Oesophageal cancer surgery : predictors of health-related quality of life and survival

Abstract: Oesophageal cancer is a devastating disease with a bleak prognosis. Only 25% of patients are eligible for surgery which is afflicted with 15% postoperative complications an overall 5-year survival of 30-50%. In the short term patients’ health- related quality of life (HRQOL) is highly deteriorated and postoperative complications contribute to this impairment. This thesis aims at shedding light on the recovery of HRQOL in the longer term and indicators of HRQOL and survival. Study I and II were based on a prospective nationwide cohort of oesophageal cancer patients operated on between 2001-2005 and followed up postoperatively with the HRQOL questionnaires EORTC QLQ-C30 and the oesophageal-specific module EORTC QLQ-OES18 and included 5-year survivors. Study I investigated postoperative HRQOL changes over time and compared to the general population. HRQOL outcomes seemed to recover; however, a subgroup of patients still suffered poor HRQOL in the longer term. Study II examined the effect of major postoperative complications on long-term HRQOL and found that the negative impact of these complications is long-standing. Study III and IV were retrospective nationwide cohort studies of oesophageal cancer patients who underwent surgery between1987-2005. Study III investigated whether the experience of the hospital or surgeon with oesophageal cancer influenced prognosis. The amount of operations performed by the hospital was not associated with mortality in the short or long term. Patients who were operated on by a surgeon who had performed more such operations over time and operated frequently had the lowest short-term mortality. Study IV examined the determinants of splenic injury and unintended splenectomy during surgery and its influence on prognosis and severe infections. Experienced surgeons (described above) had less risk of both injuring the spleen and conducting unintended splenectomy. Accidental splenectomy was followed by an increased risk of overall mortality and of sepsis or meningitis. In conclusion, for each HRQOL outcome some oesophageal cancer surgery survivors do not recover and postoperative complications exert a long-lasting negative effect in HRQOL. Patients operated on by experienced surgeons have an increased risk of survival and a decreased risk of splenic injury and accidental splenectomy. Accidental splenectomy confers an increased risk of mortality and severe infections.