Maryam Derogar

Influence of Major Postoperative Complications on Health-Related Quality of Life Among Long-Term Survivors of Esophageal Cancer Surgery

PURPOSE To evaluate the effect of major postoperative complications on health-related quality of life (HRQL) in 5-year survivors of esophageal cancer surgery. PATIENTS AND METHODS This study was based on the Swedish Esophageal and Cardia Cancer register with almost complete nationwide coverage and data on esophageal cancer surgery collected prospectively between 2001 and 2005. Patients who were alive 5 years after surgery were eligible. HRQL was assessed longitudinally until 5 years after surgery by using the validated European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and OES18. Linear mixed models were used to assess the mean score difference (MD) with 95% CIs of each aspect of HRQL in patients with or without major postoperative complications. Adjustment was made for several potential confounders. RESULTS Of 153 patients who survived 5 years, 141 patients (92%) answered the 5-year HRQL questionnaires. Of these individuals, 46 patients (33%) sustained a major postoperative complication. Dyspnea (MD, 15; 95% CI, 6 to 23), fatigue (MD, 13; 95% CI, 5 to 20), and eating restrictions (MD, 10; 95% CI, 2 to 17) were clinically and statistically significantly deteriorated throughout the follow-up in patients with major postoperative complications compared with patients without major complications. Although problems with choking declined to levels comparable with patients without major postoperative complications, sleep difficulties and gastroesophageal reflux progressively worsened during follow-up. CONCLUSION The occurrence of postoperative complications exerts a long-lasting negative effect on HRQL in patients who survive 5 years after esophagectomy for cancer.

Hospital and Surgeon Volume in Relation to Survival After Esophageal Cancer Surgery in a Population-Based Study

PURPOSE The influence of hospital and surgeon volume on survival after esophageal cancer surgery deserves clarification, particularly the prognosis after the early postoperative period. The interaction between hospital and surgeon volume, and the influence of known prognostic factors need to be taken into account. METHODS A nationwide Swedish population-based cohort study of 1,335 patients with esophageal cancer who underwent esophageal resection in 1987 to 2005, with follow-up for survival until February 2011, was conducted. The associations between annual hospital volume, annual surgeon volume, and cumulative surgeon volume and risk of mortality were calculated with multivariable parametric survival analysis, providing hazard ratios (HRs) with 95% CIs. HRs were mutually adjusted for the surgery volume variables and further adjusted for the prognostic factors age, sex, comorbidity, calendar period, tumor stage, tumor histology, and neoadjuvant therapy. RESULTS There was no independent association between annual hospital volume and overall survival, and hospital volume was not associated with short-term mortality after adjustment for hospital clustering effects. A combination of higher annual and cumulative surgeon volume reduced the mortality occurring at least 3 months after surgery (P trend < .01); the HR was 0.78 (95% CI, 0.65 to 0.92) comparing surgeons with both annual and cumulative volume above the median with those below the median. These results remained when hospital and surgeon clustering were taken into account. CONCLUSION Because surgeon volume rather than hospital volume independently influences the prognosis after esophageal cancer surgery, centralization of this surgery to fewer surgeons seems warranted.

Reference values for the EORTC QLQ-C30 quality of life questionnaire in a random sample of the Swedish population.

Aim. To obtain reference values for health-related quality of life (HRQL) measured with the European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30) in a random sample of the adult Swedish population. Methods. A population-based survey of a random sample of 7002 Swedish adults aged 40–79 years, frequency-matched to reflect the age and sex distribution of upper gastrointestinal cancer patients. Scales were scored on a 0–100 metric according to standard procedures. Functions and symptoms were dichotomized into “poor” versus “good” function, and “symptomatic” and “no or minor symptoms”, respectively. The results were stratified for age and gender. Results. The questionnaire was completed by 4910 (70.5%) of 6969 eligible participants. Missing values were limited. HRQL was found to vary according to age and sex. Generally, men reported better functioning and fewer symptoms than women. The most common symptoms were fatigue, pain, and insomnia. Conclusion. The reference values provided can be used as a surrogate baseline measure in HRQL research, and when evaluating the effect of interventions on HRQL in cancer patients.

Increased risk of colorectal cancer after obesity surgery.

Objective: The purpose was to determine whether obesity surgery is associated with a long-term increased risk of colorectal cancer. Background: Long-term cancer risk after obesity surgery is not well characterized. Preliminary epidemiological observations and human tissue biomarker studies recently suggested an increased risk of colorectal cancer after obesity surgery. Methods: A nationwide retrospective register-based cohort study in Sweden was conducted in 1980–2009. The long-term risk of colorectal cancer in patients who underwent obesity surgery, and in an obese no surgery cohort, was compared with that of the age-, sex- and calendar year-matched general background population between 1980 and 2009. Obese individuals were stratified into an obesity surgery cohort and an obese no surgery cohort. The standardized incidence ratio (SIR), with 95% confidence interval (CI), was calculated. Results: Of 77,111 obese patients, 15,095 constituted the obesity surgery cohort and 62,016 constituted the obese no surgery cohort. In the obesity surgery cohort, we observed 70 patients with colorectal cancer, rendering an overall SIR of 1.60 (95% CI 1.25–2.02). The SIR for colorectal cancer increased with length of time after surgery, with a SIR of 2.00 (95% CI 1.48–2.64) after 10 years or more. In contrast, the overall SIR in the obese no surgery cohort (containing 373 colorectal cancers) was 1.26 (95% CI 1.14–1.40) and remained stable with increasing follow-up time. Conclusions: Obesity surgery seems to be associated with an increased risk of colorectal cancer over time. These findings would prompt evaluation of colonoscopy surveillance for the increasingly large population who undergo obesity surgery.

Discontinuation of Low-Dose Aspirin Therapy After Peptic Ulcer Bleeding Increases Risk of Death and Acute Cardiovascular Events

BACKGROUND & AIMS Little is known about how discontinuation of low-dose aspirin therapy after peptic ulcer bleeding affects patient mortality or acute cardiovascular events. METHODS We performed a retrospective cohort study by using data from patients who received low-dose aspirin therapy and were treated for bleeding peptic ulcers between 2007 and 2010 at Karolinska University Hospital, Stockholm, Sweden. We used a multivariable Cox regression model to adjust for potential confounders and analyze associations between discontinuation of low-dose aspirin therapy at discharge, death, and acute cardiovascular events. RESULTS Of the 118 patients who received low-dose aspirin therapy, the therapy was discontinued for 47 (40%). During a median follow-up period of 2 years after hospital discharge, 44 of the 118 patients (37%) either died or developed acute cardiovascular events. Adjusting for confounders, patients with cardiovascular comorbidities who discontinued low-dose aspirin therapy had an almost 7-fold increase in risk for death or acute cardiovascular events (hazard ratio, 6.9; 95% confidence interval, 1.4-34.8) compared with patients who continued this therapy during the first 6 months of the follow-up period. A corresponding association was not observed among patients without cardiovascular comorbidities when the study began. CONCLUSIONS In patients with cardiovascular disease, discontinuation of low-dose aspirin therapy after peptic ulcer bleeding increases risk of death and acute cardiovascular events almost 7-fold.

Validation of oesophageal cancer surgery data in the Swedish Patient Registry.

Background. The Swedish Patient Registry provides data about diagnoses and surgical procedures for research purposes. There are, however, almost no validation studies of the data on surgical procedures, and none of oesophageal cancer surgery. Material and methods. This was a validation study of the accuracy of codes representing oesophageal cancer resection, surgical approach and oesophageal substitute in the Swedish Patient Registry during the period 1987–2005. The registered data were compared with a thorough review of the corresponding operation charts collected from medical records. Results. Among 1358 patients with a code representing oesophageal resection in the Patient Registry, the positive predictive value was 99.6%. The dominant surgical procedures in terms of surgical approach (transthoracic) and type of oesophageal substitute (gastric conduit) had positive predictive values of 99.8% and 99.4%, respectively. The more rare procedures with regards to approach (transhiatal) and substitute (bowel) had lower positive predictive values of 68.8% and 68.5%, respectively. Conclusion. The high accuracy of the data regarding oesophageal cancer resection in the Swedish Patient Registry stresses its appropriateness for research purposes.

Influence of co-morbidity on long-term quality of life after oesophagectomy for cancer

The extent to which co‐morbidities affect recovery of health‐related quality of life (HRQoL) in long‐term survivors of oesophageal cancer surgery is poorly understood.

Hospital teaching status and volume related to mortality after pancreatic cancer surgery in a national cohort

The association between hospital teaching status and mortality after pancreatic resection is not well explored. Although hospital volume is related to short‐term mortality, the effect on long‐term survival needs investigation, taking into account hospital teaching status and selective referral patterns.

Reoperation after oesophageal cancer surgery in relation to long-term survival: a population-based cohort study

Objectives The influence of reoperation on long-term prognosis is unknown. In this large population-based cohort study, it was aimed to investigate the influence of a reoperation within 30 days of oesophageal cancer resection on survival even after excluding the initial postoperative period. Design This was a nationwide population-based retrospective cohort study. Setting All hospitals performing oesophageal cancer resections during the study period (1987–2010) in Sweden. Participants Patients operated for oesophageal cancer with curative intent in 1987–2010. Primary and secondary outcomes Adjusted HRs of all cause, early and late mortality up to 5 years after reoperation following oesophageal cancer resection. Results Among 1822 included patients, the 200 (11%) who were reoperated had a 27% increased HR of all-cause mortality (adjusted HR 1.27, 95% CI 1.05 to 1.53) and 28% increased HR of disease-specific mortality (adjusted HR 1.28, 95% CI 1.04 to 1.59), compared to those not reoperated. Reoperation for anastomotic insufficiency in particular was followed by an increased mortality (adjusted HR 1.82, 95% CI 1.19 to 2.76). Conclusions This large and population-based nationwide cohort study shows that reoperation within 30 days after primary oesophageal resection was associated with increased mortality, even after excluding the initial 3 months after surgery. This finding stresses the need to consider any actions that might prevent complications and reoperation after oesophageal cancer resection.

Erectile Function and Oncologic Outcomes Following Open Retropubic and Robot-assisted Radical Prostatectomy: Results from the LAParoscopic Prostatectomy Robot Open Trial

BACKGROUND Whether surgeons perform better utilising a robot-assisted laparoscopic technique compared with an open approach during prostate cancer surgery is debatable. OBJECTIVE To report erectile function and early oncologic outcomes for both surgical modalities, stratified by prostate cancer risk grouping. DESIGN, SETTING, AND PARTICIPANTS In a prospective nonrandomised trial, we recruited 2545 men with prostate cancer from seven open (n=753) and seven robot-assisted (n=1792) Swedish centres (2008-2011). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Clinometrically-validated questionnaire-based patient-reported erectile function was collected before, 3 mo, 12 mo, and 24 mo after surgery. Surgeon-reported degree of neurovascular-bundle preservation, pathologist-reported positive surgical margin (PSM) rates, and 2-yr prostate-specific antigen-relapse rates were measured. RESULTS AND LIMITATIONS Among 1702 preoperatively potent men, we found enhanced erectile function recovery for low/intermediate-risk patients in the robot-assisted group at 3 mo. For patients with high-risk tumours, point estimates for erectile function recovery at 24 mo favoured the open surgery group. The degree of neurovascular bundle preservation and erectile function recovery were greater correlated for robot-assisted surgery. In pT2 tumours, 10% versus 17% PSM rates were observed for open and robot-assisted surgery, respectively; corresponding rates for pT3 tumours were 48% and 33%. These differences were associated with biochemical recurrence in pT3 but not pT2 disease. The study is limited by its nonrandomised design and relatively short follow-up. CONCLUSIONS Earlier recovery of erectile function in the robot-assisted surgery group in lower-risk patients is counterbalanced by lower PSM rates for open surgeons in organ-confined disease; thus, both open and robotic surgeons need to consider this trade-off when determining the plane of surgical dissection. Robot-assisted surgery also facilitates easier identification of nerve preservation planes during radical prostatectomy as well as wider dissection for pT3 cases. PATIENT SUMMARY For prostate cancer surgery, an open operation reduces erection problems in high-risk cancers but has higher relapse rates than robotic surgery. Relapse rates appear similar in low/intermediate-risk cancers and the robot appears better at preserving erections in these cases.