Complications after esophagectomy: it is time to speak the same language

It is unusual for the editors of a scientific journal to comment on an article published in another journal, but the study recently published in the Annals of Surgery by the Esophagectomy Complications Consensus Group (ECCG) entitled: ‘International Consensus on standardization of data collection for complications associated with esophagectomy’,1 deserves special attention. The ECCG involved 21 experienced surgeons from 14 countries and was supported by all the major thoracic and gastrointestinal societies, including the International Society for Diseases of the Esophagus (two of the group’s meetings were held during ISDE Congresses, bearing witness to the strong bond between the ECCG and our Society). It was also one of the first international consensus projects on esophageal disease to involve both thoracic and upper Gastro-Intestinal (GI) surgeons. By means of Delphi surveys and group meetings, the ECCG arrived at a consensus on a standard definition of the complications and quality measures to consider after esophagectomy, such as mortality, comorbidities, blood transfusion, grading of complication severity, changes in level of care, and readmission rates. Our journal is dedicated to esophageal diseases and receives 4 to 5 manuscripts a month on the topic of esophageal resections: the reporting and definition of complications is highly subjective and even the definition of such common surgical complications as anastomotic leak is not always consistent. This is not surprising: in a review of over 53 000 esophagectomies, Blencowe et al.2 found that less than 40% of the studies provided a precise definition of complications. Even mortality itself an apparently clear-cut event may be misleading because, if only 30-day mortality is reported, this may underestimate the real mortality by a factor of 4 compared with in-hospital mortality or 90-day mortality.3 The ECCG concluded that 30-day and in-hospital mortality should be reported, and 90-day mortality should preferably be recorded too. An extensive list of possible complications is given in the table 1 below (with permission from the Annals of Surgery). Other informations that should not be overlooked when reporting the outcome of esophagectomy are hospital readmissions, changes in level of care (i.e. returning to the Intensive Care Unit (ICU) or High Dependency Unit (HDU)), and destination on discharge (home or nursing/rehabilitation facilities). A second fundamental issue addressed by the ECCG concerns the standardization of definitions of four common ‘surgical’ complications: anastomotic leak, conduit necrosis, chyle leak, and vocal cord palsy, as shown in the second table below (with permission from the Annals of Surgery). Adopting the definitions of the ECCG in future studies will enable us to draw meaningful comparisons among different surgical techniques and treatment approaches for esophageal cancer. Clearly, no definition is perfect, and some overlap may exist between different conditions, such as anastomotic leak and conduit necrosis. Nevertheless, the ECCG is the first to take a systematic approach to the consistent classification and definition of esophagectomy complications. The editors of Diseases of the Esophagus will do their best to encourage the use of this classification from now on for reporting the outcome of esophagectomy in our journal. Complication basic platform CDC, Center for Disease Control and Prevention; CPR, Cardiopulmonary Resuscitation; CVA, Cerebrovascular Accident; NG, Nasogastric Tube. Complication basic platform CDC, Center for Disease Control and Prevention; CPR, Cardiopulmonary Resuscitation; CVA, Cerebrovascular Accident; NG, Nasogastric Tube. Definitions GI, Gastrointestinal; TPN, Total Parenteral Nutrition. Definitions GI, Gastrointestinal; TPN, Total Parenteral Nutrition.