In this study using ANZASM data,5 we analyzed all in-hospital mortalities following esophago-gastric cancer surgery in Australia over 10 years. We identified 636 complications and 123 clinical management issues in 105 mortalities. The most common causes of death were cardio-respiratory in nature. Based on independent reviewers’ assessment of each case, we report that 47% of deaths were deemed potentially preventable.

After comparing potentially preventable and non-preventable deaths, we found that potentially preventable cases were characterized by higher rates of generalized sepsis, multiorgan dysfunction syndrome, reoperation, small bowel obstruction, delayed conduit emptying that required reintervention, and jejunostomy-related issues. Importantly, potentially preventable mortalities had a significantly higher number of clinical management issues per patient, which adversely impacted on all phases of patient care. Moreover, unlike perioperative mortality in general, preventable mortality was not predictable preoperatively.

Our thematic analysis of clinical management issues has highlighted recurrent areas of deficiency in patient care. Preoperatively, inadequate surgical assessment, planning, and/or optimization of patient fitness for surgery, inappropriate decision to offer surgery, and incorrect choice or approach to an operation were the most common preventable deficiencies. Intraoperatively, technical error, incorrect decision-making, and lack of senior surgeon availability were common preventable contributors to mortality. Postoperatively, failure to rescue, poor decision-making, and treatment delays were the most common themes identified that were potentially preventable and contributed to an inability to salvage patients when complications occurred.