks weeks before surgery. Smoking cessation, comes after esophagectomy for esophageal cancer: Outcomes in anaemia control, hypertension and diabetic management are but patients 80 years and older. Ann Surg Oncol. 2013; 20(3): 1020-1026. a few conditions that these patients often have as well. Optimis- doi: 10.1245/s10434-008-9867-4 ing these prior to surgery could reduce their overall peri-operative risks.
10. Wagner D. Role of frailty and sarcopenia in predicting out- comes among patients undergoing gastrointestinal surgery. World J FUTURE Gastrointest Surg. 2016; 8(1): 27-40. doi: 10.4240/wjgs.v8.i1.27 Pre-assessment for oesophageal cancer is continuing to improve 11. Moyes LH, McCaffer CJ, Carter RC, Fullarton GM, Mackay with models of care learnt from other areas of medicine and surgi- CK, Forshaw MJ. Cardiopulmonary exercise testing as a predictor cal sub-specialties. Enhanced recovery principles along with tai- of complications in oesophagogastric cancer surgery. Ann R Coll loring patient’s pre-operative care through pre-habilitation could Surg Engl. 2013; 95(2): 125-130. doi: 10.1308/rcsann.2013.95.2.125 greatly improve oesophageal surgical outcome with development of adequate evidence-based support.
12. Nagamatsu Y, Shima I, Yamana H, Fujita H, Shirouzu K, Ishitake T. Preoperative evaluation of cardiopulmonary reserve CONFLICTS OF INTEREST with the use of expired gas analysis during exercise testing in pa- tients with squamous cell carcinoma of the thoracic esophagus. The authors declare that they have no conflicts of interest. J Thorac Cardiovasc Surg. 2001;121(6): 1064-1068. doi: 10.1067/ mtc.2001.113596