Cancer Recurrence After Esophagectomy: Impact of Postoperative Infection in Propensity-Matched Cohorts

Abstract

Background Postoperative infection increases cancer recurrence and worsens survival for colorectal cancer, but the relationship after esophagectomy for esophagogastric adenocarcinoma is not well-defined. We aimed to determine whether recurrence and survival after minimally invasive esophagectomy for esophagogastric adenocarcinoma were influenced by postoperative infection using propensity-matched analysis. Methods We abstracted data for 810 patients (1997–2010) and defined exposure as at least one in-hospital/30-day infectious complication (n=206; 25%). Using 29 pretreatment/intraoperative variables, patients were propensity score matched (caliper=0.05). Time-to-cancer recurrence and survival (Kaplan-Meier curves, Breslow test), and associated factors (Cox regression with shared frailty) were assessed. Results After propensity-matching (n=167 pairs), median bias across propensity score variables was reduced from 12.9% (p<0.001) to 4.4% (p=1.000). Postoperative infection was not associated with rate (n=60 versus 63; McNemar’s p=0.736) or time to recurrence in those who recurred (median 10.7 versus 11.1 months; Wilcoxon signed-rank p-value=0.455), but was associated with shorter overall survival (n=124 versus 102 deaths; median 26 versus 41 months, Breslow p=0.002). After adjusting for age, body mass index, neoadjuvant therapy, sex, comorbidity score, positive resection margins, pathologic stage, R0 resection and recurrence, postoperative infection was associated with a 44% greater hazard for death (HR 1.44; 95% CI 1.10–1.89). Conclusions In patients with esophagogastric adenocarcinoma, post-esophagectomy infections were not associated with increased rate or earlier time to recurrence when baseline characteristics associated with infection risk were balanced using propensity-matching. Despite this, overall survival was shorter in patients with infectious complications. After adjusting for other important survival predictors, post-esophagectomy continued to be independently associated with worse survival.

Recurrence Following Anastomotic Leakage After Surgery for Carcinoma of the Distal Esophagus and Gastroesophageal Junction: A Systematic Review

“…There was no disagreement regarding eligibility of full-text articles (Cohen kappa=1). Finally, a total of seven articles fulfilled the selection criteria and were therefore included in this systematic review (21)(22)(23)(24)(25)(26)(27); this pool of articles were retrospective reports. Characteristics of the included studies are presented in Table I, which shows patient information, and in Table II, which demonstrates outcomes of interest.…”

“…Table III present a summary of the data of interest. Three out of seven studies dealt only with patients with recurrence (22,23,26); the others included cohorts of patients with or without recurrence or AL (21,24,25,27). AL rates patients with recurrence was 9-13%.…”

“…Indeed, they considered the risk of systemic recurrence as the most relevant, the liver being the most common site, therefore suggesting the possible systemic effects of circulating factors. As well another article cited (26), they also considered delayed administration of adjuvant systemic therapy responsible for increased risk of recurrence.…”

Impact of postoperative infective complications on long-term survival after liver resection for hepatocellular carcinoma

“…In the present study, there were many differences among patients with and without postoperative infective complications. One previous study adopted the statistical approach of propensity score matching to examine the relationship between postoperative infective complications and long‐term oncological outcomes for the purpose of balancing baseline characteristics before comparative analyses between the two groups. This statistical method may not be appropriate as it may lead to an increase in selection bias between the two groups.…”

“…Postoperative complications have been associated with increased hospital stay, as well as higher reoperation rates, hospital costs, and risk of early death after major surgery. Among complications after surgery, infective complications are among the most common and are associated with worse long‐term oncological outcomes after major surgery for oesophageal, gastric, lung, head and neck, colorectal and metastatic colorectal cancers. The effect of postoperative infective complications on long‐term outcomes following liver resection for HCC has not been well defined.…”