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Original Articles: General Thoracic

Invited Commentary

Department of Surgery, Maimonides Medical Center, 4802 10th Ave, 4th Floor Admin Bldg, Brooklyn, NY 11219

(Email: jlocicero{at}maimonidesmed.org).

Lagarde and colleagues [1] relate a number of preoperative esophagectomy variables to morbidity and mortality. They chose three different types of variables: (1) "general" factors, (2) function tests, and (3) therapy-related predictors. The general factors include some disease states, such as cardiac disease defined by electrocardiographic abnormalities; some past events, such as previous myocardial infarction or stroke; and demographic variables, such as age.

Based on other large data sets and formulas for predicting perioperative morbidity and mortality, such as the National Surgical Quality Improvement Program (NSQIP) and the Euroscore, or the Northern New England risk calculator for coronary artery surgery, two other classes of variables are also important. These two classes are (1) the presence of organ dysfunction, such as heart failure, and (2) the objective measures of organ function, such as cardiac ejection fraction or creatinine. The Society of Thoracic Surgeons' thoracic database may be a promising tool for this purpose. As more thoracic surgeons participate, and the database grows, we may be able to validate and then use more objective measures of organ function.

It is assumed the operations that Lagarde and associates [1] performed were by standard open techniques. Experienced foregut surgeons are migrating to minimally invasive procedures. Several centers, including ours perform a total minimally invasive approach. With newer, less invasive operative assist devices and staplers, it may be possible to perform an Ivor Lewis esophagectomy with no incision larger than 2 cm. This may change the predictive weight given to the operation, especially for the transthoracic approach.

It is important to note that even the lowest risk patient in this series has a 30% chance of some complication. A typical 80-year-old patient with a previous myocardial infarction, persistent electrocardiographic changes, and moderate chronic obstructive pulmonary disease has only a 12% chance of undergoing esophagectomy without complication. Although the score rises linearly for age, we prepare our oldest patients differently from our younger patients, but the effect of preoperative preparation of the older adult on postoperative outcomes is unknown.

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1. Lagarde SM, Reitsma JB, Maris A-KD, et al. Preoperative prediction of the occurrence and severity of complications after esophagectomy for cancer with use of a nomogram Ann Thorac Surg 2008;85:1938-1946.[Abstract/Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by LoCicero, J. Search for Related Content PubMed PubMed Citation Articles by LoCicero, J., III Related Collections Esophagus - cancer Related Article