Systematic Reviews
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Jul 27, 2023; 15(7): 1485-1500
Published online Jul 27, 2023. doi: 10.4240/wjgs.v15.i7.1485
Combined and intraoperative risk modelling for oesophagectomy: A systematic review
James Paul Grantham, Amanda Hii, Jonathan Shenfine
James Paul Grantham, Amanda Hii, Department of General Surgery, Modbury Hospital, Modbury 5092, South Australia, Australia
Jonathan Shenfine, Department of General Surgical Unit, Jersey General Hospital, Saint Helier JE1 3QS, Jersey, United Kingdom
Author contributions: Grantham JP and Shenfine J designed the research; Grantham JP and Hii A performed the research and analysed the data; Grantham JP, Hii A and Shenfine J all contributed to writing and reviewing the paper.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the 2009 PRISMA Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: James Paul Grantham, MBBS, MSc, Doctor, Department of General Surgery, Modbury Hospital, Smart Road, Modbury 5092, South Australia, Australia. jamespgrantham91@gmail.com
Received: November 26, 2022
Peer-review started: November 26, 2022
First decision: February 20, 2023
Revised: March 13, 2023
Accepted: May 22, 2023
Article in press: May 22, 2023
Published online: July 27, 2023
Processing time: 237 Days and 13 Hours
Abstract
BACKGROUND

Oesophageal cancer is the eighth most common malignancy worldwide and is associated with a poor prognosis. Oesophagectomy remains the best prospect for a cure if diagnosed in the early disease stages. However, the procedure is associated with significant morbidity and mortality and is undertaken only after careful consideration. Appropriate patient selection, counselling and resource allocation is essential. Numerous risk models have been devised to guide surgeons in making these decisions.

AIM

To evaluate which multivariate risk models, using intraoperative information with or without preoperative information, best predict perioperative oesophagectomy outcomes.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane databases was undertaken from 2000-2020. The search terms used were [(Oesophagectomy) AND (Model OR Predict OR Risk OR score) AND (Mortality OR morbidity OR complications OR outcomes OR anastomotic leak OR length of stay)]. Articles were included if they assessed multivariate based tools incorporating preoperative and intraoperative variables to forecast patient outcomes after oesophagectomy. Articles were excluded if they only required preoperative or any post-operative data. Studies appraising univariate risk predictors such as preoperative sarcopenia, cardiopulmonary fitness and American Society of Anesthesiologists score were also excluded. The review was conducted following the preferred reporting items for systematic reviews and meta-analyses model. All captured risk models were appraised for clinical credibility, methodological quality, performance, validation and clinical effectiveness.

RESULTS

Twenty published studies were identified which examined eleven multivariate risk models. Eight of these combined preoperative and intraoperative data and the remaining three used only intraoperative values. Only two risk models were identified as promising in predicting mortality, namely the Portsmouth physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and POSSUM scores. A further two studies, the intraoperative factors and Esophagectomy surgical Apgar score based nomograms, adequately forecasted major morbidity. The latter two models are yet to have external validation and none have been tested for clinical effectiveness.

CONCLUSION

Despite the presence of some promising models in forecasting perioperative oesophagectomy outcomes, there is more research required to externally validate these models and demonstrate clinical benefit with the adoption of these models guiding postoperative care and allocating resources.

Keywords: Oesophagectomy; Risk model; Oesophageal cancer; Preoperative; Intraoperative; Morbidity; Mortality

Core Tip: Performing an oesophagectomy is a technically demanding procedure for the surgeon and a physiologically demanding undertaking for the patient. Aspects relating to the operation, as well as preoperative patient characteristics both have a significant impact on perioperative outcomes. These factors have been harnessed in the construction of numerous multivariate models aimed at identifying individuals at heightened risk. Given the plethora of options available, it is important to determine which of these models is most accurate in doing this and thereby most effective in guiding resource allocation.