Annals of the Royal College of Surgeons of England (1992) vol. 74, 401-405
Audit
of
an oesophageal unit
A D Hill
D Moraes MB
MB MMedSc Senior House Officer
House Officer
T N Walsh
T P J Hennessy MD FRCS
MCh FRCSI Lecturer in Surgery
Professor of Surgery
Trinity College, Department of Surgery, St James's Hospital, Dublin, Ireland Key words: Audit; Oesophagus; Quality control; Cost-effectiveness
We report an audit of 786 oesophageal procedures, including 53 oesophagectomies, performed during 1990 in a specialist oesophageal unit. Apart from assessing morbidity and mortality, audit allows a review of cost efficiency and justification for certain practices with regard to patient management. The data reported here may provide a framework against which individual surgeons may assess their own results and compare costs of procedures with a similar outcome.
Audit has been defined by The Royal College of Surgeons of England as "the systematic appraisal of the implementation and outcome of any process in the context of prescribed targets and standards" (1). The difficulty with this definition lies in the uncertainty about what prescribed targets and standards are in the context of a surgical firm. They will depend on the case mix, the demographic structure of the catchment population, the available facilities and the special interests of the unit. This difficulty is magnified when trying to audit a specialist unit with a large referral practice. The aim of this study was to attempt, by auditing the work performed in a specialist oesophageal unit during one year, to identify reasonable targets and standards in the management of diseases of the oesophagus. It was felt that audit should not only assess the morbidity and mortality of procedures, but should encompass a review of the entire practice, including cost efficiency and justification for certain practices with regard to patient management. Such an audit would imply a commitment to change practice where necessary.
Patients and methods During 1990 the clinical records of all patients admitted to one unit with a special interest in oesophageal disease
Correspondence to: Professor T P J Hennessy, Department of Surgery, St James's Hospital, Dublin 8, Ireland
were stored on a database (Reflex). The oesophageal laboratory is part of the unit and investigates benign oesophageal disease using ambulatory and stationary manometry and 24 h pH monitoring. For the purposes of this audit, detailed analysis was limited to patients who had diseases or procedures related to the oesophagus. The total number of admissions, operative procedures, investigations, outpatient numbers and costs were obtained by reviewing the operating theatre log book, the day ward procedure book, the computerised hospital activity data programme, the oesophageal resection database, medical administrative statistics and data from the hospital finance department. Two groups were selected for individual analysis, those having endoscopic procedures and those having oesophageal surgery.
Endoscopic procedure Endoscopic procedures were performed either as day procedures or in the operating theatre. Two day ward sessions per week, each of 3 h, were used for upper and lower gastrointestinal endoscopy, including therapeutic procedures such as oesophageal dilatation, polypectomy and injection of varices. Procedures reserved for the operating theatre were largely those carrying a risk of bleeding or perforation. Such procedures included injection of varices in high-risk patients, first time dilatation of strictures, dilatation of tight strictures with a perceived risk of perforation and insertion of oesophageal stents (Atkinson's tube). All patients had their endoscopic procedure after receiving 2-10 mg of midazolam unless the patient requested endoscopy without sedation. The sedation was reversed after the endoscopic procedure by using the benzodiazapine antagonist flumazanil.
Oesophageal resections Patients with malignant disease of the oesophagus underwent preoperative investigations to determine stage and
402
A D Hill et al.
resectability of the tumour, which included physical examination, chest radiograph, abdominal ultrasound and endoscopy. Computed tomography was carried out only if resectability was doubtful, such as in extensive middle third tumours or where repeated biopsies of a suspicious lesion were negative for tumour. Endoscopy was performed to determine the exact site and extent of the tumour as well as confirming the type and stage. Barium studies were performed in all cases, and were particularly helpful in defining the stricture length, gastric extension and fistula formation where tight stricturing limited endoscopy. Routine haematological and biochemical profiles were assessed as well as arterial blood gases and pulmonary function tests. All patients received a full dietetic assessment preoperatively to assess nutritional status and received supplementation where nutritional impairment was observed. At least 5 days of intensive in-hospital chest physiotherapy was given prior to surgery and each patient was instructed on the use of an incentive spirometer to provide further motivation. An arterial Po2 of greater than 10 kPa/l, and a forced expiratory volume in one second (FEVI) of greater than 1 litre were the minimum respiratory requirements for undertaking oesophageal resection. All patients were digitalised preoperatively. After surgery, all patients were managed in the intensive care unit. All oesophagectomies were performed by one surgeon. The majority of patients were extubated in the recovery area before returning to the intensive care unit or within 6 h. Overnight intubation is avoided in all but patients with severely compromised cardiorespiratory reserve. Clinical trials The caseload and practice was influenced to a large degree in the unit by clinical trials which were started or were ongoing during this period. These included a controlled clinical trial on the role of adjuvant chemotherapy and radiotherapy followed by surgery versus surgery alone in the treatment of oesophageal carcinoma, the optimum size for dilatation in the management of benign oesophageal strictures and the effect of intensive acid suppression on Barrett's oesophagus. Cost analysis The cost of each outpatient visit was calculated based on the cost of staffing the outpatients and the average length of time spent with each patient. Theatre costs were calculated based on the cost of staff salaries, drugs, gases, lines, blood products, and theatre equipment such as sutures, gowns and gloves. The cost per day of intensive care stay included the cost of anaesthetic and physiotherapy staffing, blood tests, portable chest radiographs, antiobiotics and surgical equipment such as chest drains and intravenous monitoring lines including central venous pressure monitor lines and Swan-Ganz catheters. The cost of a day in a hospital bed was based on hospital running costs, including salaries of all personnel caring
for patients, and routine maintenance costs. Indirect ie productivity losses due to illness, permanent disability or premature death were not included in the calculation. costs,
Results The unit has 16 beds as well as access to a five-bed intensive care unit. On average each bed was occupied by 57 different patients during the year. These beds were also used to service an oncall commitment to the casualty department every fourth night. There were 512 elective oesophageal admissions to the unit during the year with 109 other elective general surgical admissions and 293 emergency admissions through the casualty department-a total of 932 admissions (Table I). There were 718 procedures performed as day cases, 381 (53%) of which were upper intestinal endoscopies. Oesophageal investigations performed in the laboratory included ambulatory pH studies in 303 patients, 310 stationary oesophageal manometry studies and 50 ambulatory manometry studies. There were 99 outpatient sessions at which 1186 patients were seen, of whom 395 were new patients. Of the 786 oesophageal procedures performed, 71 were open operations. The open operations which were performed in the operating theatre as well as 334 endoscopic procedures required a total of 580 operating hours. The open operations consisted of 53 oesophageal resections (three as an emergency for perforation of which two occurred in house and one was referred from another institution). Ten patients had a Rossetti-Hell fundoplication, one of whom had a failed Angelchik prosthesis removed at the same procedure. Two Celestin tubes were inserted, one in a patient with recurrence of tumour postoesophagectomy and another in a patient with an unresectable tumour. One of each of the following procedures was performed: Heller's myotomy, insertion and removal of a Denver shunt, a thoracotomy for bleeding after oesophagectomy, repair of a Zenker's diverticulum, repair of an oesophageal tear, and repair of an anastomotic leak (Table II).
Endoscopy There were 715 diagnostic or therapeutic endoscopic procedures performed, of which 381 (53%) were performed as day cases in 82 day ward sessions occupying 246 hours.
Table I. Admissions to the unit Elective oesophageal Elective general surgical Emergency via Casualty Total
512 109 293 932
Audit of an oesophageal unit Table III. Type of oesophagectomy
Table II. Oesophageal procedures Diagnostic endoscopy Oesophagitis Barrett's Carcinoma No abnormality
Therapeutic endoscopy Dilatation of strictures Injection
of varices
Insertion of Atkinson's tube
operations Oesophagectomy Rossetti-Hell fundoplication Insertion of Celestin tube Heller's myotomy Insertion of Denver shunt Thoracotomy for bleeding after oesophagectomy Repair of Zenker's diverticulum Repair of oesophageal tear Repair of anastomotic leak Total
403
Three-stage procedure 78 57 59 357 120 40 4
Midline and left chest Ivor-Lewis Pharyngolaryngoesophagectomy Transhiatal Colon interposition Total
24 11 10 5 2 1 53
Table IV. Complications of 53 oesophagectomies
Open
53 10 2 1
1 1 1
1 1
786
Diagnostic endoscopy Of the 551 diagnostic endoscopies performed, 357 (64%) revealed no abnormality in the oesophagus. Seventyeight patients had grade I-III oesophagitis; 57 patients had histologically proven Barrett's oesophagus-one of whom developed an oesophageal carcinoma while under surveillance; and 59 patients had a diagnosis of carcinoma of the oesophagus confirmed at oesophagoscopy. Therapeutic endoscopy Therapeutic endoscopic procedures included dilatation of strictures in 38 patients, injection of varices in 20 patients and the insertion of four Atkinson tubes. Three were inserted for palliation and one to seal an anastomotic leak. Thirty-eight patients had oesophagitis with stricturing, of whom four were due to anastomotic stricturing after oesophagectomy, two to oesophageal carcinoma and 32 to reflux. There were 120 oesophageal dilatations performed in 38 patients with strictures during which perforation occurred in two patients with malignant strictures. Of the 117 dilatations with benign stricturing, 16 were carried out in four patients with anastomotic strictures after oesophagectomy-one patient requiring 12 dilatations during the year for an anastomotic stricture which followed external beam and intraluminal radiotherapy and chemotherapy before surgery. The remaining 101 dilatations were performed on 32 patients with benign strictures, requiring a mean of 3.4 dilatations during the year. All patients with benign strictures were dilated to either 45G or 52G as part of a randomised trial. No benign stricture sustained a perforation. Twenty patients had oesophageal varices injected during the year, of whom two presented for the first
Respiratory Effusion Infection Pneumothorax Aspiration
Cardiovascular Arrhythmias Renal Urinary retention Renal failure Others Anastomotic leak Subphrenic abscess Haemorrhage
17 13 1 1 6 3 3 2
1 1
time. In this group of 20 patients, eight were in Child's category A, seven in category B, and five were in category C. Eighteen patients had their varices injected as part of a long-term sclerotherapy programme. A total of 40 endoscopies were performed at which varices were injected.
Oesophageal resection A total of 53 patients had an oesophagectomy performed, 25 for squamous cell carcinoma and 28 for adenocarcinoma; 50 were performed electively while three were emergency operations for perforation. The different types of oesophagectomies performed are outlined in Table III. Four patients died after elective oesophagectomy within 90 days of their operation, while one of three emergency procedures had a fatal outcome. A total of 24 patients had evidence of lymph node involvement on histological examination of their specimens. The average stay in hospital was 27 days (range 12-83 days). All oesophagectomies returned to the intensive care unit postoperatively, their mean stay being 5.7 days (range 2-43 days). Postoperatively, only four patients were ventilated overnight. The complications are listed in Table IV. Cost analysis The cost to the hospital of an outpatient visit was IR£23.00*, a day in a hospital bed cost IR£130.00, a day *
Current exchange rate IR£1.00 = £0.93.
404
A D Hill et al.
in the intensive care unit cost IR£550.00, and an hour of operating time in theatre cost IR£187.00. The average cost of a work-up for an oesophagectomy including blood tests and radiographs was IR£325.00. The cost of an oesophagectomy carried out without complications and under optimum conditions was IRE3500. However, if significant complications occurred the costs could escalate. A Rossetti-Hell fundoplication cost IR£993 and a Heller's myotomy cost IR£1087.
Discussion Systematic appraisal of surgical practice has been the focus of increasing attention both from Governmental and Surgical Colleges in the United Kingdom and Ireland (2,3). As the demand for medical care will always exceed available resources, cost efficiency and justification for surgical practices is a recurring issue in all health care systems. The management philosophy for oesophageal carcinoma of this unit centres on the belief that oesophagectomy provides the best palliation and the best hope of cure for disease confined to the oesophagus or to local nodes. The type of oesophagectomy performed depends on the site of the tumour and the evolution of operative experience over 21 years. As a result of continuous reassessment of our practice and results, the 90-day hospital mortality rate for an elective oesophagectomy was reduced to 8% in 1990. It is difficult to define an acceptable morbidity and mortality rate for major surgery. A study to establish an acceptable mortality rate for oesophagectomy in 1986 retrospectively reviewed 3107 resections in 50 specialist thoracic units in the United Kingdom from 1980 to 1983, and concluded that a 14% mortality rate was as near optimal as possible given the nature of the disease and the characteristics of the population undergoing operation in the United Kingdom (4). Our relatively low mortality rate can be attributed to improved preoperative preparation, improved postoperative care and careful choice of operative procedure. Our practice includes the requirement for 5 days of aggressive in-hospital physiotherapy during routine preoperative assessment, which has led to decreased requirement for postoperative ventilation. The mean hospital stay of 27 days is due in part to the initiation in 1990 of a randomised trial on the role of adjuvant chemotherapy and radiotherapy followed by surgery versus surgery alone in the treatment of oesophageal cancer. The mean period of 5 days in the intensive care unit is considered essential to cater for the potential complications consequent on oesophagectomy. The complications of the 53 oesophagectomies are listed in Table IV. Respiratory complications occurred in over 40% of patients, pleural effusion being the most common, occurring in 32% of patients. Of endoscopies, 53% were performed as day cases. This figure reflects the fact that day ward sessions are limited and the majority of patients travel a long distance
and require inpatient accommodation, plus the fact that additional investigations are often indicated necessitating overnight admission. Only histologically proven benign strictures are dilated due to the high risk of perforation associated with dilatation of malignant strictures. All endoscopic procedures are performed under sedation. This policy is adhered to as many of our patients require repeat endoscopy during their lifetime due to the nature of their disease. Reversal by the benzodiazapine antagonist flumazanil is chiefly aimed at reducing patient recovery time and increasing efficiency of day ward beds. A long-term injection sclerotherapy programme for patients with oesophageal varices has catered for 41 patients over the past 10 years. The 5-year survival for all patients on this programme is 40% and compares favourably with other reports (5). Surgery is reserved for Child's category A or B patients in whom sclerotherapy fails to control the bleeding or in whom bleeding necessitates frequent readmissions to hospital, and no patient fulfilled these criteria in 1990. It has been shown conclusively that surgery for patients in Child's category C is not 'cost-effective' due to the high mortality associated with the procedure (6). Ten patients with symptomatic oesophageal reflux who had oesophagitis confirmed at endoscopy and reflux confirmed by 24 h pH assessment, had a Rossetti-Hell fundoplication. The cost of a Rossetti-Hell fundoplication was IR£993. Anti-reflux surgery is associated with an 85% success rate at 5-year follow-up (7). The cost of cimetidine for the same 5-year period would be IR£1680 and for omeprazole it would be IR£3720. The cost of a Heller's myotomy was IR£1087. Comparative costing with balloon dilatation is difficult owing to the different regimens advocated by gastroenterologists resulting in differing costs. However, in the only reported prospective study comparing the two techniques, the outcome after myotomy was successful in 95% as compared with 65% after balloon dilatation (8). Cost-effectiveness in surgery is difficult to define and comparisons between different units almost impossible owing to the variation in case mix, availability of resources, patient expectations as well as annual inflation and the cost of health care in different societies. Sophisticated economic analysis is clearly necessary but is difficult under current administrative arrangements. Data collection must be undertaken prospectively to establish values against which individual surgeons can assess their own results and compare costs of procedures with a similar outcome. The results presented here might provide a framework around which such data collection could take place.
References 1 Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. BrJy Surg 1991;78:356-60. 2 Royal College of Surgeons of England. Guidelines to Clinical Audit in Surgical Practice. London: Royal College of Surgeons of England, 1989.
Audit of an oesophageal unit 3 Government White Paper. Working for Patients. Medical Audit: Working Paper 6. London: Her Majesty's Stationery Office, 1989. 4 Mathews HR, Powell DJ, McConkey CC. Effect of surgical experience on the results of resection for oesophageal carcinoma. Br J Surg 1986;73:621-3. S Terblanche J, Bornman PC, Kahn D et al. Failure of repeated injection sclerotherapy to improve long-term survival after oesophageal variceal bleeding. Lancet 1983;2:132832. 6 Inokuchi K. Japanese research society for portal hypertension. Present status of surgical treatment of oesophageal
405
varices in Japan: a nationwide survey of 3588 patients. World J Surg 1985;9: 171-80. 7 Csendes A, Braghetto I, Korn 0, Cortes C. Late subjective and objective evaluations of antireflux surgery in patients with reflux esophagitis: analysis of 215 patients. Surgery 1989;105: 374-82. 8 Csendes AM, Braghetto I, Henriquez A, Cortes C. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 1989;30:299-304.
Received 22 January 1992
Book review Human Cross-sectional Anatomy - Atlas of Body Sections and CT Images by H Ellis, B Logan and A Dixon. 180 pp, illustrated. Butterworth-Heinemann, Oxford. 1991. No price given. ISBN 0 7506 1241 X The justification for the production of another book of crosssectional anatomy is stated as the recent improvement in CT imaging technology. When the meticulous efforts of reputed clinical anatomist, prosector and radiologist are combined in a detailed, attractive yet robust, practical ringback atlas, there is little room for doubt. With the evolution of modern imaging there is a need for anatomists, clinicians and radiologists to be more familiar with cross-sectional anatomical relationships throughout the body. The layout in this book of a double page spread throughout, comprising on the left a clear indication of the level of section alongside the anatomical specimen in colour and on the right the appropriate CT image along with a separate tracing and relevant notes, is well chosen. Labelling of structures on the specimen and tracing is by unobtrusive compatible numbers and a separate table on each page spread identifies the numbered structures. All sections are orientated in the axial plane as viewed from below. In the limbs, the left side is selected throughout and in the head the orientation is parallel to the Frankfort plane. Thus, uniformity is achieved throughout, making the book extremely user-friendly. The book begins with most helpful descriptions of preservation technique, sectioning technique, CT and orientation notes.
In all there are 90 cross-sections arranged in order of head and neck (28), thorax (11), abdomen (10), pelvis (18), lower limb (12) and upper limb (11). Both sexes are illustrated where appropriate. Clearly, images of patients cannot exactly correspond to cadaveric sections, especially at diaphragmatic level where the effects of inspiration for imaging purposes can shift structures from their resting vertebral levels. Some CT images are less than optimal quality and contrast has been used in many of the abdomino-pelvic examinations. However, the line tracings enable the reader to overcome visually this occasional handicap. The index is adequate, referring to structures by page number rather than section number. Overall, this is an impressive and unambiguous atlas, probably of considerable use to the anatomist, radiologist and radiographer. The specialist surgeon inevitably would find most of the work outside his immediate area of interest, however, and with the rate of progression of interventional radiology, MRI and ultrasound one suspects that the clinical relevance of this book will pass. However, it stands as an anatomical mile post and model for future atlases based on other imaging techniques.
P J LEOPARD Consultant Oral and Maxillofacial Surgeon Central Outpatients Department Stoke-on-Trent
Audit
of
an oesophageal unit
A D Hill
D Moraes MB
MB MMedSc Senior House Officer
House Officer
T N Walsh
T P J Hennessy MD FRCS
MCh FRCSI Lecturer in Surgery
Professor of Surgery
Trinity College, Department of Surgery, St James's Hospital, Dublin, Ireland Key words: Audit; Oesophagus; Quality control; Cost-effectiveness
We report an audit of 786 oesophageal procedures, including 53 oesophagectomies, performed during 1990 in a specialist oesophageal unit. Apart from assessing morbidity and mortality, audit allows a review of cost efficiency and justification for certain practices with regard to patient management. The data reported here may provide a framework against which individual surgeons may assess their own results and compare costs of procedures with a similar outcome.
Audit has been defined by The Royal College of Surgeons of England as "the systematic appraisal of the implementation and outcome of any process in the context of prescribed targets and standards" (1). The difficulty with this definition lies in the uncertainty about what prescribed targets and standards are in the context of a surgical firm. They will depend on the case mix, the demographic structure of the catchment population, the available facilities and the special interests of the unit. This difficulty is magnified when trying to audit a specialist unit with a large referral practice. The aim of this study was to attempt, by auditing the work performed in a specialist oesophageal unit during one year, to identify reasonable targets and standards in the management of diseases of the oesophagus. It was felt that audit should not only assess the morbidity and mortality of procedures, but should encompass a review of the entire practice, including cost efficiency and justification for certain practices with regard to patient management. Such an audit would imply a commitment to change practice where necessary.
Patients and methods During 1990 the clinical records of all patients admitted to one unit with a special interest in oesophageal disease
Correspondence to: Professor T P J Hennessy, Department of Surgery, St James's Hospital, Dublin 8, Ireland
were stored on a database (Reflex). The oesophageal laboratory is part of the unit and investigates benign oesophageal disease using ambulatory and stationary manometry and 24 h pH monitoring. For the purposes of this audit, detailed analysis was limited to patients who had diseases or procedures related to the oesophagus. The total number of admissions, operative procedures, investigations, outpatient numbers and costs were obtained by reviewing the operating theatre log book, the day ward procedure book, the computerised hospital activity data programme, the oesophageal resection database, medical administrative statistics and data from the hospital finance department. Two groups were selected for individual analysis, those having endoscopic procedures and those having oesophageal surgery.
Endoscopic procedure Endoscopic procedures were performed either as day procedures or in the operating theatre. Two day ward sessions per week, each of 3 h, were used for upper and lower gastrointestinal endoscopy, including therapeutic procedures such as oesophageal dilatation, polypectomy and injection of varices. Procedures reserved for the operating theatre were largely those carrying a risk of bleeding or perforation. Such procedures included injection of varices in high-risk patients, first time dilatation of strictures, dilatation of tight strictures with a perceived risk of perforation and insertion of oesophageal stents (Atkinson's tube). All patients had their endoscopic procedure after receiving 2-10 mg of midazolam unless the patient requested endoscopy without sedation. The sedation was reversed after the endoscopic procedure by using the benzodiazapine antagonist flumazanil.
Oesophageal resections Patients with malignant disease of the oesophagus underwent preoperative investigations to determine stage and
402
A D Hill et al.
resectability of the tumour, which included physical examination, chest radiograph, abdominal ultrasound and endoscopy. Computed tomography was carried out only if resectability was doubtful, such as in extensive middle third tumours or where repeated biopsies of a suspicious lesion were negative for tumour. Endoscopy was performed to determine the exact site and extent of the tumour as well as confirming the type and stage. Barium studies were performed in all cases, and were particularly helpful in defining the stricture length, gastric extension and fistula formation where tight stricturing limited endoscopy. Routine haematological and biochemical profiles were assessed as well as arterial blood gases and pulmonary function tests. All patients received a full dietetic assessment preoperatively to assess nutritional status and received supplementation where nutritional impairment was observed. At least 5 days of intensive in-hospital chest physiotherapy was given prior to surgery and each patient was instructed on the use of an incentive spirometer to provide further motivation. An arterial Po2 of greater than 10 kPa/l, and a forced expiratory volume in one second (FEVI) of greater than 1 litre were the minimum respiratory requirements for undertaking oesophageal resection. All patients were digitalised preoperatively. After surgery, all patients were managed in the intensive care unit. All oesophagectomies were performed by one surgeon. The majority of patients were extubated in the recovery area before returning to the intensive care unit or within 6 h. Overnight intubation is avoided in all but patients with severely compromised cardiorespiratory reserve. Clinical trials The caseload and practice was influenced to a large degree in the unit by clinical trials which were started or were ongoing during this period. These included a controlled clinical trial on the role of adjuvant chemotherapy and radiotherapy followed by surgery versus surgery alone in the treatment of oesophageal carcinoma, the optimum size for dilatation in the management of benign oesophageal strictures and the effect of intensive acid suppression on Barrett's oesophagus. Cost analysis The cost of each outpatient visit was calculated based on the cost of staffing the outpatients and the average length of time spent with each patient. Theatre costs were calculated based on the cost of staff salaries, drugs, gases, lines, blood products, and theatre equipment such as sutures, gowns and gloves. The cost per day of intensive care stay included the cost of anaesthetic and physiotherapy staffing, blood tests, portable chest radiographs, antiobiotics and surgical equipment such as chest drains and intravenous monitoring lines including central venous pressure monitor lines and Swan-Ganz catheters. The cost of a day in a hospital bed was based on hospital running costs, including salaries of all personnel caring
for patients, and routine maintenance costs. Indirect ie productivity losses due to illness, permanent disability or premature death were not included in the calculation. costs,
Results The unit has 16 beds as well as access to a five-bed intensive care unit. On average each bed was occupied by 57 different patients during the year. These beds were also used to service an oncall commitment to the casualty department every fourth night. There were 512 elective oesophageal admissions to the unit during the year with 109 other elective general surgical admissions and 293 emergency admissions through the casualty department-a total of 932 admissions (Table I). There were 718 procedures performed as day cases, 381 (53%) of which were upper intestinal endoscopies. Oesophageal investigations performed in the laboratory included ambulatory pH studies in 303 patients, 310 stationary oesophageal manometry studies and 50 ambulatory manometry studies. There were 99 outpatient sessions at which 1186 patients were seen, of whom 395 were new patients. Of the 786 oesophageal procedures performed, 71 were open operations. The open operations which were performed in the operating theatre as well as 334 endoscopic procedures required a total of 580 operating hours. The open operations consisted of 53 oesophageal resections (three as an emergency for perforation of which two occurred in house and one was referred from another institution). Ten patients had a Rossetti-Hell fundoplication, one of whom had a failed Angelchik prosthesis removed at the same procedure. Two Celestin tubes were inserted, one in a patient with recurrence of tumour postoesophagectomy and another in a patient with an unresectable tumour. One of each of the following procedures was performed: Heller's myotomy, insertion and removal of a Denver shunt, a thoracotomy for bleeding after oesophagectomy, repair of a Zenker's diverticulum, repair of an oesophageal tear, and repair of an anastomotic leak (Table II).
Endoscopy There were 715 diagnostic or therapeutic endoscopic procedures performed, of which 381 (53%) were performed as day cases in 82 day ward sessions occupying 246 hours.
Table I. Admissions to the unit Elective oesophageal Elective general surgical Emergency via Casualty Total
512 109 293 932
Audit of an oesophageal unit Table III. Type of oesophagectomy
Table II. Oesophageal procedures Diagnostic endoscopy Oesophagitis Barrett's Carcinoma No abnormality
Therapeutic endoscopy Dilatation of strictures Injection
of varices
Insertion of Atkinson's tube
operations Oesophagectomy Rossetti-Hell fundoplication Insertion of Celestin tube Heller's myotomy Insertion of Denver shunt Thoracotomy for bleeding after oesophagectomy Repair of Zenker's diverticulum Repair of oesophageal tear Repair of anastomotic leak Total
403
Three-stage procedure 78 57 59 357 120 40 4
Midline and left chest Ivor-Lewis Pharyngolaryngoesophagectomy Transhiatal Colon interposition Total
24 11 10 5 2 1 53
Table IV. Complications of 53 oesophagectomies
Open
53 10 2 1
1 1 1
1 1
786
Diagnostic endoscopy Of the 551 diagnostic endoscopies performed, 357 (64%) revealed no abnormality in the oesophagus. Seventyeight patients had grade I-III oesophagitis; 57 patients had histologically proven Barrett's oesophagus-one of whom developed an oesophageal carcinoma while under surveillance; and 59 patients had a diagnosis of carcinoma of the oesophagus confirmed at oesophagoscopy. Therapeutic endoscopy Therapeutic endoscopic procedures included dilatation of strictures in 38 patients, injection of varices in 20 patients and the insertion of four Atkinson tubes. Three were inserted for palliation and one to seal an anastomotic leak. Thirty-eight patients had oesophagitis with stricturing, of whom four were due to anastomotic stricturing after oesophagectomy, two to oesophageal carcinoma and 32 to reflux. There were 120 oesophageal dilatations performed in 38 patients with strictures during which perforation occurred in two patients with malignant strictures. Of the 117 dilatations with benign stricturing, 16 were carried out in four patients with anastomotic strictures after oesophagectomy-one patient requiring 12 dilatations during the year for an anastomotic stricture which followed external beam and intraluminal radiotherapy and chemotherapy before surgery. The remaining 101 dilatations were performed on 32 patients with benign strictures, requiring a mean of 3.4 dilatations during the year. All patients with benign strictures were dilated to either 45G or 52G as part of a randomised trial. No benign stricture sustained a perforation. Twenty patients had oesophageal varices injected during the year, of whom two presented for the first
Respiratory Effusion Infection Pneumothorax Aspiration
Cardiovascular Arrhythmias Renal Urinary retention Renal failure Others Anastomotic leak Subphrenic abscess Haemorrhage
17 13 1 1 6 3 3 2
1 1
time. In this group of 20 patients, eight were in Child's category A, seven in category B, and five were in category C. Eighteen patients had their varices injected as part of a long-term sclerotherapy programme. A total of 40 endoscopies were performed at which varices were injected.
Oesophageal resection A total of 53 patients had an oesophagectomy performed, 25 for squamous cell carcinoma and 28 for adenocarcinoma; 50 were performed electively while three were emergency operations for perforation. The different types of oesophagectomies performed are outlined in Table III. Four patients died after elective oesophagectomy within 90 days of their operation, while one of three emergency procedures had a fatal outcome. A total of 24 patients had evidence of lymph node involvement on histological examination of their specimens. The average stay in hospital was 27 days (range 12-83 days). All oesophagectomies returned to the intensive care unit postoperatively, their mean stay being 5.7 days (range 2-43 days). Postoperatively, only four patients were ventilated overnight. The complications are listed in Table IV. Cost analysis The cost to the hospital of an outpatient visit was IR£23.00*, a day in a hospital bed cost IR£130.00, a day *
Current exchange rate IR£1.00 = £0.93.
404
A D Hill et al.
in the intensive care unit cost IR£550.00, and an hour of operating time in theatre cost IR£187.00. The average cost of a work-up for an oesophagectomy including blood tests and radiographs was IR£325.00. The cost of an oesophagectomy carried out without complications and under optimum conditions was IRE3500. However, if significant complications occurred the costs could escalate. A Rossetti-Hell fundoplication cost IR£993 and a Heller's myotomy cost IR£1087.
Discussion Systematic appraisal of surgical practice has been the focus of increasing attention both from Governmental and Surgical Colleges in the United Kingdom and Ireland (2,3). As the demand for medical care will always exceed available resources, cost efficiency and justification for surgical practices is a recurring issue in all health care systems. The management philosophy for oesophageal carcinoma of this unit centres on the belief that oesophagectomy provides the best palliation and the best hope of cure for disease confined to the oesophagus or to local nodes. The type of oesophagectomy performed depends on the site of the tumour and the evolution of operative experience over 21 years. As a result of continuous reassessment of our practice and results, the 90-day hospital mortality rate for an elective oesophagectomy was reduced to 8% in 1990. It is difficult to define an acceptable morbidity and mortality rate for major surgery. A study to establish an acceptable mortality rate for oesophagectomy in 1986 retrospectively reviewed 3107 resections in 50 specialist thoracic units in the United Kingdom from 1980 to 1983, and concluded that a 14% mortality rate was as near optimal as possible given the nature of the disease and the characteristics of the population undergoing operation in the United Kingdom (4). Our relatively low mortality rate can be attributed to improved preoperative preparation, improved postoperative care and careful choice of operative procedure. Our practice includes the requirement for 5 days of aggressive in-hospital physiotherapy during routine preoperative assessment, which has led to decreased requirement for postoperative ventilation. The mean hospital stay of 27 days is due in part to the initiation in 1990 of a randomised trial on the role of adjuvant chemotherapy and radiotherapy followed by surgery versus surgery alone in the treatment of oesophageal cancer. The mean period of 5 days in the intensive care unit is considered essential to cater for the potential complications consequent on oesophagectomy. The complications of the 53 oesophagectomies are listed in Table IV. Respiratory complications occurred in over 40% of patients, pleural effusion being the most common, occurring in 32% of patients. Of endoscopies, 53% were performed as day cases. This figure reflects the fact that day ward sessions are limited and the majority of patients travel a long distance
and require inpatient accommodation, plus the fact that additional investigations are often indicated necessitating overnight admission. Only histologically proven benign strictures are dilated due to the high risk of perforation associated with dilatation of malignant strictures. All endoscopic procedures are performed under sedation. This policy is adhered to as many of our patients require repeat endoscopy during their lifetime due to the nature of their disease. Reversal by the benzodiazapine antagonist flumazanil is chiefly aimed at reducing patient recovery time and increasing efficiency of day ward beds. A long-term injection sclerotherapy programme for patients with oesophageal varices has catered for 41 patients over the past 10 years. The 5-year survival for all patients on this programme is 40% and compares favourably with other reports (5). Surgery is reserved for Child's category A or B patients in whom sclerotherapy fails to control the bleeding or in whom bleeding necessitates frequent readmissions to hospital, and no patient fulfilled these criteria in 1990. It has been shown conclusively that surgery for patients in Child's category C is not 'cost-effective' due to the high mortality associated with the procedure (6). Ten patients with symptomatic oesophageal reflux who had oesophagitis confirmed at endoscopy and reflux confirmed by 24 h pH assessment, had a Rossetti-Hell fundoplication. The cost of a Rossetti-Hell fundoplication was IR£993. Anti-reflux surgery is associated with an 85% success rate at 5-year follow-up (7). The cost of cimetidine for the same 5-year period would be IR£1680 and for omeprazole it would be IR£3720. The cost of a Heller's myotomy was IR£1087. Comparative costing with balloon dilatation is difficult owing to the different regimens advocated by gastroenterologists resulting in differing costs. However, in the only reported prospective study comparing the two techniques, the outcome after myotomy was successful in 95% as compared with 65% after balloon dilatation (8). Cost-effectiveness in surgery is difficult to define and comparisons between different units almost impossible owing to the variation in case mix, availability of resources, patient expectations as well as annual inflation and the cost of health care in different societies. Sophisticated economic analysis is clearly necessary but is difficult under current administrative arrangements. Data collection must be undertaken prospectively to establish values against which individual surgeons can assess their own results and compare costs of procedures with a similar outcome. The results presented here might provide a framework around which such data collection could take place.
References 1 Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. BrJy Surg 1991;78:356-60. 2 Royal College of Surgeons of England. Guidelines to Clinical Audit in Surgical Practice. London: Royal College of Surgeons of England, 1989.
Audit of an oesophageal unit 3 Government White Paper. Working for Patients. Medical Audit: Working Paper 6. London: Her Majesty's Stationery Office, 1989. 4 Mathews HR, Powell DJ, McConkey CC. Effect of surgical experience on the results of resection for oesophageal carcinoma. Br J Surg 1986;73:621-3. S Terblanche J, Bornman PC, Kahn D et al. Failure of repeated injection sclerotherapy to improve long-term survival after oesophageal variceal bleeding. Lancet 1983;2:132832. 6 Inokuchi K. Japanese research society for portal hypertension. Present status of surgical treatment of oesophageal
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varices in Japan: a nationwide survey of 3588 patients. World J Surg 1985;9: 171-80. 7 Csendes A, Braghetto I, Korn 0, Cortes C. Late subjective and objective evaluations of antireflux surgery in patients with reflux esophagitis: analysis of 215 patients. Surgery 1989;105: 374-82. 8 Csendes AM, Braghetto I, Henriquez A, Cortes C. Late results of a prospective randomised study comparing forceful dilatation and oesophagomyotomy in patients with achalasia. Gut 1989;30:299-304.
Received 22 January 1992
Book review Human Cross-sectional Anatomy - Atlas of Body Sections and CT Images by H Ellis, B Logan and A Dixon. 180 pp, illustrated. Butterworth-Heinemann, Oxford. 1991. No price given. ISBN 0 7506 1241 X The justification for the production of another book of crosssectional anatomy is stated as the recent improvement in CT imaging technology. When the meticulous efforts of reputed clinical anatomist, prosector and radiologist are combined in a detailed, attractive yet robust, practical ringback atlas, there is little room for doubt. With the evolution of modern imaging there is a need for anatomists, clinicians and radiologists to be more familiar with cross-sectional anatomical relationships throughout the body. The layout in this book of a double page spread throughout, comprising on the left a clear indication of the level of section alongside the anatomical specimen in colour and on the right the appropriate CT image along with a separate tracing and relevant notes, is well chosen. Labelling of structures on the specimen and tracing is by unobtrusive compatible numbers and a separate table on each page spread identifies the numbered structures. All sections are orientated in the axial plane as viewed from below. In the limbs, the left side is selected throughout and in the head the orientation is parallel to the Frankfort plane. Thus, uniformity is achieved throughout, making the book extremely user-friendly. The book begins with most helpful descriptions of preservation technique, sectioning technique, CT and orientation notes.
In all there are 90 cross-sections arranged in order of head and neck (28), thorax (11), abdomen (10), pelvis (18), lower limb (12) and upper limb (11). Both sexes are illustrated where appropriate. Clearly, images of patients cannot exactly correspond to cadaveric sections, especially at diaphragmatic level where the effects of inspiration for imaging purposes can shift structures from their resting vertebral levels. Some CT images are less than optimal quality and contrast has been used in many of the abdomino-pelvic examinations. However, the line tracings enable the reader to overcome visually this occasional handicap. The index is adequate, referring to structures by page number rather than section number. Overall, this is an impressive and unambiguous atlas, probably of considerable use to the anatomist, radiologist and radiographer. The specialist surgeon inevitably would find most of the work outside his immediate area of interest, however, and with the rate of progression of interventional radiology, MRI and ultrasound one suspects that the clinical relevance of this book will pass. However, it stands as an anatomical mile post and model for future atlases based on other imaging techniques.
P J LEOPARD Consultant Oral and Maxillofacial Surgeon Central Outpatients Department Stoke-on-Trent
