Perioperative Complications in the Cancer Patient: A Robust Prognostic Factor

Abstract

As surgeons, we grew up learning about postoperative complications in the forum known as the Morbidity and Mortality (M&M) conference. We learned that certain genre of complications, such as intra-abdominal infections, myocardial ischemia, pneumonia, and deep venous thrombosis, portend especially detrimental outcomes for our surgical patients. The concept of the M&M conference developed from the seminal work of Dr. Ernest Amory Codman who, in the early 1900s working at Massachusetts General Hospital, recognized that in order to learn from our mistakes and improve patient care we had to discuss unsuccessful outcomes, quantify and catalogue these misadventures, and follow the course of our patients. These tenets espoused by Codman were not embraced by his fellow Boston physicians and he was invited to remove himself from the environment of the medical staff and hospital! Codman’s early endeavors into developing databases and reporting outcomes served, however, as the basis for the quality initiatives first developed by the American College of Surgeons (ACS) during the infancy of that organization in the second decade of the twentieth century. Subsequently, the creation of risk-adjusted instruments, such as the Veterans Administration (VA)initiated National Surgical Quality Improvement Program (NSQIP) launched in the early 1990s and the ACS–NSQIP promulgated to all hospitals more recently, has provided analytic tools not only to evaluate the consequences of surgical complications during the immediate postoperative period but to assess the ultimate effects of these events on the entire course of an illnesses, such as cancer. As an important derivative from the ACS–NSQIP, the Surgical Risk Calculator recently has been launched to facilitate the computation of the likelihood of 30-day outcomes for a large number of surgical procedures given the presence of preoperative comorbidities. The late Shukri Khuri, working with his VA colleagues using the VA-NSQIP database, showed that the 30-day complication rate is a robust factor in determining both short(30-day) and long-term survivals for all patients undergoing eight common operations. Although not directed previously to cancer patients, Khuri’s work suggested that the ‘‘inflammatory response’’ resulting from postoperative complications was a detrimental factor in determining long-term survival and was independent of patients’ preoperative risks. The importance of this work had obvious implications for patients with malignancy. The prognosis of cancer is dependent on adequate staging of patients. More recently, molecular markers along with anatomical staging have been added to the taxonomy of outcomes of cancer patients. Unfortunately, the role of comorbidities, although championed by some, continues to be unrecognized as a major factor in the outcomes of cancer patients. Along with this, we have generally failed to understand the importance of the postoperative complication on the future of our cancer patient. Perhaps complicated outcomes are associated with other factors. The adverse effect of blood transfusion has been delineated as a reason for reduced survival in cancer patients, perhaps as a consequence of reduced immunocompetence resulting from transfusion. Obviously patients with postoperative complications may have an increased This is an editorial to the article available at doi: 10.1245/s10434013-3267-0.