Journal of Gastrointestinal Surgery

, Volume 13, Issue 4, pp 611–618 | Cite as

Risk Prediction Scores for Postoperative Mortality After Esophagectomy: Validation of Different Models

  • U. Zingg
  • C. Langton
  • B. Addison
  • B. P. L. Wijnhoven
  • J. Forberger
  • S. K. Thompson
  • A. J. Esterman
  • D. I. Watson
original article



Different prediction models for operative mortality after esophagectomy have been developed. The aim of this study is to independently validate prediction models from Philadelphia, Rotterdam, Munich, and the ASA.


The scores were validated using logistic regression models in two cohorts of patients undergoing esophagectomy for cancer from Switzerland (n = 170) and Australia (n = 176).


All scores except ASA were significantly higher in the Australian cohort. There was no significant difference in 30-day mortality or in-hospital death between groups. The Philadelphia and Rotterdam scores had a significant predictive value for 30-day mortality (p = 0.001) and in-hospital death (p = 0.003) in the pooled cohort, but only the Philadelphia score had a significant prediction value for 30-day mortality in both cohorts. Neither score showed any predictive value for in-hospital death in Australians but were highly significant in the Swiss cohort. ASA showed only a significant predictive value for 30-day mortality in the Swiss. For in-hospital death, ASA was a significant predictor in the pooled and Swiss cohorts. The Munich score did not have any significant predictive value whatsoever.


None of the scores can be applied generally. A better overall predictive score or specific prediction scores for each country should be developed.


Risk prediction models Esophagectomy In-hospital death 30-day mortality 



The authors thank Carolyn Lally, Lorelle Smith, and Janet Pinno, Discipline of Surgery, Royal Adelaide Hospital, and Tanya Ellis, Department of Surgery, Flinders Medical Center, for help in gathering the data and support with the database.


  1. 1.
    McCulloch P, Ward J, Tekkis PP for the ASCOT group of surgeons. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BJM 2003;327:1192–7. doi: 10.1136/bmj.327.7425.1192.CrossRefGoogle Scholar
  2. 2.
    Low DE, Kunz S, Schembre D, Otero H, Malpass T, His A et al. Esophagectomy—it’s not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer. J Gastrointest Surg 2007;11:1395–402. doi: 10.1007/s11605-007-0265-1.PubMedCrossRefGoogle Scholar
  3. 3.
    Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR et al. Minimally invasive esophagectomy. Outcomes in 222 patients. Ann Surg 2003;238:486–95.PubMedGoogle Scholar
  4. 4.
    Liu JF, Watson DI, Devitt PG, Mathew G, Myburgh J, Jamieson GG. Risk factor analysis of postoperative mortality in oesophagectomy. Dis Esophagus 2000;13:130–135. doi: 10.1046/j.1442-2050.2000.00099.x.PubMedCrossRefGoogle Scholar
  5. 5.
    Schroeder W, Bollschweiler E, Kossow C, Hoelscher AH. Preoperative risk analysis—a reliable predictor of postoperative outcome after transthoracic esophagectomy. Langenbecks Arch Surg 2006;391:455–460. doi: 10.1007/s00423-006-0067-z.CrossRefGoogle Scholar
  6. 6.
    Dimick JB, Wainess RM, Upchurch GR Jr, Iannettoni MD, Orringer MB. National trends in outcomes for esophageal resection. Ann Thorac Surg 2005;79:212–216. doi: 10.1016/j.athoracsur.2004.06.044.PubMedCrossRefGoogle Scholar
  7. 7.
    Tekkis PP, McCulloch P, Poloniecki JD, Prytherch DR, Kessaris N, Steger AC. Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM. Br J Surg 2004;91:288–295. doi: 10.1002/bjs.4414.PubMedCrossRefGoogle Scholar
  8. 8.
    Lai F, Kwan TL, Yuen WC, Wai A, Siu YC, Shung E. Evaluation of various POSSUM models for predicting mortality in patients undergoing elective oesophagectomy for carcinoma. Br J Surg 2007;94:1171–1178. doi: 10.1002/bjs.5793.CrossRefGoogle Scholar
  9. 9.
    Lagarde SM, Maris AK, de Castro SM, Busch OR, Obertop H, van Lanschot JJ. Evaluation of O-POSSUM in predicting in-hospital mortality after resection for oesophageal cancer. Br J Surg 2007;94:1521–1526. doi: 10.1002/bjs.5850.PubMedCrossRefGoogle Scholar
  10. 10.
    Nagabhushan JS, Srinath S, Weir F, Angerson WJ, Sugden BA, Morran CG. Comparison of P-POSSUM and O-POSSUM in predicting mortality after oesophagogastric resections. Postgrad Med J 2007;83:355–358. doi: 10.1136/pgmj.2006.053223.PubMedCrossRefGoogle Scholar
  11. 11.
    Steyerberg EW, Neville BA, Koppert LB, Lemmens VE, Tilanus HW, Coeberg JW et al. Surgical mortality in patients with esophageal cancer: development and validation of a simple risk score. J Clin Oncol 2006;24:4277–4284. doi: 10.1200/JCO.2005.05.0658.PubMedCrossRefGoogle Scholar
  12. 12.
    Ra J, Paulson EC, Kucharczuk J, Armstrong K, Wirtalla C, Rapaport-Kelz R et al. Postoperative mortality after esophagectomy for cancer: development of a preoperative risk prediction model. Ann Surg Oncol 2008;15:1577–1584. doi: 10.1245/s10434-008-9867-4.PubMedCrossRefGoogle Scholar
  13. 13.
    Bartels H, Stein HJ, Siewert JR. Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer. Br J Surg 1998;85:840–844. doi: 10.1046/j.1365-2168.1998.00663.x.PubMedCrossRefGoogle Scholar
  14. 14.
    Sauvanet A, Mariette C, Thomas P, Lozac’h P, Segol P, Tiret E et al. Mortality and morbidity after resection for adenocarcinoma of the gastrointestinal junction: predictive factors. J Am Coll Surg 2005;201:253–262. doi: 10.1016/j.jamcollsurg.2005.02.002.PubMedCrossRefGoogle Scholar
  15. 15.
    Rodgers M, Jobe BA, O’Rourke RW, Sheppard B, Diggs B, Hunter JG. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg 2007;142:829–837. doi: 10.1001/archsurg.142.9.829.PubMedCrossRefGoogle Scholar
  16. 16.
    Karl RC, Schreiber R, Boulware D, Baker S, Coppola D. Factors affecting morbidity, mortality and survival in patients undergoing Ivor Lewis esophagogastrectomy. Ann Surg 2000;231:635–643. doi: 10.1097/00000658-200005000-00003.PubMedCrossRefGoogle Scholar
  17. 17.
    Law S, Wong KH, Kwok KF, Chu KM, Wong J. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg 2004;240:791–800. doi: 10.1097/01.sla.0000143123.24556.1c.PubMedCrossRefGoogle Scholar
  18. 18.
    Abunasra H, Lewis S, Beggs L, Duffy J, Beggs D, Morgan E. Predictors of operative death after oesophagectomy for carcinoma. Br J Surg 2005;92:1029–1033. doi: 10.1002/bjs.5049.PubMedCrossRefGoogle Scholar
  19. 19.
    Alexiou C, Khan OA, Black E, Field ML, Onyeaka P, Beggs L et al. Survival after esophageal resection for carcinoma: the importance of the histologic cell type. Ann Thorac Surg 2006;82:1073–1077. doi: 10.1016/j.athoracsur.2006.03.012.PubMedCrossRefGoogle Scholar
  20. 20.
    Siewert RJ, Stein HJ, Feith M, Bruecher BLDM, Bartels H, Fink U. Histologic tumor type is an independent prognostic parameter in esophageal cancer: lessons from more than 1000 consecutive resections at a single center in the western world. Ann Surg 2001;234:360–369. doi: 10.1097/00000658-200109000-00010.PubMedCrossRefGoogle Scholar
  21. 21.
    Orringer MB, Marshall B, Iannettoni MD. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999;230:392–403. doi: 10.1097/00000658-199909000-00012.PubMedCrossRefGoogle Scholar
  22. 22.
    Khan OA, Alexiou C, Soomro I, Duffy JP, Morgan WE, Beggs FD. Pathological determinants of survival in node-negative oesophageal cancer. Br J Surg 2004;91:1586–1591. doi: 10.1002/bjs.4778.PubMedCrossRefGoogle Scholar
  23. 23.
    Hulscher JB, van Sandick JW, de Boer AG, Wijnhoven BP, Tijssen JG, Fockens P et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002;347:1662–1669. doi: 10.1056/NEJMoa022343.PubMedCrossRefGoogle Scholar
  24. 24.
    Wijnhoven BP, Tran KT, Esterman A, Watson DI, Tilanus HW. An evaluation of prognostic factors and tumor staging of resected carcinoma of the esophagus. Ann Surg 2007;245:717–725. doi: 10.1097/01.sla.0000251703.35919.02.PubMedCrossRefGoogle Scholar
  25. 25.
    Urba SG, Orringer MB, Turrisi A, Iannettoni M, Forastiere A, Strawderman M. Randomized trial of preoperative chemoradiation versus surgery alone in patients with locoregional esophageal carcinoma. J Clin Oncol 2001;19:305–13.PubMedGoogle Scholar
  26. 26.
    Mariette C, Piessen G, Lamblin A, Mirabel X, Adenis A, Triboulet JP. Impact of preoperative radiochemotherapy on postoperative course and survival in patients with locally advanced squamous cell oesophageal carcinoma. Br J Surg 2006;93:1077–1083. doi: 10.1002/bjs.5358.PubMedCrossRefGoogle Scholar
  27. 27.
    Rice DC, Correa AM, Vaporciyan AA, Sodhi N, Smythe WR, Swisher SG et al. Preoperative chemoradiotherapy prior to esophagectomy in elderly patients is not associated with increased morbidity. Ann Thorac Surg 2005;79:391–397. doi: 10.1016/j.athoracsur.2004.08.045.PubMedCrossRefGoogle Scholar
  28. 28.
    Urschel JD, Vasan H. A meta-analysis of randomized controlled trials that compared neoadjuvant chemoradiation and surgery to surgery alone for resectable esophageal cancer. Am J Surg 2003;185:538–543. doi: 10.1016/S0002-9610(03)00066-7.PubMedCrossRefGoogle Scholar
  29. 29.
    Kuo EY, Chang Y, Wright CD. Impact of hospital volume on clinical and economic outcomes for esophagectomy. Ann Thorac Surg 2001;72:1118–1124. doi: 10.1016/S0003-4975(01)02962-9.PubMedCrossRefGoogle Scholar
  30. 30.
    Swisher SG, Deford L, Merriman KW, Walsh GL, Smythe R, Vaporicyan A et al. Effect of operative volume on morbidity, mortality and hospital use after esophagectomy for cancer. J Thorac Cardiovasc Surg 2000;119:1126–1132. doi: 10.1067/mtc.2000.105644.PubMedCrossRefGoogle Scholar
  31. 31.
    Santin B, Kulwicki A, Price P. Mortality rate associated with 56 consecutive esophagectomies performed at a low-volume hospital: is procedure volume as important as we are trying to make it. J Gastrointest Surg 2008;12:1346–1350. doi: 10.1007/s11605-008-0550-7.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2008

Authors and Affiliations

  • U. Zingg
    • 1
    • 2
  • C. Langton
    • 1
  • B. Addison
    • 1
  • B. P. L. Wijnhoven
    • 1
    • 3
  • J. Forberger
    • 2
  • S. K. Thompson
    • 4
  • A. J. Esterman
    • 5
  • D. I. Watson
    • 1
  1. 1.Flinders University Department of SurgeryFlinders Medical CenterAdelaideAustralia
  2. 2.Department of SurgeryTriemli HospitalZurichSwitzerland
  3. 3.Department of SurgeryErasmus Medical CenterRotterdamThe Netherlands
  4. 4.Discipline of SurgeryUniversity of AdelaideAdelaideAustralia
  5. 5.School of Nursing and MidwiferyUniversity of South AustraliaAdelaideAustralia

Personalised recommendations