Understanding Potentially Preventable Mortality Following Oesophago-Gastric Cancer Surgery: Analysis of a National Audit of Surgical Mortality

Using a national audit database, we identified with high granularity the underlying causes, complications and management issues that contributed to mortality following oesophago-gastric cancer surgery in Australia. Our key findings were: (1) approximately 50% of deaths were potentially preventable; (2) of these, most mortalities were preceded by multiple complications and clinical management issues; and (3) potentially preventable mortalities were associated with significantly higher rates of complications and clinical management issues than non-preventable mortalities. Moreover, our thematic analysis highlighted recurrent areas of deficiency to better direct future quality-improvement efforts.

Based on a national postoperative mortality rate of 3.5% for oesophago-gastric cancer resections in Australia,2 the 105 mortalities presented here were derived from approximately 3000 surgeries performed in multiple centres over 10 years. While each death is likely to be well considered within its respective units, a collective review of all these cases have not been available until now. Thus, our study is unique in its dissection of the clinical events leading to potentially preventable mortality after oesophago-gastric cancer surgery.

Our analysis showed that potentially preventable mortality was characterized by an increasing number of complications per patient (median, 7 per patient), higher rates of re-operation, sepsis and multiorgan failure, as well as significantly more clinical management issues at every phase of patient care (Tables 2 and S2). Importantly, it is difficult to predict potentially preventable mortality. Indeed, we noted a trend towards a lower preoperative risk of death in this group compared with the non-preventable mortality group. These findings evoke Reason’s Swiss Cheese Model for patient safety, which proposed that harm results from the alignment of multiple inherent weaknesses within a continuum of care.16 Synonymously, in most cases within our cohort, there were multiple opportunities for intervention that may have averted complications and death. Therefore, while it is generally accepted that oesophago-gastric cancer surgery carries a significant morbidity risk,17 the key is to implement processes to safeguard against omissions and correct commissions, however small, to avoid the conversion of morbidity into mortality.

Broadly, the themes identified from our analysis of clinical management issues overlapped with other examinations of mortality following cholecystectomy,18 neurosurgery,19 cardiothoracic surgery,20 pancreaticoduodenectomy21 and hepatectomy.22

The main themes identified in preoperative care were insufficient patient workup and poor decision-making. Within these themes, we found that suboptimal assessment of patient fitness, inappropriate decisions to offer surgery, incorrect procedural approaches and inadequate personnel or facility support were recurrent issues. These themes highlight the importance of patient selection in oesophago-gastric cancer surgery. Case selection extends beyond tumour staging and involves understanding each patient’s perioperative risks as well as their physiological reserve to surmount any complications that arise. This is critically important as most oesophago-gastric cancer patients have poor baseline fitness23 and are frequently malnourished at diagnosis.24 Moreover, their body composition and functional status are further impaired by neoadjuvant therapies,25 putting them at increased risk of morbidity and mortality. To enable adequate case selection, there are now validated risk prediction models and multi-faceted prehabilitation programs tailored for this patient population.26,27 In particular, a prehabilitation program should objectively assess (at baseline), optimize, and reassess (post-optimization) each patient’s medical, physical, nutritional and psychological fitness for surgery.27 Although various facets of prehabilitation are currently under investigation, evidence suggests that such programs improve outcomes for surgical patients with oesophago-gastric cancer.27 Notably, the benefit of prehabilitation is most pronounced in reducing cardio-respiratory complications,27 which were responsible for most of the morbidity and mortality in our cohort. Ideally, outcomes from risk prediction and prehabilitation should be incorporated into cancer-board discussions to guide patient management. In this way, the intent of treatment, as well as the approach, timing and location of surgery, takes into consideration not only tumour biology, but also patient physiology.

The main themes identified in intraoperative care were the absence of a senior surgeon (especially at re-operation), incorrect decision making, and technical errors. While intraoperative clinical management issues contributed the least to preventable mortality, they emphasized the relative complexities of an oesophago-gastric cancer resection, particularly if undertaken in a high-stress environment, where the surgeon is at risk of tunnel vision and cognitive overload.28 In this context, mistakes in decision-making and technical errors can have significant repercussions for patient outcomes. To address these issues, it is now recognized that surgical safety checklists,29 availability of a highly functioning team30 and close consultant supervision improve outcomes for complex surgeries.31,32 Practice guidelines from the Royal College of Surgeons of England describes the importance of an ‘expert team’ rather than an ‘expert surgeon’ in minimizing intraoperative errors.33 A highly functioning team consists of personnel who are confident in their own abilities and are familiar with the operation, other team members, and theatre resources. Accordingly, this team is able to anticipate and compensate for mishaps that may occur in theatre, thereby decreasing the rate and impact of errors.33 Markar et al. showed that surgeon experience is directly associated with patient mortality following oesophago-gastric cancer resections.34 They and others propose that complex surgeries should be undertaken by two surgeons, either in a partnership or mentor-mentee capacity, to facilitate shared decision-making, reduce cognitive overload, and manage errors when they occur.34,35,36

The main themes identified in postoperative care were failure to recognize the deteriorating patient, incorrect decision making and treatment delays. Consistent with other studies, postoperative clinical management issues contributed the most to preventable mortality.19,20,21,22 While close consultant input and increased vigilance by all team members for signs of deterioration are undoubtedly important in the postoperative period, it is recognized that senior clinicians may not always be on site, and junior team members may be inexperienced in recognizing (or acting on) these signs. To address these issues, many centres have implemented enhanced recovery pathways.37 Although these pathways vary among institutions, studies have demonstrated their efficacy in decreasing postoperative complications.37,38 Moreover, these pathways serve as a template for uneventful recovery following oesophago-gastric cancer surgery. Any deviation from the expected clinical course may facilitate early diagnosis and management of potential complications. Additionally, as these programs are typically multidisciplinary and well-documented within an institution, they can improve shared decision-making and minimize misunderstanding between teams. In the authors’ experience, embedding a dedicated cancer care coordinator or nurse practitioner within these programs further enhances communication between treatment teams and improves the quality of care.

It has been argued that the centralization of cancer services can reduce in-hospital mortality. Indeed, recent analyses of administrative datasets by our group have demonstrated a hospital volume-outcome relationship for Australia, in favour of high-volume centres (≥ 12 resections per year per centre) producing the lowest in-hospital mortality (1.6%).7 This is consistent with experiences from Europe, Asia and the USA.4,5,6 It is suggested that improved performance in higher volume centres can be partly attributable to staff members being more familiar with managing surgical patients with oesophago-gastric cancer. These centres may have system processes in place to better select and optimize patients, as well as to recognize problems and rescue early. Moreover, system improvements within a hospital may be easier to implement when there is a higher patient throughput. Despite these potential benefits, efforts towards the centralization of cancer services within Australia have faced numerous challenges. These include resistive societal attitudes, mixed public/private health services, state-governed healthcare, and vast geographical distances with a sparse population density. Additionally, issues surrounding the definition of high-volume, and the relative importance of surgeon versus hospital volume needs to be resolved. Fortunately, in-hospital mortality following oesophago-gastric cancer resections has steadily declined over the last 30 years across Australia. This suggests that, even in the absence of centralization, local quality-improvement efforts across the preoperative, intraoperative and postoperative domains are critically important to minimize surgical mortality.

This study has several limitations. First, the assessors’ comments were subjective. However, we found that for most potentially preventable mortalities, there were two independent assessors. Second, the ANZASM database is limited to patients who died. It is not a national registry for all patients who undergo oesophago-gastric cancer surgery. Therefore, we could not provide a population estimate for some of the comparisons. Third, participation from the private sector is incomplete. We recognize that the models of care and patient risk profiles are different between public and private sectors. Fourth, the overall sample size is low despite near-complete national participation in the ANZASM process. Fifth, this study drew on cases across a 10-year period. It is possible that clinical practices may have changed over time in these centres. Finally, the scope of the data obtained by ANZASM does not capture all case note details, such as surgical approach; however, this information was available to all second-line assessors.

Overall, the findings from this study can inform surgical practice and training, and can be used as a basis for prioritizing quality improvement initiatives. Moreover, many of our findings can be applied to other surgical specialties,18,19,20,21,22 and other disciplines may also benefit from a similar analysis of mortality data.

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