Impact of Smoking Status on Perioperative Morbidity, Mortality, and Long-Term Survival Following Transthoracic Esophagectomy for Esophageal Cancer

Abstract

Introduction Esophagectomy is a key component in the curative treatment of esophageal cancer. Little is understood about the impact of smoking status on perioperative morbidity and mortality and the long-term outcome of patients following esophagectomy. Objective This study aimed to evaluate morbidity and mortality according to smoking status in patients undergoing esophagectomy for esophageal cancer. Methods Consecutive patients undergoing two-stage transthoracic esophagectomy (TTE) for esophageal cancers (adenocarcinoma or squamous cell carcinoma) between January 1997 and December 2016 at the Northern Oesophagogastric Unit were included from a prospectively maintained database. The main explanatory variable was smoking status, defined as current smoker, ex-smoker, and non-smoker. The primary outcome was overall survival (OS), while secondary outcomes included perioperative complications (overall, anastomotic leaks, and pulmonary complications) and survival (cancer-specific survival [CSS], recurrence-free survival [RFS]). Results During the study period, 1168 patients underwent esophagectomy for cancer. Of these, 24% (n = 282) were current smokers and only 30% (n = 356) had never smoked. The median OS of current smokers was significantly shorter than ex-smokers and non-smokers (median 36 vs. 42 vs. 48 months; p = 0.015). However, on adjusted analysis, there was no significant difference in long-term OS between smoking status in the entire cohort. The overall complication rates were significantly higher with current smokers compared with ex-smokers or non-smokers (73% vs. 66% vs. 62%; p = 0.018), and there were no significant differences in anastomotic leaks and pulmonary complications between the groups. On subgroup analysis by receipt of neoadjuvant therapy and tumor histology, smoking status did not impact long-term survival in adjusted multivariable analyses. Conclusion Although smoking is associated with higher rates of short-term perioperative morbidity, it does not affect long-term OS, CSS, and RFS following esophagectomy for esophageal cancer. Therefore, implementation of perioperative pathways to optimize patients may help reduce the risk of complications.

Economic burden of complications and readmission following oesophageal cancer surgery

“…15 Pre-operative 'prehabilitation', optimisation of nutrition and smoking cessation have also been considered as opportunities to minimize postoperative morbidity in patients with oesophageal cancer. 16,17,18 Given 14% of patients were current smokers at time of surgery, interventions to aid smoking cessation may aid to modify morbidity of the operation. Ultimately, further studies on the feasibility of perioperative interventions to reduce complications is indicated.…”

Textbook outcome after minimally invasive esophagectomy is an important prognostic indicator for predicting long-term oncological outcomes with locally advanced esophageal squamous cell carcinoma

“…Importantly, the absence of a previous history of smoking has been shown to reduce the incidence of postoperative lung disease. Smoking is also considered to be a risk factor for morbidity after esophagectomy, especially in cases involving pulmonary complications (34,35). In clinical practice, ECSS patients with these high-risk factors should be identified, and a more comprehensive treatment plan should be developed for such patients.…”

Risk Factors for Failure of Direct Oral Feeding Following a Totally Minimally Invasive Esophagectomy

“…For squamous cell carcinoma, this may be explained by its underlying pathogenesis, wherein major etiological factors are tobacco smoking and alcohol consumption—which also act synergistically—and poor diet [ 27 ]. It has previously been reported that these patients have a higher preoperative risk profile, e.g., due to a poorer nutritional status and poorer pulmonary function, thereby increasing the risk of postoperative morbidity in these patients [ 27 , 28 , 29 ]. Although data on the extent of smoking (pack years) and the exact amount of alcohol consumption in this current cohort was limited, there was no significant association between SCC and a higher preoperative risk profile (i.e., smoking, alcohol consumption, obesity, comorbidity), as shown in Supplementary Table S5 .…”