Published Articles

List of Esophageal Cancer Publications and Presentations by Virginia Mason Physicians

1.  Outcomes and health-related quality of life after esophagectomy for high-grade dysplasia and intramucosal cancer. Moraca RJ, Low DE. Arch Surg. 2006 Jun;141(6):545-551.

This paper is one of the first to demonstrate that, contrary to previous perceptions, patients requiring esophageal resection for both benign and malignant conditions can demonstrate excellent quality of life when measured at an average of five years after surgery. Quality of life in these patients can typically equal or exceed quality of life parameters of the general population.

2. Esophageal cancer: Update of outcomes of surgical treatment. Low DE. Virginia Mason Bulletin 2005;60:10-16.

In a consecutive series of 302 patients, this publication demonstrated improved levels of morbidity and one of the lowest published levels of mortality in patients undergoing esophageal resection for cancer.

3. A multi-disciplinary approach to minimize blood loss and transfusion requirements and facilitate immediate extubation and early mobilization with decreased morbidity and mortality associated with esophagectomy. Low DE.  International Society of Digestive Surgery, Rome, Italy, November 2006.

The results from Virginia Mason's prospective esophageal resectional database demonstrates that a multi-disciplinary approach can improve outcomes in esophageal resection. The study demonstrated that blood loss and transfusion requirements in patients undergoing esophageal resection at Virginia Mason were lower than in previous published series. This factor coupled with advanced methods of peri-operative pain control and early mobilization were felt to be significant contributors to improved levels of morbidity and mortality.

4.  Endotherapy versus esophagectomy for Barrett's esophagus with high-grade dysplasia or intra-mucosal carcinoma: A review of outcomes. Schembre D, Huang J, Felisky C, Cantone N, Low DE. Presented at the American Gastrointestinal Association Meeting, New Orleans, May 2004. Submitted for publication Clinical Journal of Gastroenterology and Hepatology.

This paper is one of the first to specifically examine the difference in presentation, outcome and costs of endoscopic management of high-grade dysplasia and intra-mucosal cancer versus esophagectomy. This study demonstrated that these treatments, as delivered at Virginia Mason, can produce excellent results, especially when the treatments are tailored for the specific presentation of the patient.

5. Polyflex self-expanding removable plastic stents: Assessment of treatment efficacy and safety in a variety of benign and malignant conditions of the esophagus. Karbowski M, Schembre D, Kozarek R, Ayub K, Low DE. Presented Western Surgical Association, Cabos San Lucas, Mexico, November 2006. Submitted for publication Archives of Surgery.

This presentation describes the largest current series of application of a new removable stent technology in patients with both benign and malignant diseases of the esophagus. This study demonstrated that this stent can be considered for application in a wide variety of patients with both benign and malignant strictures of the esophagus.

6. Comparison of intra-operative hemodynamics and post-operative outcomes in patients undergoing transhiatal versus transthoracic esophagectomy. Felisky C, Low DE. American College of Surgeons Meeting, Sun River, Oregon, June 2006; Canadian Association of Thoracic Surgeons, Calgary, Alberta, September 2006.

This paper takes an in-depth look at intra-operative hemodynamic differences in patients undergoing esophageal resection with and without a thoracic incision. It demonstrated that hemodynamic variability is higher in patients undergoing the transhiatal resection, but that both procedures can be done safely in appropriate patients.

7. Near Total Esophagectomy: The Influence of Standardized Multimodal Management and Intraoperative Fluid Restriction Neal JM, Wilcox RT, Allen HW, Low DE (2003). Regional Anesthesia and Pain Medicine, 28(4): 328-334.

Esophagectomies (removal of the esophagus for cancer or benign disease) can be associated with high perioperative morbidity and mortality, ranging between 30-50 percent and 2-30 percent respectively. Every year, Virginia Mason performs between 30-40 esophagectomies. Each operative approach is designed around the individual characteristics of the patients and the disease entity. Virginia Mason's morbidity is 18 percent and operative mortality is zero. We believe these results come from a multimodal diversified approach to perioperative management including intraoperative fluid restriction and extubation before leaving the operating room. This paper outlines a unique approach to intra-operative management during esophageal resection, which has led to significantly improved results compared to national standards.

8. Useful Benchmarks to Evaluate Outcomes After Esophagectomy and Pancreaticoduodenectomy Traverso LW, Shinchi H, Low DE (2004). American Journal of Surgery, 187(5): 604-608.

Donald Low, MD and L. William Traverso, MD have generated prospective databases for outcomes of Esophagectomies (EG) and Pancreaticoduodenectomies (PD), respectively. These two operations are currently among the most carefully scrutinized procedures in the United States due to increasing evidence that morbidity and mortality is directly linked to the volume of these cases performed by individual hospitals and surgeons. These surgeons practice in a multispecialty clinic within a tertiary-referral, resident-training hospital. From January 1996 to December 2002, 174 consecutive patients underwent EG performed by Dr. Low, and 232 consecutive patients underwent PD by Dr. Traverso. These outcomes are compared with those recently published EG and PD series.

Virginia Mason's mortality rate for both operations is zero. For the EG series, the estimated blood loss was 204mL compared with recent published literature of 964mL. Transfusion rate was 3.5 percent versus 34 percent, length of hospital stay was 11.1 days versus 16.6, and an anastomotic leak occurred in 2.9 percent of the cases versus 9.1 percent. For the PD series, the estimated blood loss was 382mL compared to 1183mL, length of hospital stay was 11.2 days versus 17.8 and an anastomotic leak occurred in 6.5 percent of cases versus 9.9 percent. The re-operation rate is 0.4 percent compared to 3.8.

These two series demonstrate some of the best results ever reported by individual surgeons and potential additional benchmarks to help better define acceptable outcomes after EG and PD.

9. A Prospective Evaluation of Dietary Status and Symptoms After Near Total Esophagectomy Without Gastric Emptying Procedure Ludwig DJ, Thirlby RC, Low DE (2001). American Journal of Surgery, 181(5): 454-458.

Many patients treated for esophageal cancer will need to undergo a near-total esophagectomy, or surgery, to remove nearly all of the esophagus. This type of surgery involves reshaping the digestive tract, and it is well known that, after surgery, most patients will not be able to eat exactly as they did prior to their operation. Surgeons at Virginia Mason have a very high level of experience treating esophageal cancer, and doctors here have demonstrated their expertise with gastric reconstruction after near-total esophagectomy. Among the patients treated at Virginia Mason, published data show that the vast majority (85%) are able to have a diet which they perceive to be normal or only minimally restricted following their surgery.

10. Removal of Esophageal Expandable Metal Stents
Low DE, Kozarek RA (2003). Surgical Endoscopy, 17:990-996.

Expandable metal stents are widely used to relieve dysphagia (difficulty swallowing) and treat esophageal fistula in patients with malignant esophageal disease. These stents are effective and easy to place endoscopically. By design, they are engineered to stay in one place after they have been inserted; it is generally acknowledged that these stents are at best difficult and likely impossible to remove short of surgical resection. Although this permanence is of great clinical benefit, doctors at Virginia Mason recognized that the ability to remove the devices without surgery would be useful as well. Donald Low, MD and Richard Kozarek, MD, demonstrated that expandable metal stents could be successfully retrieved, and they describe their technique in a recent issue of Surgical Endoscopy. This ability will potentially open new applications for these devices in patients with benign conditions.

11. Esophageal resection: Improved outcomes are associated with a diversified approach. Author: Donald E. Low, MD.

This paper was presented in June of 2005 in the Plenary Session of the Western Thoracic Surgical Association Meeting in Victoria, B.C.

SUMMARY

This publication reports the results of esophageal resection in 302 consecutive patients operated on at Virginia Mason Hospital between 1991 and 2004. The surgery was done for cancer in 270 patients, Barrett’s with high-grade dysplasia in 20 patients, and benign disease in 12 patients. The surgical approach was individualized in each patient according to individual patient characteristics and comorbidities as well as specific issues related to the disease entity, particularly location, size and extra esophageal involvement of the patient’s cancer. A meticulous approach to surgical dissection resulted in a mean operative blood loss of under 250 cc and only 9.9% of patients required transfusions. Median ICU stay was 2.0 days and median hospital stay was 10.0 days. All patients had insertion of thoracic epidural catheters which dramatically improved perioperative pain management and facilitated 99.3% of patients being extubated immediately following their operation and all patients being mobilized in the immediate postoperative period. Anastomotic leaks occurred in 3.5% of patients in hospital and 30-day mortality occurred in one patient (0.3%).

This paper documents outstanding results in a large group of patients and reports a mortality rate significantly lower than other published series of esophageal resections.

Other Medical Publications Examining the Relationship of Hospital Volume with Outcomes Including Mortality, Complications and Cost in Certain Major Cancer Operations (Specifically Esophageal Resection)

1. Hospital volume and surgical mortality in the United States. Birkmeyer JD et al. New England Journal of Medicine 346(15):1128-1137, 2002.

This publication utilized the National Medicare Claims Database to examine mortality rates with respect to six different cardiovascular procedures and eight major cancer resections between 1994-1999 (total number of procedures 2.5 million). This paper demonstrated that as surgical volume increased mortality rates decreased. The largest differences between high and low volume hospitals were noted with esophageal resection (20.3% vs. 8.4%), pancreatic resection (16.3% vs. 3.8%), and pneumonectomy (16.1% vs. 10.7%). The authors concluded that patients undergoing elective cancer procedures can significantly reduce their risk of operative death by selecting a high-volume hospital.

2. Impact of hospital volume on operative mortality for major cancer surgery. Begg CB et al. Journal of the American Medical Association 280(20):1747-1751, 1998.

This study examined the mortality rates associated with certain surgical cancer procedures in low-volume vs. high-volume medical centers. This report utilized the National SEER Database (Surveillance, Epidemiology, and End Results) to assess the outcomes in five major cancer operations taking into account patients’ co-morbid illnesses, age, and the stage of the cancer at presentation. They found a direct link with respect to high volume and lower mortality with respect to esophageal resection and pancreatic resection. The most striking results, however, were with esophageal resection where the mortality rate was 3.4% in high-volume hospitals vs. 17.3% in low-volume hospitals.

3. Complications and costs after high risk surgery: Where should we focus quality improvement initiatives? Dimick JB. Journal of the American College of Surgery 196(5):671-678, 2003.

This paper examined the outcomes of two high risk surgical procedures – hepatectomy (n=569) and esophageal resection (n=366) from 1994-1998 in the state of Maryland. This study demonstrated that patients sustaining postoperative complications after high-risk surgery demonstrated increased levels of mortality, length of hospital stay, and hospital costs.

4. Surgical volume and quality of care for esophageal resection: Do high-volume hospitals have fewer complications? Dimick JB. et al. Annals of Thoracic Surgery 75:337-341, 2003.

This paper specifically examines the outcomes in patients undergoing esophageal resection in high-volume vs. low-volume hospitals in the state of Maryland between 1994-1998. It compared the rates of ten postoperative complications and demonstrated significant differences in mortality rate (15.4% vs. 2.5%) between high-volume and low-volume hospitals. They also demonstrated that the incidence of specific complications, specifically renal failure, pulmonary failure, septicemia, surgical complications, and aspiration were significantly less likely to occur in high-volume hospitals.

5. Effect of operative volume on morbidity and mortality and hospital use after esophagectomy for cancer. Swisher SG et al. Journal of Thoracic and Cardiovascular Surgery 119(6):1126-1134, 2000.

This paper examined the effect of the number of operations, hospital size, and cancer specialization with respect to morbidity and mortality and hospital utilization after esophageal resection for cancer. This group utilized information available through the Health Care Utilization Project to examine all Medicare reimbursed esophageal resections for cancer between 1994-1996 in 13 national cancer institutions and 88 community hospitals. This paper demonstrated that operative mortality was directly linked to the number of esophageal resections done within an institution, not the number of overall operations, hospital size, or level of cancer specialization. There was also an indication that high-volume hospitals had decreased levels of complications, length of stay, and overall costs of the surgical treatment of cancer of the esophagus.

6. Selective referral to high-volume hospitals estimating potentially avoidable deaths. Dudley RA. Journal of the American Medical Association 283(9):1159-1166, 2000.

This paper specifically examined the mortality rates in a variety of cardiac, vascular and cancer related surgeries in high-volume vs. low-volume hospitals in California. The author demonstrated a significant number of operations including esophageal resection are likely to be associated with a lower mortality rate in high-volume vs. low-volume institutions.

7. A hospital's annual rate of esophagectomy influences the operative mortality rate. Patti MG. Journal of Gastrointestinal Surgery 2:186-192, 1998.

This publication reviewed the mortality rate associated with esophageal resection in various hospitals in California between 1990-1994. Data was obtained from the office of State-wide Health Planning and Development. Hospitals were grouped according to the number of esophageal resections they performed over a five-year period. Within the state of California esophageal resections were performed in 273 hospitals. However, 88% of these hospitals were categorized as low volume in that they performed two or fewer resections each year. The mortality rate in hospitals with more than 30 esophagectomies for the five-year period was 4.8% compared to 16% for hospitals with fewer than 30 esophagectomies over the same period.

8. Impact of hospital volume on clinical and economic outcomes for esophagectomy. Kuo EY. Annals of Thoracic Surgery 72:1118-1124, 2001.

This paper examined outcomes of esophageal resection in high-volume vs. low-volume hospitals in the state of Massachusetts between 1992-2000. 1,193 patients underwent esophageal resection during this eight-year period. There were three high-volume hospitals performing 56.5% of all of the resections, 61 low-volume hospitals performing 43.5% of the resections. High-volume hospitals demonstrated a significant difference in length of stay in Intensive Care and overall hospital stay. There was a 3.7 time decrease in hospital mortality in high-volume vs. low-volume hospitals. High-volume hospitals also demonstrated a trend towards decreased overall costs for esophageal resection.

9. Hospital volume and hospital mortality for esophagectomy. Van Lanschot JJ et al. Cancer 91:1574-1578, 2001.

This paper examined the effect of hospital volume on mortality associated with esophageal resection for cancer in the Netherlands. It examined the Dutch National Medical Registry and the Dutch Network and National Database for Pathology between 1993-1998. This analysis found that 52% of esophageal resections were done at low-volume centers, 6% done at medium-volume centers, 42% at high-volume centers. Hospital mortality was directly related to volume of esophageal resections, 12.1% in low-volume centers, 7.5% in intermediate-volume centers, and 4.9% in high-volume centers.