Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery

KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation

The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.

Predictive Effects of Lung function test on Postoperative Pneumonia in Squamous Esophageal Cancer

Pulmonary function tests had prospective implications for postoperative pneumonia, which occurred frequently after esophagectomy. Understanding factors that were associated with pulmonary infection may help in patient selection and postoperative management. We performed a retrospective review of 2 independent cohorts including 216 patients who underwent esophagectomy between November 2011 and May 2014, aiming at identifying predictors of primary pneumonia. Univariate analysis was used to identify potential covariates for the development of primary pneumonia. Adjustments for multiple comparisons were made using False Discovery Rate (FDR) (Holm-Bonferroni method). Multivariable logistic regression analysis was used to identify independent predictors and construct a regression model based on a training cohort (n = 166) and then the regression model was validated using an independent cohort (n = 50). It showed that low PEF (hazard ratio 0.97, P = 0.009) was independent risk factors for the development of primary pneumonia in multivariate analyses and had a predictive effect for primary pneumonia (AUC = 0.691 and 0.851 for training and validation data set, respectively). Therefore, PEF has clinical value in predicting postoperative pneumonia after esophagectomy and it may serve as an indicator of preoperative lung function training.

Preoperative Evaluation: Estimation of Pulmonary Risk

Postoperative pulmonary complications (PPCs) are common after major non-thoracic surgery and associated with significant morbidity and high cost of care. A number of risk factors are strong predictors of PPCs. The overall goal of the preoperative pulmonary evaluation is to identify these potential, patient and procedure-related risks and optimize the health of the patients before surgery. A thorough clinical examination supported by appropriate laboratory tests will help guide the clinician to provide optimal perioperative care.

The Gamma Gap and All-Cause Mortality

Background

The difference between total serum protein and albumin, i.e. the gamma gap, is a frequently used clinical screening measure for both latent infection and malignancy. However, there are no studies defining a positive gamma gap. Further, whether it is an independent risk factor of mortality is unknown.

Methods and Findings

This study examined the association between gamma gap, all-cause mortality, and specific causes of death (cardiovascular, cancer, pulmonary, or other) in 12,260 participants of the National Health and Nutrition Examination Survey (NHANES) from 1999–2004. Participants had a comprehensive metabolic panel measured, which was linked with vital status data from the National Death Index. Cause of death was based on ICD10 codes from death certificates. Analyses were performed with Cox proportional hazards models adjusted for mortality risk factors. The mean (SE) age was 46 (0.3) years and the mean gamma gap was 3.0 (0.01) g/dl. The population was 52% women and 10% black. During a median follow-up period of 4.8 years (IQR: 3.3 to 6.2 years), there were 723 deaths. The unadjusted 5-year cumulative incidences across quartiles of the gamma gap (1.7–2.7, 2.8–3.0, 3.1–3.2, and 3.3–7.9 g/dl) were 5.7%, 4.2%, 5.5%, and 7.8%. After adjustment for risk factors, participants with a gamma gap of ≥3.1 g/dl had a 30% higher risk of death compared to participants with a gamma gap <3.1 g/dl (HR: 1.30; 95%CI: 1.08, 1.55; P = 0.006). Gamma gap (per 1.0 g/dl) was most strongly associated with death from pulmonary causes (HR 2.22; 95%CI: 1.19, 4.17; P = 0.01).

Conclusions

The gamma gap is an independent risk factor for all-cause mortality at values as low as 3.1 g/dl (in contrast to the traditional definition of 4.0 g/dl), and is strongly associated with death from pulmonary causes. Future studies should examine the biologic pathways underlying these associations.

Impact of the surgical technique on pulmonary morbidity after esophagectomy

BACKGROUND

Pulmonary complications occur frequently after esophagectomy. Although multifactorial, these complications could be influenced by surgical technique. We sought to compare the respiratory complications of patients undergoing esophagectomy through different approaches, and identify technical risk factors.

METHODS

We conducted a retrospective analysis of consecutive esophagectomies performed at 2 institutions from January 2002 to January 2009. Primary outcome measures included postoperative ventilatory requirements, pneumonia, effusion requiring intervention, length of stay, and mortality.

RESULTS

A total of 220 esophagectomies were performed through 6 different approaches: 79 minimally invasive (MIE) with neck anastomosis, 20 MIE with chest anastomosis, 37 transhiatal, 33 McKeown, 36 Ivor Lewis, and 15 left thoracoabdominal. Patients who underwent MIE were more likely to be extubated in the operating room (p<0.01) and had fewer pleural effusions (p<0.01). A thoracotomy was associated with a higher incidence of tracheostomy (p=0.02) and pleural effusions (p=0.02). Neck anastomoses were negatively associated with early extubation (p=0.04) and predicted recurrent laryngeal nerve injury (p=0.04), but were not associated with pneumonia or other pulmonary complications. Multivariate analysis showed that pneumonia was independently associated with advancing age (p=0.02), lack of a pyloric drainage procedure (p=0.03), and less significantly with MIE (p=0.06, fewer events). Surgical approach was not a significant predictor of length of stay or mortality.

CONCLUSIONS

Patients undergoing MIE are less likely to remain intubated. Omission of a pyloric drainage procedure or performance of thoracic or neck incisions appear to be important determinants of respiratory complications. Technical aspects of the procedure in addition to the surgical approach influence important respiratory outcomes.

Prognostic indicators of surgery for esophageal cancer: a 5 year experience

BACKGROUND/AIM

To assess the prognostic indicators preoperatively presenting and influencing the mortality rate following esophagectomy for esophageal cancer.

MATERIALS AND METHODS

This study was a retrospective cohort study, conducted at the Department of Surgery, Lady Reading Hospital, Peshawar, from 1 January 2003 till 31 December 2008. Group 1 included patients who had undergone sub-total esophagectomy and were alive at completion of 12 months; whereas Group 2 included those patients who died by the completion of 12 months. Data were recollected from the Data Bank. A list of variables common to all patients from both groups was categorized and subsequently all data related to each individual patient were placed and analyzed on the version 13.0 of SPSS R for Windows.

RESULTS

Significant findings of a lower mean level of serum albumin from Group 2 were observed, whereas serum transferrin levels, also found lower in Group 2, were not statistically significant. Findings of serum pre-albumin, with a mean value of 16.12 mg/dl (P < 0.05) and Geansler's index for the evaluation of the presence of obstructive pulmonary disease prior to surgery showed a lower reading of mean ratio in Group 2. Anastamotic leak was not a common finding in the entire study. In most cases, the choice of conduit was the remodeled stomach. Nine patients from Group 2 were observed with evident leak on the fifth to seventh post-operative day following contrast swallow studies. This was statistically insignificant (P = 0.051) on multivariate analysis.

CONCLUSION

Pre-operative variables including weight loss, low serum albumin and pre-albumin, Geansler's index, postoperative chylothorax, pleural effusion, and hospital stay, are predictive of mortality in patients who undergo esophagectomy for esophageal cancer.

Significance of preoperative C-reactive protein as a parameter of the perioperative course and long-term prognosis in squamous cell carcinoma and adenocarcinoma of the oesophagus

AIM: C-reactive protein (CRP) is an acute-phase reactant and a known indicator of the malignant potential of the tumour. The aim of this study was to investigate the significance of preoperative CRP as a parameter of the perioperative course and long-term prognosis in patients with squamous cell carcinoma and adenocarcinoma of the oesophagus.

METHODS: Serum CRP was determined preoperatively in 291 of 371 patients undergoing oesophagectomy for cancer from December 1989 to March 2004. Median patient age was 59 (28-79) year, 82.5% of patients were males. Squamous cell carcinoma was diagnosed in 151 (51.9%) and adenocarcinoma in 122 patients. Transhiatal oesophagectomy was done in 151 (51.9%) patients and 134 (46.0%) patients underwent the abdominothoracic procedure.

RESULTS: In 127 (43.6%) patients the preoperative serum CRP concentration was within the normal range (< 5 mg/dL), elevated CRP levels were measured in 164 (56.4%) patients. Tumour extension (P < 0.0005) and the number of lymph nodes affected by metastatic spread (P = 0.015) were significantly increased in the group with elevated CRP levels. Among the perioperative parameters both the number of blood transfusions (P = 0.006) and the general complication rate (P = 0.002) were higher in patients with elevated preoperative CRP levels. The long-term survival rate of 13.6 (0-109.8) mo was poorer in the group with elevated CRP levels compared to 18.9 (0-155.4) mo in the group with normal CRP levels (log-rank test: P = 0.107). Multivariate analysis with backward variables selection identified preoperative CRP as an independent prognostic factor of the long-term prognosis in patients with oesophageal carcinoma, with a hazard ratio of 1.182 (95% confidence interval: 1.030-1.356).

CONCLUSION: The preoperative serum CRP-level is an easily determined independent prognostic marker in patients with squamous cell carcinoma and adenocarcinoma of the oesophagus.

Impact of induction concurrent chemoradiotherapy on pulmonary function and postoperative acute respiratory complications in esophageal cancer

STUDY OBJECTIVE

To evaluate the effects of induction concurrent chemoradiotherapy (cCRT) on pulmonary function and postoperative acute respiratory complications (PARCs).

DESIGN

A retrospective review of our patients treated with induction cCRT to determine the impact on pulmonary function and identify predictors of PARCs. Correlations were sought between patient demographics, clinical characteristics, pre-cCRT and post-cCRT pulmonary function, radiotherapy dose, chemotherapy agents, and the development of PARCs.

PARTICIPANTS

One hundred fifty-five patients treated in three separate clinical trials were identified; 47 patients received 30 Gy (150 cGy bid) of radiation concurrently with a single course of cisplatin/5-fluorouracil (5FU), and 108 patients received 45 Gy (150 cGy bid in a split course) concurrent with two courses of either cisplatin/5FU (n = 69) or cisplatin/paclitaxel (n = 39). Esophagectomy was performed in 141 of these 155 patients following cCRT.

RESULTS

cCRT was only associated with significant worsening of the diffusion capacity of the lung for carbon monoxide (Dlco), which decreased a median of 21.7% in the 45-Gy group (p = 0.007), and 8.6% in the 30-Gy group (p = 0.07). This Dlco decrease was statistically greater in the 45-Gy group than in the 30-Gy group (p = 0.02). PARCs developed in 18 patients. Percentage of predicted FEV(1) and FVC, both before and after cCRT, were both significantly higher in patients without PARCs than in patients with PARCs (p = 0.031 and p = 0.010, respectively). Post-cCRT Dlco was also significantly worse in patients with PARCs (p = 0.002). PARCs occurred significantly more often among those treated with 45 Gy (17 of 102 patients) compared to those treated with 30 Gy (1 of 39 patients) [p = 0.025]. In the 18 patients with PARCs, the median survival was only 2.1 months. This was significantly less than the 16.4-month median survival in the 123 patients who did not have PARCs (p = 0.001).

CONCLUSIONS

In patients treated with induction cCRT, higher radiation doses result in increasing impairment of gas exchange. PARCs were more likely in those patients with lower lung volumes, lower post-cCRT Dlco, and in those receiving higher radiation doses. These acute respiratory complications were also associated with a significant reduction in patient survival.

Morbidity and mortality after esophagectomy for esophageal carcinoma: a risk analysis

BACKGROUND

The study was aimed to identify pre- and intraoperative risk factors that potentially influence morbidity and mortality after esophagectomy for esophageal carcinoma with particular emphasis on the predominant tumor types.

PATIENTS AND METHODS

Between September 1985 and March 2004, 424 patients underwent esophagectomy for esophageal carcinoma. Of these, 186 (43.9%) patients had a transhiatal, and 231 (54.5%) patients underwent a transthoracic procedure with two-field lymphadenectomy. Pre-, intraoperative risk factors and tumor characteristics were included in the risk analysis to assess their influence on postoperative morbidity and mortality.

RESULTS

Multivariate analysis (logistic regression model) identified the surgical procedure as the most important risk factor for postoperative morbidity and mortality with the transthoracic technique associated with a significant higher risk. The comparison of the risk profile between the different histological tumor types, a significantly higher nutritional risk, poorer preoperative lung function and a higher prevalence of hepatopathy was observed in patients with squamous cell carcinoma (n = 229) compared to adenocarcinoma (n = 150) (p < 0.05). Although there was no significant difference in surgical complications between the two groups, the rate of general complications, length of postoperative intensive care unit-stay and mortality rate was significantly higher in patients with squamous cell carcinoma (p < 0.05).

CONCLUSION

The present risk analysis shows that the selection and the type of the surgical procedure are crucial factors for both the incidence of postoperative complications and the mortality rate. The higher risk of the transthoracic procedure is justified with a view to a better long term prognosis.

Association of angiotensin-converting enzyme insertion/deletion polymorphism with serum level and development of pulmonary complications following esophagectomy

BACKGROUND

Pulmonary complications remain the major cause of postoperative mortality in patients with esophageal cancer undergoing esophagectomy. It was unclear whether this dismal complication has a genetic predisposition. We therefore investigated the role of an angiotensin-converting enzyme (ACE) insertion/deletion polymorphism in developing these complications.

METHODS

We conducted a prospective study including 152 patients with esophageal cancer who underwent esophagectomy in National Taiwan University Hospital between 1996 and 2002. The ACE genotype was determined by polymerase chain reaction amplification of leukocyte DNA obtained before surgery. The serum ACE concentration was determined by enzyme-linked immunosorbent assay.

RESULTS

Thirty-five patients (23%) developed pulmonary complications following esophagectomy. As compared with patients with the I/I and I/D genotypes, those with the D/D genotype had a higher risk for pulmonary complications (adjusted odds ratio [OR], 3.12; 95% confidence interval [CI], 1.01-9.65). The risk was additively enhanced by combination of the ACE D/D genotype with other clinical risk factors (old age, hypoalbuminemia, and poor pulmonary function). The circulating ACE level was also dose-dependently with the presence of ACE D allele. As compared with the patients with circulating ACE less than 200 ng/mL, the patients with circulating ACE of 200 to 400 ng/mL and over 400 ng/mL had ORs (95% CI) of 2.75 (1.12-6.67) and 15.00 (4.3-52.34) to present with ACE D allele, respectively.

CONCLUSIONS

An ACE insertion/deletion polymorphism might modulate the function of ACE gene and play a role in affecting individual susceptibility to pulmonary injury following esophagectomy in patients of esophageal cancer.

Postoperative pulmonary complications are associated with worse short- and long-term outcomes after extended esophagectomy

BACKGROUND

Risk analysis of pulmonary complications after extended esophagectomy with three-field lymph node dissection (3FLND) has been little reported in the literature.

METHODS

Risk factors of developing postoperative pneumonia after extended esophagectomy and its effects on in-hospital death and overall long-term survival were compared between 38 patients who developed pneumonia and 80 patients who did not.

RESULTS

Eight patients died of postoperative complications during the hospital stay after esophagectomy. Seven of those 8 patients developed pneumonia, whereas 31 patients of 110 patients who were discharged from the hospital developed pneumonia (P < 0.01). Pneumonia occurred more frequently in elderly patients (P < 0.01), in heavy smokers (P < 0.05), in patients with preoperative pulmonary obstructive dysfunction (P < 0.05), and in patients who received 3 U or more perioperative blood transfusion (P < 0.05). Five-year overall survival rate (26.7%) of 38 patients who developed pneumonia was significantly worse than 53.4% who did not develop pneumonia (P < 0.01). Multivariate analysis of prognostic factors for overall survival showed that pathological tumor stage (hazard ratio 5.380, P < 0.01) and pneumonia (hazard ratio 2.369, P < 0.01) were independent risk factors. Postoperative pneumonia is correlated with in-hospital death and poorer long-term survival after extended esophagectomy with 3FLND.

CONCLUSIONS

Elderly patients with a history of heavy smoking and poor pulmonary function should be regarded as a high-risk group of patients for developing pneumonia and very careful selection is required before subjecting such patients to extended esophagectomy.

Perioperative granulocyte colony-stimulating factor does not prevent severe infections in patients undergoing esophagectomy for esophageal cancer: a randomized placebo-controlled clinical trial

OBJECTIVE

Esophagectomy for esophageal cancer is associated with substantial postoperative morbidity as a result of infectious complications. In a prior phase II study, granulocyte colony-stimulating factor (G-CSF) was shown to improve leukocyte function and to reduce infection rates after esophagectomy. The aim of the current randomized, placebo-controlled, multicenter phase III trial was to investigate the clinical efficacy of perioperative G-CSF administration in reducing infection and mortality after esophagectomy for esophageal cancer.

PATIENTS AND METHODS

One hundred fifty five patients with resectable esophageal cancer were randomly assigned to perioperative G-CSF at standard doses (77 patients) or placebo (76 patients), administered from 2 days before until day 7 after esophagectomy. The G-CSF and placebo groups were comparable as regards age, gender, risk, cancer stage, frequency of neoadjuvant radiochemotherapy, and type of esophagectomy (transthoracic or transhiatal esophageal resection).

RESULTS

Of 155 randomized patients, 153 were eligible for the intention-to-treat analysis. The rate of infection occurring within the first 10 days after esophagectomy was 43.4% (confidence interval 32.8-55.9%) in the placebo and 44.2% (confidence interval 32.1-55.3%) in the G-CSF group (P = 0.927). 30-day mortality amounted to 5.2% in the G-CSF group versus 5.3% in the placebo group (P = 0.985). Similar results were found in the per-protocol analysis.

CONCLUSION

Perioperative administration of G-CSF failed to reduce postoperative morbidity, infection rate, or mortality in patients with esophageal cancer who underwent esophagectomy.

Pleural drainage after transthoracic esophagectomy: experience with a vacuum system

Conventional pleural cavity drainage after esophagectomy involves one to two large-bore drainage tubes connected to underwater bottles. The purpose of this study is to evaluate the use of a small mobile vacuum drainage system. Out of 173 patients who underwent transthoracic esophagectomy, 167 (97%) had the vacuum drain successfully placed at the end of the operation. Of those, use of the vacuum drain was uneventful for 131 until its removal (78%). Air leaks necessitating connection to underwater drainage occurred in 34 patients (20%), but in 26 of them this was only temporary. Overall success was therefore achieved in 157 patients (94%). Median in-situ placement of the vacuum drain was 4 days, and 85% of patients had their drains removed by the seventh postoperative day. The presence of lung adhesions significantly increased the need for underwater drainage. Postoperative outcomes were no different from a historical cohort with conventional underwater drainage. No drain-related complications were reported. The vacuum drain is an alternative to the conventional, large-bore, chest tube system after transthoracic esophagectomy.

Should patients over 85 years old be operated on for colorectal cancer?

BACKGROUND

The aim of this study is to evaluate risk factors for mortality, morbidity, and long-term survival in very old patients with colorectal cancer compared with old patients.

METHODS

Patients operated on with colorectal cancer aged 75 years old or older were divided into 2 groups: Group A (75-84 years, n = 93) and Group B (>or=85, n = 21).

RESULTS

The serum albumin level, oxygen pressure in arterial blood gases, and forced expiratory volume in 1 second in Group B were significantly lower than in Group A, respectively (P = 0.0094, 0.0264, 0.0363). Pulmonary complications were developed significantly more frequently in Group B than in Group A (P = 0.0019). Group B had a significantly higher mortality rate than Group A (P = 0.0477). There was no significant difference between the 2 groups in the 2- and 5-year survival rates.

CONCLUSIONS

Very old patients with colorectal cancer should not be denied surgery on account of chronological age alone, although the perioperative risks for the very old are very high.

Derivação retroesternal com tubo gástrico isoperistáltico no carcinoma irressecável de esôfago

OBJETIVO: Avaliar o benefício do tratamento paliativo pela derivação esofágica com o tubo gástrico isoperistáltico em pacientes com carcinoma de esôfago irressecável. MÉTODO: Foram estudados 53 pacientes com carcinoma espino celular do esôfago sem condições de ressecabilidade avaliados por critérios endoscópicos e radiológicos. A maioria dos pacientes era do sexo masculino com idade média de 56,8 anos. A operação realizada foi a derivação esofágica com o tubo gástrico isoperistáltico, de grande curvatura e transposto através do espaço retro esternal. RESULTADOS: Vinte e oito pacientes (52,0%) desenvolveram uma ou mais complicações, sendo a mais freqüente a deiscência e/ou estenose da anastomose cervical (15 pacientes - 28,3%). Em 48 pacientes que sobreviveram, 37 (77,0%) referiram alívio da disfagia no seguimento pós-operatório. A média de sobrevida em 23 pacientes foi de sete meses e meio (seis a 13 meses) e 14 pacientes estão em seguimento com o tempo variável entre dois e 16 meses, com boa evolução, com perda de seguimento nos 11 pacientes restantes. CONCLUSÕES: Tubo gástrico isoperistáltico tem aceitável morbidade e mortalidade para a população em estudo, permitindo paliação da disfagia na maioria dos casos.

Otolaryngologic critical care

In this chapter we have reviewed the complicated medical conditions that exist in many head and neck surgical patients. Common surgical procedures that frequently require postoperative monitoring and several infectious disorders requiring intensive care unit admission were also reviewed. Intensivists need to be familiar with these procedures and diseases. Collaboration with the surgical specialist is required to optimize patient care.

Early complications after Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management

BACKGROUND

Esophageal resection represents a major surgical and physiologic insult carrying major morbidity and mortality. We present the results of esophagectomy in a specialist unit with emphasis on early complications and their management.

STUDY DESIGN

From January 4, 1990 through January 6, 2000, 228 patients have undergone Ivor Lewis subtotal esophagectomy with two-field lymphadenectomy for malignancy under the care of one surgeon. The median age was 64 years (range 39 to 77 years), with a male to female ratio of 2.3:1 and a predominance of adenocarcinoma (n = 146) compared with squamous cell carcinoma (n = 75) and other tumors (n = 7). Detailed prospective data were collected on preoperative status, operative parameters, and postoperative complications.

RESULTS

Median ICU stay was 1 day (range 1 to 47 days) and the median postoperative hospital stay in patients surviving surgery (n= 219) was 13 days (range 9 to 159 days). There were 119 separate postoperative complications occurring in 45% of patients (102 of 228), comprising predominantly pulmonary morbidity. Major respiratory complications (17%) were significantly associated with poor preoperative spirometry (p = 0.002) and a history of smoking (p = 0.03). Seven percent of patients (16 of 228) suffered cardiovascular or thromboembolic complications. Major surgical complications occurred in 10% of patients (22 of 228) including mediastinal leaks in 4%. Isolated anastomotic leaks (2%) were successfully treated conservatively in all cases; extensive leaks from ischemic gastric conduits (1%) or gastrotomy dehiscence (1%) underwent further exploration and either local repair or resection and exclusion. Reoperation for hemostasis was required in 3% (6 of 228) and only 1% of patients (2 of 228) developed chyle leaks. Thirty-day mortality was 2%, rising to 4% for in-hospital mortality. The nine fatalities were significantly older (p = 0.02) than those who survived and 67% (6 of 9) had suffered primary surgical complications.

CONCLUSIONS

Overall morbidity after radical esophagectomy is high, but early recognition and aggressive management of complications can minimize subsequent mortality. Concentration of facilities and surgical expertise in specialist units together with more careful patient selection can decrease mortality further.

Pulmonary complications after esophagectomy

BACKGROUND

Pulmonary complications are common in patients who have undergone esophagectomy. There are no good predictive variables for these complications. In addition, the role that preoperative treatment with chemotherapy and radiation may play in postoperative complications remains unclear.

METHODS

We performed a retrospective review of all patients who underwent esophagectomy by a single surgeon at our institution over a 6-year period. Data were analyzed for a correlation between patient risk factors and pulmonary complications, including mortality, prolonged mechanical ventilation, and hospital length of stay.

RESULTS

Complete data were available on 61 patients. Nearly all patients had some pulmonary abnormality (eg, pleural effusion), although most of these were clinically insignificant. Pneumonia was the most common clinically important complication, and 19.7% of patients required prolonged ventilatory support. Significant risk factors identified included impaired pulmonary function, especially for patients with forced expiratory volume in 1 second (FEV1) less than 65% of predicted, preoperative chemoradiotherapy, and age.

CONCLUSIONS

Impaired lung function is a significant risk factor for pulmonary complications after esophagectomy. Patients with FEV1 less than 65% of predicted appear to be at greatest risk. There also seems to be an associated risk of preoperative chemoradiotherapy for pulmonary complications after esophagectomy.

Esophageal resection for carcinoma in patients older than 70 years

BACKGROUND

A larger number of older patients are presenting as candidates for esophageal resection. An aggressive surgical approach in this population is controversial.

METHODS

Four hundred thirteen patients with esophageal cancer who presented to Roswell Park Cancer Institute from 1991 to 1998 were retrospectively reviewed. Clinical data, perioperative details, and postoperative courses were compared for patients older and younger than 70 years.

RESULTS

One hundred forty-seven patients (36%) were older than 70 years. Risk factors, clinical symptoms, histology, and stage at presentation were equivalent for both age groups. A higher percentage of patients <70 years were candidates for curative resection. There were no significant differences between groups for estimated blood loss, intraoperative transfusions, length of stay, overall morbidity, or mortality. Only postoperative myocardial infarction and atrial fibrillation were increased in the older group. Excluding stage IV disease, there was a significant and similar improvement in median survival after resection for patients both <70 years and >70 years.

CONCLUSIONS

In conclusion, esophageal cancer in older patients warrants surgical resection because the benefit to the patient is the same as it is for younger patients, without a significant increase in operative morbidity or mortality.

Early complications following total gastrectomy for gastric cancer

BACKGROUND

The study shows operative results with complications occurring in first 30 days after total gastrectomy for stomach cancer.

METHODS

A retrospective analysis was performed using medical documentation and histological findings for 76 patients after total gastrectomy was done between 1990 and 1997. Mortality and postoperative complications were analyzed. Complications were sorted as specific and nonspecific. All operations were performed either for intestinal gastric cancer located in proximal stomach or for diffuse stomach cancer. All anastomoses were hand sewn.

RESULTS

There were 43 male and 33 female patients. Postoperative mortality was 14.4%. The most frequent complications were dehiscence of the oesophago-jejunal anastomosis in 15.8% of operated patients, postoperative temperature without apparent infection in 5.2%, thrombophlebitis in 5.2%, pneumothorax in 3.9%, hepatic necrosis in one patient (1.3%), and perforation of jejunal loop with nasogastric tube in another (1.3%) ended fatally. The average postoperative intra-hospital treatment lasted 12.3 days. Dehiscence of the oesophago-enteric anastomosis, resulted in generalized peritonitis in 66.6%. Six patients succumbed as a consequence, while two survived with subphrenic and interenteric abscesses. Pneumothorax in combination with total gastrectomy was always fatal.

CONCLUSIONS

Routine use of stapling surgery, subspecialization in surgery, and better early intensive care monitoring and treatment could reduce the mortality rate.

Clinical benefits of steroid therapy on surgical stress in patients with esophageal cancer

BACKGROUND

Despite improvements in surgical techniques and perioperative care, severe complications lead to long hospital stays for some esophageal cancer patients. The purpose of this study was to evaluate the safety and effectiveness of perioperative steroid therapy on the postoperative clinical course.

METHODS

Fifty-seven patients operated for esophageal cancer in 1997 and 1998 were treated with perioperative steroid therapy. Fifty consecutive patients operated in 1995 and 1996 served as a control group. In the steroid group, each patient was given 250 mg of methylprednisolone intravenously before operation followed by 125 mg on postoperative days 1 and 2. Serum interleukin-6, polymorphonuclear cell elastase, and C-reactive protein levels, and the postoperative clinical course were compared between the groups.

RESULTS

Morbidity rates including hyperbilirubinemia, anastomotic leakage, and liver dysfunction were significantly lower in the steroid group than in the control group. Days until extubation and hospital stay were significantly shorter for the steroid group. Inflammatory mediators, body temperature, heart rate, and respiratory index after the surgical procedure were significantly lower in the steroid group. Adverse effects possibly caused by steroid therapy were not observed.

CONCLUSIONS

Perioperative steroid therapy was safe and effective for the inhibition of inflammatory mediators and the improvement of the postoperative clinical course of patients with esophageal cancer.

Risk analysis in esophageal surgery

The postoperative mortality after esophagectomy still remains a major factor influencing the prognosis of esophageal cancer and largely depends on the patient's preoperative physiological status. A composite scoring system was developed to predict the risk of esophagectomy, based on quantitative assessment of preoperatively available physiological parameters. The scoring system was reviewed retrospectively on operated patients and evaluated prospectively in two subsequent patient groups. An initial retrospective multivariate analysis of 432 esophagectomy patients identified a compromised general status (p = 0.001) and poor cardiac (p < 0.001), hepatic (p < 0.05), and respiratory (p < 0.05) functions as independent predictors of a fatal postoperative course. Based on the relative risks associated with individual impaired organ functions--general status 3.6, cardiac function 2.8, hepatic function 2.1, pulmonary function 1.7--a composite risk score was established. A prospective study in 121 patients confirmed that this composite scoring system provides better identification of high-risk patients than does any of the individual parameters alone. Including this composite score into the process of patient selection and choice of procedure resulted in a decrease of postoperative mortality from 9.4% (52/553) to 1.2% (4/323) (p = 0.001). The risk of death after esophagectomy for esophageal cancer can be objectively assessed prior to surgery and quantified by a composite risk score. This score provides a useful tool in refining the criteria of patient selection for resection and choice of procedure, and markedly reduces postoperative mortality when applied prospectively.

Cancer of the esophagus and cardia: does age influence treatment selection and surgical outcomes?

BACKGROUND

Some physicians believe that an aggressive surgical approach for the management of cancer of the esophagus and cardia is unwise in elderly patients because of allegedly higher rates of mortality and morbidity and lower rates of survival than those associated with younger patients. We have long advocated an aggressive surgical approach regardless of the patient's age and have reviewed our experience to determine whether age was a factor influencing treatment and outcomes.

STUDY DESIGN

From January 1, 1970 to January 1, 1997, 505 patients with cancer of the esophagus or cardia underwent operations by one surgical team using standard surgical techniques. One hundred forty-seven patients (29.1%) were 70 years of age or older and 358 patients (70.9%) were under 70 years of age. Their records and clinicopathologic features were reviewed and compared.

RESULTS

The two groups were similar regarding the location of tumors. Tumor cell types were similar except for adenocarcinomas in Barrett's esophagus, which were less common in the older group (15.6% versus 24%; p=0.046). Surgical procedures were similar, as were the rates of resectability and the percentages of R0 resections. The hospital mortality rate was higher in the elderly patients but not significantly so, and the rates of major and minor complications combined were comparable. The differences in postresection pathologic staging were not significant. Satisfactory palliation of dysphagia was comparable between the groups, as were actuarial 5-year survival rates (24.1% of the elderly patients versus 22.4% of the younger patients).

CONCLUSIONS

Age should not be a limiting factor in using an aggressive surgical approach for the management of cancer of the esophagus or cardia in patients aged 70 years or older. Such an approach can be performed as safely as in younger patients, with comparable rates of palliation and survival.

Preoperative risk analysis and postoperative mortality of oesophagectomy for resectable oesophageal cancer

BACKGROUND

Postoperative mortality after oesophagectomy for oesophageal cancer depends largely on the preoperative physiological status of the patient.

METHODS

A composite scoring system to predict the risk of oesophagectomy based on objective preoperative parameters was developed based on a retrospective review of patients operated on and evaluated prospectively in two subsequent patient groups.

RESULTS

An initial retrospective multivariate analysis of 432 patients who had oesophagectomy identified a compromised general status (P < 0.001) and poor cardiac (P < 0.001), hepatic (P < 0.05) and respiratory (P < 0.05) function as independent predictors of a fatal postoperative course. Based on the relative risk associated with the individual impaired organ functions, a composite risk score was established. A prospective study in 121 patients confirmed that this composite scoring system provides a better identification of high-risk patients than any of the individual parameters. Inclusion of the composite score into the process of patient selection and choice of the procedure resulted in a decrease of postoperative mortality rate from 9.4 per cent (52 of 553) to 1.6 per cent (four of 252) (P < 0.001).

CONCLUSION

The risk of death after oesophagectomy for oesophageal cancer can be assessed objectively before surgery and quantified by a composite risk score. This score provides a useful tool for refining the criteria of patient selection for resection or the choice of procedure.

Relation between tumour necrosis factor alpha and interleukin 1beta producing capacity of peripheral monocytes and pulmonary complications following oesophagectomy

BACKGROUND

Adult respiratory distress syndrome and pneumonia remain a significant cause of morbidity and death following oesophagectomy. The aim of this study was to clarify the association between tumour necrosis factor (TNF) alpha and interleukin (IL) 1beta with these pulmonary complications.

METHODS

The in vitro TNF-alpha and IL-1beta producing capacity of peripheral monocytes with or without lipopolysaccaride (LPS) and serum level of IL-6 was measured in 19 patients with oesophageal cancer before and after surgery and in ten age-matched controls.

RESULTS

Six patients had raised TNF-alpha and IL-1beta producing capacity of monocytes without LPS both before operation and on the day after surgery. In these patients plasma elastase and serum IL-6 levels subsequently increased while the ratio of arterial partial pressure of oxygen to fraction inspired oxygen decreased, and they developed bilateral lung infiltration on chest radiography on days 3-7. Five of the six developed pneumonia compared with none of the remaining 13 patients (P < 0.05).

CONCLUSION

Pulmonary impairment and pneumonia following oesophageal surgery was associated with raised monocyte producing capacity of TNF-alpha and IL-1beta. These markers may be valuable in the preoperative assessment of patients awaiting oesophagectomy.

Risk factors for pulmonary complications in the postoperative head and neck surgery patient

BACKGROUND

Pulmonary complications are a primary source of increased cost and morbidity in surgically treated head and neck cancer patients. This study investigates potential risk factors related to postoperative pulmonary complications (pneumonia, adult respiratory distress syndrome (ARDS), and prolonged mechanical ventilation) in head and neck cancer patients.

METHODS

Data from 144 major head and neck procedures performed at the University of Washington between 1985 and 1991 were retrospectively reviewed. Univariate and multivariate analysis were used to evaluate preoperative and perioperative variables identified as potential risk factors for postoperative pulmonary complications.

RESULTS

Fifteen percent of patients had a postoperative pulmonary complication, (n = 21: 18 postoperative pneumonia; 2 ARDS; and 4 prolonged ventilation). The most common pneumonia pathogen was Staphylococcus aureus (62%). Univariate analysis identified smoking and weight loss as significant factors associated with pulmonary complications. The variables preoperative blood urea nitrogen, white blood cell count, and operative chest flap closure all approached but did not reach significance. Multivariate analysis of a subgroup of patients identified smoking history and perioperative antibiotic choice as the only independently significant variables.

CONCLUSIONS

Patient smoking history was the primary variable related to postoperative pulmonary problems, with evidence of increasing risk with increased exposure. Other variables added only limited additional risk association information after multivariate analysis.

Transhiatal esophagectomy for esophageal cancer

The two main approaches currently used for surgical treatment of esophageal cancer are transhiatal esophagectomy (THE) and esophagectomy through a right thoracotomy. Among technical variations of THE, wide opening of the diaphragm with ample mediastinal exposure allows resection under direct view with acceptable postoperative morbidity and mortality rates. Transthoracic esophagectomy, associated with extensive mediastinal lymphadenectomy, still offers the best chance of definitive cure in intermediate stages (stages II and III), but does not influence survival in advanced cases (stage IV). In early stages, the lymph node invasion rate is negligible and may be treated by other techniques (THE or endoscopic mucosectomy). THE restores oral ingestion and avoids respiratory complications of thoracotomy, and consequently can be reserved for early cases (mucosal or submucosal lesions) or for patients with poor clinical status. To improve results of surgical treatment, protocols of associated radiochemotherapy are currently under research.

No obvious advantages for thoracoscopic two-stage oesophagectomy

Thoracoscopically assisted Ivor-Lewis oesophagectomy potentially combines the pulmonary advantages of transhiatal oesophageal dissection, with the visibility and control permitted by thoracotomy. This study reviewed 17 patients who underwent this procedure with an intrathoracic anastomosis. Five patients required conversion to thoracotomy, four because of technical difficulties with the anastomosis. After operation 13 patients had radiological evidence of atelectasis, six developed a left pleural effusion and five had clinically significant pneumonia. Three patients developed an anastomotic leak, two of whom died giving an in-hospital mortality rate of 12 per cent. Median postoperative hospital stay was 12 days. Four patients developed benign anastomotic strictures requiring dilatation. The 1- and 2-year survival rates were 73 per cent (11 of 15 patients) and 63 per cent (five of eight) respectively. The use of minimal access techniques in this context does not appear to reduce the postoperative incidence of either pulmonary or anastomotic complications.

Value of preoperative spirometry to predict postoperative pulmonary complications

In order to determine the incidence of postoperative pulmonary complications (POPC) and the value of preoperative spirometry to predict pulmonary complications after upper abdominal surgery, 24 women and 36 men (total 60 patients) were studied prospectively (mean age 48 center dot 3 years). On the day before the operation and for 15 days after the operation, each patient's respiratory status was assessed by clinical examination, chest radiography, spirometry and blood gas analysis, and patients were monitored for pulmonary complications by a chest physician and a surgeon independently. In this study, postoperative pulmonary complications developed in 21 (35%) patients (pneumonia in 10 patients, bronchitis in nine patients, atelectasis in one patient, pulmonary embolism in one patient). Of 31 patients with abnormal preoperative spirometry, 14 (45 center dot 2%) patients showed complications, whereas among 29 patients with normal preoperative spirometry, 7 (24 center dot 1%) patients showed complications (P <0 center dot 05). The incidence of POPC was higher in patients with advanced age, smoking, preoperative abnormal findings obtained from physical examination of the chest, higher ASA class and longer duration of operation. The sensitivity (0 center dot 76) and specificity (0 center dot 79) of abnormal preoperative findings obtained from physical examination to predict POPC were higher than abnormal preoperative spirometry (0 center dot 67 and 0 center dot 56 retrospectively). There was no significant difference between patients with and without pulmonary complications in regard to weight, serum albumin, type of incision, incidence of abnormal preoperative blood gases and duration of postoperative hospital stay. We conclude that POPC is still a serious cause of postoperative morbidity. Multiple risk factors include preoperative abnormal spirometry responsible for development of POPC. If used alone, spirometry has limited clinical value as a screening test to predict POPC after upper abdominal surgery.

Southwestern Internal Medicine Conference: preoperative pulmonary evaluation

The purpose of preoperative pulmonary assessment is to predict which patients are at greater risk of pulmonary complications, under which circumstances such complications may occur, and whether surgery should be denied based on that risk. In this article, the author addresses the following major issues in preoperative pulmonary assessment: 1) the risk of pulmonary complications in relation to the type of surgical procedure; 2) the value of preoperative pulmonary function testing, including when such testing should be performed and how the results should be used; and 3) guidelines for assessment of those patients about to undergo resectional surgery of the lung.

Two-team synchronous oesophagectomy

Between 1984 and 1992, 131 patients underwent two-team synchronous oesophagectomy for carcinoma. Some 95 per cent of tumours were successfully resected by this technique. In 5 per cent of patients the tumour was found to be irresectable at operation and gastric bypass was performed. The overall operative mortality rate was 8 per cent and the pulmonary complication rate 10 per cent. The actuarial survival rate was 55 per cent at 1 year, 22 per cent at 3 years and 16 per cent at 5 years. When compared with the traditional two-stage Lewis approach, two-team synchronous oesophagectomy was significantly faster (mean 222 versus 282 min), but was not significantly different with respect to blood loss, transfusion requirement, pulmonary complications or operative mortality rate. Patients undergoing two-team oesophagectomy had a significantly shorter hospital stay than those receiving the two-stage procedure (mean 16 versus 24 days).

Associated primary esophageal and lung carcinoma: a study of 39 patients

From 1979 to 1992, of 1,294 patients with esophageal squamous cell carcinoma, 39 patients (3.2%) (38 male patients, 1 female patient; mean age, 58 years) had associated primary lung carcinoma. Criteria for the diagnosis of primary lung carcinoma were: (1) non-squamous cell carcinoma tumors, (2) tumors existing before the esophageal squamous cell carcinoma, and (3) solitary squamous cell carcinoma presenting with endobronchial involvement. The two tumors were observed synchronously in 22 patients (56%) and metachronously in 17, with a mean tumor-free interval of 46 months (range, 18 to 77 months). In patients with synchronous disease, 10 underwent nonoperative treatment or a palliative surgical procedure, and 12 (55%) underwent a curative operation. In patients with metachronous disease, a curative operation was performed in all for the first tumor and in 9 (53%) for the second tumor. The overall postoperative mortality rate was 15%. Two patients (10%) died after the curative operation. None of the patients died who underwent curative esophagectomy combined with lobectomy. For the patients with synchronous disease, the 5-year survival rate was 11% in those who underwent a curative operation, and the longest survival in those who received palliative treatment was 18 months. For the patients with metachronous disease, the 5-year survival rates from the date of the diagnosis of the second tumor were 17% for those who had a curative operation and 11% for those who received palliative treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibody response correlates with septic complications following esophagectomy for cancer

Correlations between preoperative antibody response and postoperative septic complications were examined in patients with esophageal cancer. Thirty-three patients and 9 age-matched controls were immunized with 23-valent pneumococcal polysaccharide (PPS) vaccine, and serum anti-PPS IgG, IgA, and IgM were measured. Of 28 patients undergoing transthoracic esophagectomy, 9 had postoperative septic complications (SCP) and 19 did not (SCN). Median titers of anti-PPS IgG-producing capacity were 158 ELISA units (EU) (interquartile range, 71-1,862 EU) in the SCP group and 1,349 EU (interquartile range, 741-2,951 EU) in the SCN group (P = 0.01). No significant differences in anti-PPS IgA and IgM were found between the two groups. These results indicated that low antibody response to polysaccharides is associated with the occurrence of postoperative septic complications in patients with esophageal cancer. Thus, a preoperative evaluation of antibody-producing capacity may serve to predict these complications.

Prediction of pulmonary complications after transthoracic oesophagectomy

Postoperative pulmonary complications are often fatal in patients with oesophageal cancer. The influence of various preoperative and perioperative risk factors in the prediction of such complications was analysed. Some 170 oesophageal resections performed through a thoracotomy between January 1977 and December 1991 were reviewed. Twenty-two parameters generated from various medical risk categories were studied. Six variables were significant (P < 0.05) on univariate analysis: vital capacity, serum albumin level, partial pressure of carbon dioxide in arterial blood, presence of liver cirrhosis, presence of chronic obstructive airway disease and clinical stage of the tumour. Multivariate discriminant analysis of these six factors identified three as significant, namely vital capacity (P < 0.0001), liver cirrhosis (P = 0.01) and tumour stage (P = 0.01), yielding an equation for assessment of the risk of postoperative pulmonary complications. Calculation of the risk score showed that 42 of 53 patients with pulmonary complications had scores of 0 or more and that 74 of 102 without had scores below 0. The mean risk score was 0.34 for patients with complications and -0.26 for those without. The equation predicted pulmonary complications after transthoracic oesophagectomy with 74.8 per cent accuracy, 79.2 per cent sensitivity and 72.5 per cent specificity. It is concluded that the risk of postoperative pulmonary complications can be accurately assessed in individual patients by calculation of a risk score based on vital capacity, liver cirrhosis and tumour stage.

Risk analysis in resection of squamous cell carcinoma of the esophagus

A study of risk factors that affect morbidity and mortality in 523 patients with squamous cell cancer of the esophagus who had one-stage resection was undertaken. The 30-day and hospital mortality rates were 5.0% and 15.5%, respectively. Pulmonary complications, malignant cachexia, and surgical complications accounted for 42%, 25%, and 21% of hospital deaths, respectively. Major pulmonary complications occurred in 23% of patients. Multivariate analysis identified six factors that predicted major pulmonary complications: age, mid-arm circumference, percent of predicted FEV1, abnormal chest radiograph, amount of blood loss, and palliative resection. Three risk groups of pulmonary complications were identified: low, median, and high risk group with complications in 3%, 17%, and 43% of patients, respectively. Significantly, patients with curative resection had a lower hospital mortality rate (9%) than those with palliative resection (20%), p = 0.001. Patients with stage I, IIa, or IIb disease had a lower hospital mortality rate (9%) than those with stage III or IV disease (18%), p = 0.026. Multivariate analysis identified six factors that predicted hospital death: age, mid-arm circumference, history of smoking, incentive spirometry, number of stairs climbed, and amount of blood loss. Three risk groups of hospital death were identified: low, median, and high risk groups with death in 7%, 30%, and 38%, respectively. Anastomotic leakage rate was 4%. Technical faults were identified in 53% of patients with leakage. Together with other surgical complications, a presumed or apparent technical error was noted in 63% of patients. The identification of high-risk patients and prevention of technical faults can help improve surgical outcome.

What is the value of preoperative pulmonary function testing?

This article reviews the current information regarding the value of different tests of lung function in patients undergoing abdominal or thoracic surgery. Risk factors as well as the pathophysiology of postoperative pulmonary complications are also discussed. Finally, a rational approach synthesizing clinical features with pulmonary function test results to estimate risk and minimize complication is presented.

Tracheal occlusion from an intrathoracic stomach

A patient presented with recurrent respiratory failure following esophagectomy. Systematic evaluation detected a previously unreported process causing this problem. Simple therapeutic measures were effective once the diagnosis was established.

Influence of surgical stress on bactericidal activity of neutrophils and complications of infection in patients with esophageal cancer

The association between surgical stress-related depression in bactericidal activities of neutrophils and the occurrence of postoperative infections was investigated. Bactericidal activities of neutrophils were measured in 19 patients undergoing esophagectomy, 15 gastrectomy, and 16 cholecystectomy. Five patients had complications of infection following esophagectomy. In 45 patients with no postoperative infections, intracellular killing index (KI) and superoxide anion production (SOP) levels decreased on postoperative day 1 while myeloperoxidase (MPO) activity increased on days 1-3. In 5 patients with esophageal cancer and postoperative infections, decreases in KI and SOP were less prominent, as compared to findings in 14 esophageal cancer patients without such problems but the MPO activity decreased on days 1-3. This evidence suggests that postoperative septic complications are not directly associated with surgical stress-related transient depression of bactericidal activities immediately after surgery but rather with neutrophil-mediated tissue injuries based on degranulation.

Multivariate analysis of postoperative complications after esophageal resection

To determine the contributing factors for eight postoperative complications after esophagectomy through a right thoracoabdominal approach, a multivariate analysis was carried out on preoperative and intraoperative variables in 141 patients with thoracic esophageal cancer. Although postoperative complications occurred in 125 patients, only 7 died of such complications. The multivariate analysis indicated that the retrosternal route was a significant factor predisposing to postoperative atelectasis. Age, preoperative arterial oxygen tension, and volume transfused were significant factors predisposing to postoperative hypoxemia, whereas age, routes other than the intrathoracic route, and volume transfused were significant factors predisposing to prolonged respiratory support. In addition, preoperative total serum bilirubin level and volume transfused were significant factors predisposing to postoperative hyperbilirubinemia; preoperative serum creatinine level was a significant contributing factor for postoperative renal insufficiency; and sex, antesternal route, and substituted colon were significant contributing factors for anastomotic leakage. There were no significant factors predisposing to postoperative pneumonia and liver dysfunction. These significant factors should be taken into consideration not only during perioperative management but also when choosing the operative procedures and extending the surgical indication for esophagectomy through a right thoracoabdominal approach.

Acute phase proteins and infectious complications after surgery for esophageal cancer

Severe septic complications are the major cause of operative mortality in patients with esophageal cancer. We examined the levels of acute phase proteins together with infection-related complications after surgery in a large number of patients with esophageal cancer and compared them with a group of patients with gastric cancer and healthy controls. Elevations in alpha 1-antitrypsin, alpha 1-acidglycoprotein, haptoglobin and ceruloplasmin were evident in patients with esophageal cancer, being more predominant when compared to the findings in patients with gastric cancer. Although the mean levels of alpha 2-macroglobulin were not significantly elevated in either patients with esophageal cancer or those with gastric cancer, the average level immediately prior to surgery was higher in esophageal cancer patients with postoperative septic complications than in those without any such problems. Preoperative radiation therapy and total parenteral nutrition did not significantly alter the levels of acute phase proteins. It would thus appear that the elevation in alpha 2-macroglobulin is associated with the occurrence of infectious complications following surgery in patients with esophageal cancer.