World Journal of Surgery

, Volume 38, Issue 11, pp 2882–2890 | Cite as

Impact of Preoperative Risk Factors on Morbidity after Esophagectomy: Is There Room for Improvement?

  • Styliani Mantziari
  • Martin Hübner
  • Nicolas Demartines
  • Markus SchäferEmail author



Despite progress in multidisciplinary treatment of esophageal cancer, oncologic esophagectomy is still the cornerstone of therapeutic strategies. Several scoring systems are used to predict postoperative morbidity, but in most cases they identify nonmodifiable parameters. The aim of this study was to identify potentially modifiable risk factors associated with complications after oncologic esophagectomy.


All consecutive patients with complete data sets undergoing oncologic esophagectomy in our department during 2001–2011 were included in this study. As potentially modifiable risk factors we assessed nutritional status depicted by body mass index (BMI) and preoperative serum albumin levels, excessive alcohol consumption, and active smoking. Postoperative complications were graded according to a validated 5-grade system. Univariate and multivariate analyses were used to identify preoperative risk factors associated with the occurrence and severity of complications.


Our series included 93 patients. Overall morbidity rate was 81 % (n = 75), with 56 % (n = 52) minor complications and 18 % (n = 17) major complications. Active smoking and excessive alcohol consumption were associated with the occurrence of severe complications, whereas BMI and low preoperative albumin levels were not. The simultaneous presence of two or more of these risk factors significantly increased the risk of postoperative complications.


A combination of malnutrition, active smoking and alcohol consumption were found to have a negative impact on postoperative morbidity rates. Therefore, preoperative smoking and alcohol cessation counseling and monitoring and improving the nutritional status are strongly recommended.


Postoperative Morbidity Serum Albumin Level Active Smoking Excessive Alcohol Consumption Esophageal Resection 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflict of interest



  1. 1.
    Mariette C (2008) [Practical considerations in prescribing immunonutrition]. J Chir (Paris) 145(Suppl 4):9S 10–9S 14Google Scholar
  2. 2.
    Tekkis PP, McCulloch P, Poloniecki JD et al (2004) Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM. Br J Surg 91:288–295PubMedCrossRefGoogle Scholar
  3. 3.
    Cerantola Y, Hübner M, Grass F et al (2011) Immunonutrition in gastrointestinal surgery. Br J Surg 98:37–48PubMedCrossRefGoogle Scholar
  4. 4.
    Agnelli G, Eriksson BI, Cohen AT et al (2009) Safety assessment of new antithrombotic agents: lessons from the EXTEND study on ximelagatran. Thromb Res 123:488–497PubMedCrossRefGoogle Scholar
  5. 5.
    McCulloch P, Ward J, Tekkis PP et al (2003) Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ 327:1192–1197PubMedCrossRefPubMedCentralGoogle Scholar
  6. 6.
    Lagarde SM, Reitsma JB, Maris AK et al (2008) Preoperative prediction of the occurrence and severity of complications after esophagectomy for cancer with use of a nomogram. Ann Thorac Surg 85:1938–1945PubMedCrossRefGoogle Scholar
  7. 7.
    Derogar M, Orsini N, Sadr-Azodi O et al (2012) Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal cancer surgery. J Clin Oncol 30:1615–1619PubMedCrossRefGoogle Scholar
  8. 8.
    Dimick JB, Weeks WB, Karia RJ et al (2006) Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg 202:933–937PubMedCrossRefGoogle Scholar
  9. 9.
    Khan NA, Quan H, Bugar JM et al (2006) Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med 21:177–180PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Turan A, Mascha EJ, Roberman D et al (2011) Smoking and perioperative outcomes. Anesthesiology 114:837–846PubMedCrossRefGoogle Scholar
  11. 11.
    Vonlanthen R, Slankamenac K, Breitenstein S et al (2011) The impact of complications on costs of major surgical procedures: a cost analysis of 1200 patients. Ann Surg 254:907–913PubMedCrossRefGoogle Scholar
  12. 12.
    Hoogeboom TJ, Dronkers JJ, Hulzebos EH et al (2014) Merits of exercise therapy before and after major surgery. Curr Opin Anaesthesiol 27:161–166PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Hulzebos EH, Elders PJ, Favié NJ et al (2006) Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA 296:1851–1857PubMedCrossRefGoogle Scholar
  14. 14.
    Hulzebos EH, Smit Y, Helders PP, et al (2012) Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev 11:CD010118Google Scholar
  15. 15.
    Dindo D, Demartines N, Clavien PA (2004) Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 240:205–213PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Wilson AP, Treasure T, Sturridge MF et al (1986) A scoring method (ASEPSIS) for postoperative wound infections for use in clinical trials of antibiotic prophylaxis. Lancet 1:311–313PubMedCrossRefGoogle Scholar
  17. 17.
    Swiss Federal Commission for Alcohol Problems. Available at:
  18. 18.
    Chwals WJ, Blackburn GL (1986) Perioperative nutritional support in the cancer patient. Surg Clin N Am 66:1137–1165PubMedGoogle Scholar
  19. 19.
    Kondrup J, Allison SP, Elia M et al (2003) ESPEN guidelines for nutrition screening 2002. Clin Nutr 22:415–421PubMedCrossRefGoogle Scholar
  20. 20.
    Pacelli F, Bossola M, Rosa F et al (2008) Is malnutrition still a risk factor of postoperative complications in gastric cancer surgery? Clin Nutr 27:398–407PubMedCrossRefGoogle Scholar
  21. 21.
    Grotenhuis BA, Winjhoven BP, Grüne F et al (2010) Preoperative risk assessment and prevention of complications in patients with esophageal cancer. J Surg Oncol 101:270–278PubMedGoogle Scholar
  22. 22.
    Kuwano H, Sumiyoshi K, Sonoda K et al (1998) Relationship between preoperative assessment of organ function and postoperative morbidity in patients with oesophageal cancer. Eur J Surg 164:581–586PubMedCrossRefGoogle Scholar
  23. 23.
    Pennathur A, Gibson MK, Jobe BA et al (2013) Oesophageal carcinoma. Lancet 381:400–412PubMedCrossRefGoogle Scholar
  24. 24.
    Haga Y, Wada Y, Takeuchi H et al (2004) Estimation of physiologic ability and surgical stress (E-PASS) for a surgical audit in elective digestive surgery. Surgery 135:586–594PubMedCrossRefGoogle Scholar
  25. 25.
    Zingg U, Smithers BM, Gotley DC et al (2011) Factors associated with postoperative pulmonary morbidity after esophagectomy for cancer. Ann Surg Oncol 18:1460–1468PubMedCrossRefGoogle Scholar
  26. 26.
    Wong J, Lam DP, Abrishami A et al (2012) Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth 59:268–279PubMedCrossRefGoogle Scholar
  27. 27.
    Kyle UG, Pirlich M, Schuetz T et al (2003) Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clin Nutr 22:473–481PubMedCrossRefGoogle Scholar
  28. 28.
    Schiesser M, Kirchhoff P, Müller MK et al (2009) The correlation of nutrition risk index, nutrition risk score, and bioimpedance analysis with postoperative complications in patients undergoing gastrointestinal surgery. Surgery 145:519–526PubMedCrossRefGoogle Scholar
  29. 29.
    Han-Geurts IJ, Hop WC, Tran TC et al (2006) Nutritional status as a risk factor in esophageal surgery. Dig Surg 23:159–163PubMedCrossRefGoogle Scholar
  30. 30.
    Nass R, Johannsson G, Christiansen JS et al (2009) The aging population—is there a role for endocrine interventions? Growth Horm IGF Res 19:89–100PubMedCrossRefGoogle Scholar
  31. 31.
    Sheetz KH, Zhao L, Holcombe SA et al (2013) Decreased core muscle size is associated with worse patient survival following esophagectomy for cancer. Dis Esophagus 26:716–722PubMedPubMedCentralGoogle Scholar
  32. 32.
    Lien YC, Hsieh CC, Wu YC et al (2004) Preoperative serum albumin level is a prognostic indicator for adenocarcinoma of the gastric cardia. J Gastrointest Surg 8:1041–1048PubMedCrossRefGoogle Scholar
  33. 33.
    Gupta D, Lis CG (2010) Pretreatment serum albumin as a predictor of cancer survival: a systematic review of the epidemiological literature. Nutr J 9:69PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Kondrup J, Rasmussen HH, Hamberg O et al (2003) Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 22:321–336PubMedCrossRefGoogle Scholar
  35. 35.
    Kudsk KA, Tolley EA, DeWitt RC et al (2003) Preoperative albumin and surgical site identify surgical risk for major postoperative complications. JPEN J Parenter Enteral Nutr 27:1–9PubMedCrossRefGoogle Scholar
  36. 36.
    Oppedal K, Møller AM, Pedersen B, et al (2012) Preoperative alcohol cessation prior to elective surgery. Cochrane Database Syst Rev 7:CD008343Google Scholar
  37. 37.
    Tonnesen H, Rosenberg J, Nielsen HJ et al (1999) Effect of preoperative abstinence on poor postoperative outcome in alcohol misusers: randomised controlled trial. BMJ 318:1311–1316PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2014

Authors and Affiliations

  • Styliani Mantziari
    • 1
  • Martin Hübner
    • 1
  • Nicolas Demartines
    • 1
  • Markus Schäfer
    • 1
    Email author
  1. 1.Department of Visceral SurgeryUniversity Hospital CHUVLausanneSwitzerland

Personalised recommendations