Evaluation of Complications After Esophagus and Gastric Surgery According To the Comprehensive Complication Index and Calvein-Dindo Scales and Examination of the Effect of These Scales on Mortality Prediction in Gastric and Esophagus Surgery
Abstract
Yemek borusu ve mide kanseri cerrahileri, majör cerrahi komplikasyon riski ile ilişkilidir. Clavien – Dindo Classification (CDC) ölçeği ve birden fazla parametreyi esas alan sonradan tanımlanan Comprehensive Complication Index (CCI) ölçeği ameliyat sonrası komplikasyonların değerlendirilmesinde kullanılan yöntemlerdir. Bu prospektif yüksek volümlü tek merkezdeki çalışmanın amacı, mide kanseri ve yemek borusu kanseri ameliyatları geçiren hastalarda postoperatif sonuçları ölçmede CCI ve CDC ölçeklerinin etkinliğini değerlendirmek ve karşılaştırmaktır. Hastalar ve Yöntemler: Van Yüzüncü Yıl Üniversitesi Genel Cerrahi Anabilim Dalında 2022 ile 2024 yılları arasında özofagus ve mide kanseri ameliyatı geçiren hastalar çalışmaya dahil edildi. Multidisipliner bir kurulda değerlendirilen ve TNM evrelemesi sonrası cerrahi yapılan hastaların demografik verileri (yaş, cinsiyet, vücut kitle indeksi, ek hastalık bilgileri) ve ameliyat tarihleri, ameliyat tipleri, ameliyat süreleri, hastanede kalış süreleri ve komplikasyonlar kayıt altına alındı. Ameliyat sonrası 0. Günden başlayarak taburculuk sonrası ilk 1 ay içinde poliklinik kontrollerinde saptanan komplikasyonları hem cerrahi yönteme hem de sonuçlara kör olan bağımsız bir klinisyen tarafından kayıt altın alındı. İstatistiksel analiz χ² chi-square testi ve Kruskal-Wallis testi kullanılarak yapıldı. Normal dağılım Kolmogorov–Smirnov testi kullanılarak hesaplandı. Gruplar nonparametrik Mann–Whitney U testi kullanılarak karşılaştırıldı. Kaydedilen komplikasyonlar CCI'e göre komplikasyon tanımları yapıldı ve her komplikasyon skoru CCI ve CDC indeksleri kullanılarak değerlendirilip kayıt altına alındı. İstatistiksel analiz IBM SPSS Statistics V22.0'da yapıldı. p\0.05 iki taraflı istatistiksel olarak anlamlı kabul edildi. Bulgular: Çalışmaya 139' u erkek, 103 'ü kadın olmak üzere toplamda 242 hasta dahil edilmiştir. Çalışmaya dahil olunan hastaların ortalama yaşı 64,0±9,7 şeklinde hesaplandı. Tümör, lokalizasyon olarak 95'i özofagusta, 98'i mide kardiyada, 47'si distal gastrikte, 2'si ise gist TM lokalize idi. Operasyon olarak hastalara distal subtotal gastrektomi, özofajektomi, total gastrektomi ya da wedge rezeksiyon yapıldı. Hastalarımızın 174'ünde herhangi bir komplikasyon yaşanmazken; 39 hastamızda 1 adet, 14 hastamızda 2 adet, 11 hastamızda 11 adet, 3 hastamızda 4 adet, 1 hastamızda ise 7 adet komplikasyon olmak üzere toplamda 68 hastamızda komplikasyon gözlemlendi. 15 hastamız ex oldu. En çok gözlenen komplikasyonlar kardiyopulmoner sistem ile ilişkili idi. Komplikasyon gelişen hastaların en yüksek Clavien Dindo Classification oranları %17,6 (n=12) Grade I, %32,4 (n=22) Grade II, %25 (n=17) Grade IIIa, %1,5 (n=1) Grade IIIb, %2,9 (n=2) Grade IVa, %20,6 (n=14) Grade V'di. Komplikasyon 2 gelişen hastaların CCI ortalaması 41,1±33,6 minumum 9, maksimum 100, ortanca 26,2'ydi. CCI düzeyleri hastaların %17,6 (n=12) 0-10, %39,7 (n=27) 20-29, %8,8 (n=6) 30-39, %7,4 (n=5) 40 49, %4,4 (n=3) 50-60 aralığında, %22,1 (n=15) 100'dü. Komplikasyon saptanan hastaların en yüksek Clavien–Dindo Classification Grade'i ile CCI düzeyi arasında mükemmel düzeyde pozitif yönde istatistiksel olarak anlamlı ilişki saptandı (p˂0,001). Tümör lokalizayonlarında komplikasyon oranlarında istatistiksel olarak anlamlı fark saptandı (p=0,022). Özofagus ve kardiya lokalizasyonlarında komlikasyon oranı yüksek, dıstal gastrik olanlarda düşüktü. Tümör lokalizayonlarında exitus oranlarında istatistiksel olarak anlamlı fark saptanmadı (p=0,325). Tümör lokalizayonlarında en yüksek Clavien–Dindo Classification oranlarında istatistiksel olarak anlamlı fark saptanmadı (p=0,323). Exitus olan hastaların 1'i (%6,7) Grade IIIa 14'ü Grade V'di. Exitus olan hastaların Grade V oranı yaşayanlara göre istatistiksel olarak anlamlı yüksekti. Tümör lokalizayonlarında CCI düzeylerinde istatistiksel olarak anlamlı fark saptanmadı (p=0,555). Exitus olan hastaların hepsinin CCI düzeyi 100 dü. Exitus olan hastaların CCI düzeyi yaşayan hastalara göre istatistiksel olarak anlamlı yüksekti (p˂0,001). Sonuç: Mide ve özofagus kanseri hem dünyada hem de ülkemizde önemli bir sağlık sorunudur. Tanı ve tedavi süreci boyunca hasta yönetimi önemlidir. Mide ve özofagus kanserlerinin tedavisinde cerrahi en önemli basamaklardan biridir. Cerrahi tedavi ve sonrasında gelişen komplikasyonlar kayıt altına alınmalı. Kollektif çalışma ile elde edilen veriler kılavuzluğunda güncellemeler yapılmalıdır. Mide ve özogafagus kanseri operasyonu sonrası gelişen komplikasyonları irdelediğimiz, gelişen komplikasyonları sınıflandırıp mortaliteyi öngörmeye çalıştığımız bu çalışmada CDC ve CCI ölçekleri kullanıldı. CDC ve CCI ölçeklerinin mortaliteyi ön görmede başarılı oldukları ve kendi içerisinde de tutarlı oldukları tespit edilmiştir. CCI tüm komplikasyonların genel büyüklüğünü ölçtüğünden, CCI'nin sürekli izlenmesi cerrahi performansı yansıtabilir ve cerraha geri bildirim sağlayabilir. CCI'nin sürekli zaman dizilimi kaydı, bir grup cerrahın cerrahi performansını izlemek için bir referans sağlayabilir.
Esophageal and gastric surgery for cancer is associated with a high risk for major surgical complication. The Clavien–Dindo Classification (CDC) scale and the Comprehensive Complication Index (CCI) scale, which is defined later and is based on multiple parameters, are the methods used to evaluate postoperative complications. The aim of the present prospective single center study is to evaluate and compare the efficacy of CCI and Clavien Dindo Classification (CDC) in measuring postoperative outcomes in patients undergoing gastric and esophageal cancer surgeries at a high volüme center. Patients and Methods: Patients who underwent esophageal and stomach cancer surgery at the Department of General Surgery at Van Yuzuncu Yil University between 2022 and 2024 were included in the study. The patients were evaluated by a multidisciplinary board and the decision for surgery was made after TNM staging. Demographic data (age, gender, body mass index, additional disease information) and surgery dates, surgery types, surgery durations, complicationsand hospital stays of the patients who underwent surgery were recorded. All complications starting from postoperative day 0 and complications detected during outpatient clinic controls within the first month after discharge were recorded by an independent clinician who was blinded to both the surgical method and the results. Statistical analysis was performed using χ² test and Kruskal-Wallıs test. Normal distribution was calculated using the Kol mogorov–Smirnov test. Groups were compared using the nonparametric Mann–Whitney U test. Complication definitions were made according to the CCI for the recorded complications, and the score for each complication was evaluated and recorded using the CCI and CDC indices. Statistical analysis was conducted in IBM SPSS Statistics V22.0. p\0.05 two-sided was considered statistically significant. Results: A total of 242 patients, 139 male and 103 female, were included in the study. The mean age of the patients included in the study was calculated as 64.0±9.7. The tumors were localized as esophageal tumor in 95 cases, gastric cardia in 98 cases, distal gastric tumor in 47 cases, and gist tumor in 2 cases. As an operation, patients underwent distal subtotal gastrectomy, esophagectomy, total gastrectomy or wedge resection. While no complications were experienced in 174 of our patients, complications were observed in a total of 68 patients, including 1 in 39 patients, 2 in 14 patients, 11 in 11 patients, 4 in 3 patients, and 7 in 1 patient. 15 of our patients died. The most common complications were related to the cardiopulmonary system. The highest Clavien–Dindo Classification rates of patients who developed complications 4 were 17.6% (n=12) Grade I, 32.4% (n=22) Grade II, 25% (n=17) Grade IIIa, 1.5% (n=1) Grade IIIb, 2.9% (n=2) Grade IVa, and 20.6% (n=14) Grade V. The mean CCI of patients who developed complications was 41.1±33.6, minimum 9, maximum 100, and median 26.2. CCI levels of the patients were 17.6% (n=12) between 0-10, 39.7% (n=27) between 20-29, 8.8% (n=6) between 30-39, 7.4% (n=5) between 40-49, 4.4% (n=3) between 50-60, and 22.1% (n=15) between 100. A perfectly positive and statistically significant correlation was found between the highest Clavien–Dindo Classification Grade and the CCI level of patients with complications (p˂0.001). A statistically significant difference was found in the complication rates in tumor localizations (p=0.022). The complication rate was high in esophageal and cardia localizations and low in distal gastric ones. No statistically significant difference was found in exitus rates across tumor localizations (p=0.325). No statistically significant difference was found in the highest Clavien–Dindo Classification rates across tumor localizations (p=0.323). Of the patients who died, 1 (6.7%) was Grade IIIa and 14 were Grade V. The Grade V rate of patients who died was statistically significantly higher than those who survived. No statistically significant difference was found in CCI levels across tumor localizations (p=0.555). All patients who died had a CCI level of 100. The CCI level of patients who died was statistically significantly higher than that of patients who survived (p˂0.001). Conclusions: Stomach and esophageal cancer are important health problems both in the world and in our country. Patient management is important throughout the diagnosis and treatment process. Surgery is one of the most important steps in the treatment of stomach and esophageal cancer. Surgical treatment and subsequent complications should be recorded. Updates should be made under the guidance of data obtained through collective work. In this study, we examined the complications that developed after gastric and esophageal cancer surgery, classified the complications that developed, and tried to predict mortality. CDC and CCI scales were used. It was determined that CDC and CCI scales were successful in predicting mortality and were consistent within themselves. Since CCI measures the overall magnitude of all complications, continuous monitoring of CCI can reflect surgical performance and provide feedback to the surgeon. Continuous time series recording of CCI can provide a reference for monitoring surgical performance of a group of surgeons.
Esophageal and gastric surgery for cancer is associated with a high risk for major surgical complication. The Clavien–Dindo Classification (CDC) scale and the Comprehensive Complication Index (CCI) scale, which is defined later and is based on multiple parameters, are the methods used to evaluate postoperative complications. The aim of the present prospective single center study is to evaluate and compare the efficacy of CCI and Clavien Dindo Classification (CDC) in measuring postoperative outcomes in patients undergoing gastric and esophageal cancer surgeries at a high volüme center. Patients and Methods: Patients who underwent esophageal and stomach cancer surgery at the Department of General Surgery at Van Yuzuncu Yil University between 2022 and 2024 were included in the study. The patients were evaluated by a multidisciplinary board and the decision for surgery was made after TNM staging. Demographic data (age, gender, body mass index, additional disease information) and surgery dates, surgery types, surgery durations, complicationsand hospital stays of the patients who underwent surgery were recorded. All complications starting from postoperative day 0 and complications detected during outpatient clinic controls within the first month after discharge were recorded by an independent clinician who was blinded to both the surgical method and the results. Statistical analysis was performed using χ² test and Kruskal-Wallıs test. Normal distribution was calculated using the Kol mogorov–Smirnov test. Groups were compared using the nonparametric Mann–Whitney U test. Complication definitions were made according to the CCI for the recorded complications, and the score for each complication was evaluated and recorded using the CCI and CDC indices. Statistical analysis was conducted in IBM SPSS Statistics V22.0. p\0.05 two-sided was considered statistically significant. Results: A total of 242 patients, 139 male and 103 female, were included in the study. The mean age of the patients included in the study was calculated as 64.0±9.7. The tumors were localized as esophageal tumor in 95 cases, gastric cardia in 98 cases, distal gastric tumor in 47 cases, and gist tumor in 2 cases. As an operation, patients underwent distal subtotal gastrectomy, esophagectomy, total gastrectomy or wedge resection. While no complications were experienced in 174 of our patients, complications were observed in a total of 68 patients, including 1 in 39 patients, 2 in 14 patients, 11 in 11 patients, 4 in 3 patients, and 7 in 1 patient. 15 of our patients died. The most common complications were related to the cardiopulmonary system. The highest Clavien–Dindo Classification rates of patients who developed complications 4 were 17.6% (n=12) Grade I, 32.4% (n=22) Grade II, 25% (n=17) Grade IIIa, 1.5% (n=1) Grade IIIb, 2.9% (n=2) Grade IVa, and 20.6% (n=14) Grade V. The mean CCI of patients who developed complications was 41.1±33.6, minimum 9, maximum 100, and median 26.2. CCI levels of the patients were 17.6% (n=12) between 0-10, 39.7% (n=27) between 20-29, 8.8% (n=6) between 30-39, 7.4% (n=5) between 40-49, 4.4% (n=3) between 50-60, and 22.1% (n=15) between 100. A perfectly positive and statistically significant correlation was found between the highest Clavien–Dindo Classification Grade and the CCI level of patients with complications (p˂0.001). A statistically significant difference was found in the complication rates in tumor localizations (p=0.022). The complication rate was high in esophageal and cardia localizations and low in distal gastric ones. No statistically significant difference was found in exitus rates across tumor localizations (p=0.325). No statistically significant difference was found in the highest Clavien–Dindo Classification rates across tumor localizations (p=0.323). Of the patients who died, 1 (6.7%) was Grade IIIa and 14 were Grade V. The Grade V rate of patients who died was statistically significantly higher than those who survived. No statistically significant difference was found in CCI levels across tumor localizations (p=0.555). All patients who died had a CCI level of 100. The CCI level of patients who died was statistically significantly higher than that of patients who survived (p˂0.001). Conclusions: Stomach and esophageal cancer are important health problems both in the world and in our country. Patient management is important throughout the diagnosis and treatment process. Surgery is one of the most important steps in the treatment of stomach and esophageal cancer. Surgical treatment and subsequent complications should be recorded. Updates should be made under the guidance of data obtained through collective work. In this study, we examined the complications that developed after gastric and esophageal cancer surgery, classified the complications that developed, and tried to predict mortality. CDC and CCI scales were used. It was determined that CDC and CCI scales were successful in predicting mortality and were consistent within themselves. Since CCI measures the overall magnitude of all complications, continuous monitoring of CCI can reflect surgical performance and provide feedback to the surgeon. Continuous time series recording of CCI can provide a reference for monitoring surgical performance of a group of surgeons.
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Genel Cerrahi, General Surgery
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