Trends in oesophago-gastric surgery in Scotland

Healthcare Management

Trends in oesophago-gastric surgery in Scotland Background: The lasttwenty years have seen significant changes in both theincidence and treatment of gastro-oesophageal disorders as well asa process of subspecialisation in general surgery. The aim of this study is to identify thechanges in gastro-oesophageal surgery in Scotland during this period. Methods: A retrospective analysis of three years of data, taken over a 20-year period (1977, 1987 and 1997) obtained from the Information and Statistics Division of the Scottish National Health Service, examining the number of patients with oesophageal cancer, gastric cancer and gastro-oesophageal reflux disease (GORD) treated by general and thoracic surgeons. Results: There was a significant increase (p=O.001,X2) in thenumber of patients with oesophageal cancer (2.52-fold) and gastric cancer (1.4-fold) treated by general compared with thoracic surgeons. Since 1977, the overall operability for oesophageal cancer has remained unchanged, while a significant decrease in the overall operability of gastric cancer was noted (p
G.C.Oniscu S. Paterson-Brown Department of Clinical and Surgical Science (Surgery), The Royal Infirmary of Edinburgh Lauriston Place, Edinburgh, EH39YW Correspondence to: MrSimon PatersonBrown, Department of Surgery, The Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh, EH3 9YW

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INTRODUCTION The last three decades have seen significant changes in the incidence and treatment of gastro-oesophageal disorders. Despite large international variations, there has been a constant increase in the incidence of oesophageal cancer (mainly adenocarcinoma of the oesophagus), paralleled by a similar increase in the frequency of cancer of the gastric cardia."? This trend, combined with the similar characteristics and epidemiological factors, have resulted in the suggestion that these two sites be considered as an expression of the same clinical entity.'" However, while oesophageal cancer is becoming increasingly more common, there has been an overall decline in the incidence of gastric cancer, associated with a change in the anatomical site from distal to proximal." Since the 1970s, Scotland has consistently shown a high incidence of oesophageal cancer rising to © 2003 Surg J R Coli Surg Edinb Irell: 1;51-57

20 per 100,000 in the 1990s. 1O However, unlike other UK regions, there has been no decline in the incidence of gastric cancer.":" During the last 30 years, a significant trend has also been observed in the incidence of benign gastric disorders requiring surgical treatment, with a reduction in peptic ulcer disease surgery and a gradual increase in surgery for gastro-oesophageal reflux disease (GORD). This is most likely explained by the introduction of minimally invasive techniques, although an increased awareness ofGORD due to its suggested association with oesophageal cancer may have contributed.P:" During the same period there has also been a process of major restructuring in general surgery, with the development of many subspecialties, resulting in a situation whereby patients with gastro-oesophageal disorders are being treated by both thoracic and general surgeons. Controversy still persists with regards to the The Royal Colleges ofSurgeons ofEdinburgh and Ireland

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regarding the total number of patients with oesophageal disorders, oesophageal cancer, gastric disorders, gastric cancer and GORD discharged 1977 1987 1997 from all general and thoracic surgical Age groups Population (%) departments in Scotland was retrieved Population (%) Population (%) from the Information and Statistics Division of the Scottish National 0-15 1,320,095 (25.3) 1,042,988 (24.1) 1,020,671 (20) Health Service. Patient numbers were identified by the discharge diagnoses according to the ICD-8 and ICD-9 2,021 ,947 (38.7) 2,203,907 (39.5) 2,140,334 (41 .8) 16-45 codes. The resections carried out for malignant disorders and all the procedures performed for GORD 899,189 (17.2) 845,801 (16.5) 924,214 (18) 46-60 were identified using OPCS3 and OPCS4 codes. Mid-year population and age group estimates for the three >60 984,969 (18.8) 1,019,904 (19.9) 1,037,281 (20.2) years were obtained from the Office of the Registrar General Scotland. Total 5,226,200 5,112,600 5,122,500 The trends in the incidence and treatment of oesophageal and gastric cancers and GORD were analysed extent of subspecialisation in general surgery and whether highly specialised procedures and statistical differences calculated with SPSS such as oesophageal resection should only be version 9.0 software using Chi-square or Chiperformed in specialist units, be they general or square for trend, where appropriate. thoracic.'>" This study, therefore, was set up to observe the changes in gastro-oesophageal RESULTS surgery in Scotland. During the last 30 years, the Scottish population has been relatively stable, with no significant change in the ageing process (Table 1). METHODS Key for Figures 1-6 Three sets of 12 month data, 10 years apart (1977, 1987, and 1997), consisting of the Oesophageal cancer Thoracic su rgery workload of general and thoracic surgical units The number of patients with oesophageal • General surgery across Scotland were analysed. There were six disorders admitted to general and thoracic thoracic units performing oesophago-gastric surgical units in Scotland increased from 2200 in 1977 to 5363 in 1987 and 7813 in 1997. Figure 1: Number of patients with surgery in 1977, eight in 1987 and five in The workload distribution had two different oesophageal disorders admitted to 1997. Throughout the study period there were 41 general surgical units performing various patterns. While there was a continuous increase surgical units inScot/and oesophago-gastric procedures. Information for the general surgical units, the number of patients admitted to thoracic units dropped by 29% between 1987 and 1997 after an initial 7000 increase in the first decade, as shown in Figure 1. Both trends were statistically significant 6000 (p<0.001, Chi-square for trend). There was a 5000 3.3-fold increase in the number of oesophageal cancers seen by general surgeons, from 448 in Number 4000 of 1977 to 1482 in 1997, while the number of patients patients managed in thoracic units decreased by 3000 27% since 1987 (Figure 2). Overall, there was 2000 a significant increase (2.5-fold) in the incidence of patients with oesophageal cancer seen by 1000 both specialties since 1977 (Chi square, p < 0.001) and in the relative incidence of cancer 0 1987 1997 1977 between the three study decades (Table 2). The number of resections performed for Year TABLE 1. MID·YEAR POPULATION ESTIMATES INSCOTLAND FOR AGE GROUPS AND YEAR OF STUDY

• • • • The Royal Colleges ofSurgeons ofEdinburgh and Ireland

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oesophageal cancer increased continuously from 139 in 1977 to 293 in 1997 (1.5-fold), but the overall resection rate, relative to the number of patients with oesophageal cancer admitted in all units, did not vary significantly between the three periods (Table 3). In 1997, of all operations performed for oesophago-gastric disorders, oesophageal resection for cancer represented 40% in thoracic units and only 21% in general surgical units. Furthermore, a significantly higher proportion of patients treated in thoracic units underwent resection, compared with those treated in general surgical units (p=0.0038, Chi-square) (Table 3).

1600 1400 1200 1000 Number of patients

800 600 400 200 0 1977

1987

1997

Year

Gastric cancer The overwhelming majority of gastric disorders in Scotland were managed in general surgical units with only a limited number being treated by thoracic surgeons (Figure 3). After an initial increase in presentation in the first decade, there was a drop in the incidence of surgically managed gastric disorders since 1987 (Figure 3). Both changes were

statistically significant (p
Figure 2: Number of oesophageal cancer in patients admitted to surgical units in Scot/and

TABLE 2. NUMBER AND INCIDENCE (PER MILLION POPULATION) OF PATIENTS ADMIITED TO SURGICAL UNITS AND MEDICAL UNITS IN SCOTLAND (1977/1987/1997) 1977 Number ofpatients (pmp) Surgical units

1987 Number of patients (pmp)

1997 Number of patients (pmp)

p value

Medical units

Surgical units

Medical units

Surgical units

Medical units

Oesophageal 2200 disorders (420)

1925 (368)

5363 (1048)

4295 (840)

7813 (1525)

13982 (2729)

0.001

Oesophageal 720 cancer (138)

442 (84.5)

1316 (257)

718 (140)

1840 (359)

2071 (404)

0.001

Gastric disorders

8547 (1635)

6371 (1219)

10602 (2073)

12800 (2503)

9987 (1949)

17287 (3374)

0.001

Gastric cancer

1273 (243)

680 (130)

1416 (277)

750 (146)

1791 (349)

2400 (486)

0.0017

GORD

1112 (213)

1334 (255)

3070 (600)

2808 (549)

3392 (662)

3445 (672)

0.001

5226200

5226200

5112600

5112600

5122500

5122500

Total population

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The Royal Colleges ofSurgeons of Edinburgh and Ireland

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12000

gastric cancer and GORD treated in medical units as shown in Table 2.

10000 8000

DISCUSSION

This study examines the workload in general and thoracic surgical units, as collected in the Number of 6000 patients national statistics and expressed by the number of discharged patients and surgical procedures. 4000 Although these figures give an accurate indicator of the total workload in these units, 2000 they do not represent the true incidence of the disease in the general population. In addition, 0 the classification of oesophago-gastric tumours, 1977 1987 1997 in particular those situated at the cardia, was Year refined over the last 20 years and the subsequent changes in the coding system could have raised Figure 3: Number of patients of admissions for patients with gastric cancer some methodological difficulties. However, with gastric disorders admitted to has decreased significantly since 1977 (21% in 1997 vs. 57% in 1977, p
over the past 20 years. Although TABLE 4. GASTRIC CANCER OPERABILITY (TOTALAND PARTIAL GASTRECTOMY) AND these rates do not represent CHANGES BETWEEN THE THREE DECADES (1977/1987/1997) true resectability rates (as the denominator only includes Number cases Number cases Number cases Statistical those patients seen by general 1977 1987 1997 significance surgeons and thoracic surgeons and does not include only new Gastriccancer 1273 1416 1791 cases), a similar proportion of patients admitted under the p=0.008 (1997/1987) care of general or thoracic Total gastrectomy 129 137 116 p=0.002 (1997/1 977) surgical teams throughout p=N.S. (1987/1977) the study period underwent resection. In addition, there is a suggestion of a different Partialgastrectomy 593 422 255 p<0.001 forall groups clinical practice between general surgical and thoracic Resection rate 722 (56.71) 559 (39.47) 371 (20.71) p<0.001 forall groups units. A higher proportion of all patients admitted under the care of thoracic surgeons underwent resection, 1800 suggesting either a philosophy that resection 1600 is good palliation or that any subsequent follow-up or admissions which may not require 1400 surgery are under the care of different medical 1200 or surgical specialities. Number of 1000 patients Although this study has demonstrated a 800 reduction in the overall surgical workload for gastric disorders since 1987, there has been a 600 significant increase in the number of gastric 400 cancers managed in surgical units since 1977. 200 While previous reports were contradictory, o these data suggest that the incidence of 1977 1987 1997 gastric cancer is not declining in Scotland. 13,21 Year However, unlike oesophageal cancer, the resection rate for gastric cancer has decreased Figure 4: Number of patients with since 1977 with only 20% of patients admitted gastric cancer admitted to surgical in 1997 to surgical wards undergoing resection. units in Scot/and Figure 5: Number of patients with This is obviously of concern, but may be partly gastro-oesophageal reflux disease explained by the associated number of partial (GORD) admitted to surgical units gastrectomies which have halved and the total in Scot/and gastrectomies which have only decreased by 10% (Table 4). This is in keeping with data from 3500 other UK regions, which have demonstrated 3000 a reduction in distally located cancer, with a significant increase in the frequency of more 2500 aggressive proximal cancers. 13.14 Improvements Number of in staging, and an increasing reluctance of 2000 patients surgeons to operate on patients who have 1500 little hope of a cure and with other forms of palliative therapy available, will also have 1000 contributed to these results.v-" In addition, the reduction in benign gastric ulcer surgery has 500 lead to a situation whereby gastric surgery is 0 now represented by more complex procedures, 1977 1987 1997 mainly for gastro-oesophageal malignancies. Year The number of patients with GORD © 2003 Surg J R Coli Surg Edinb /re/1: 1;51-57

The Royal Colleges ofSurgeons ofEdinburgh and Ireland

11_

2~0

200 Number of patients

1~O

100 ~O

0 1977

1987

1997

Year

Figure 6: Number of patients with gastro-oesophageal reflux disease treated surgically in Scotland (1977/

1987/1997)

treated by surgeons is increasing in Scotland. Although a higher index of suspicion due to its association with oesophageal cancer may be partially responsible for the diagnostic increase, the increase in surgical treatment is most likely due to the more widespread use of minimally invasive techniques.P:" It can be argued that all these changes reflect the evolution of the referral practice away from medical gastroenterology towards its surgical counterpart. Although this may be true, it was noted that in Scotland there was a simultaneous increase in the number of patients with the diagnoses in question treated in medical units. This study has confirmed the rising number of patients with gastro-oesophageal disorders which are treated by surgeons in Scotland, with most of the increase in workload occurring within general surgical units. The data discussed have major implications, not only for the planning and provision of future healthcare delivery and resource allocation, but also for surgical training. These data provide further fuel to the increasing, existing controversy regarding what type of surgeon should operate on which upper gastrointestinal condition and, furthermore, which units should train surgeons in these procedures." The right surgeon to treat oesophago-gastric disorders does not have to be either a general or thoracic surgeon. As in all forms of surgery, however, the surgeon should be someone who can obtain exposure to the wide variety of relevant conditions and who is trained appropriately in their treatment. In Guidance on Commissioning Cancer Services produced by the NHS executive on improving outcome in gastrointestinal cancers has identified appropriate levels of activity

for individual surgical units in England and Wales." When combined with the data from this study, the implications to those in charge of healthcare planning and surgical training in Scotland becomes clear. Appropriate resources must now follow the "patients" to those units which are increasingly carrying-out oesophagogastric surgery. These units are likely to become increasingly centralised due to the volume of work and trainees will undoubtedly need to be attached to these units for appropriate oesophago-gastric experience. This, in tum, will reduce the experience in those units and hospitals which previously carried out oesophago-gastric surgery. They, in tum, may have to accept transfer of resources and a change in training opportunities offered to their surgical trainees. Close co-operation, in the form of managed clinical networks, however, may help to maintain some expertise in those hospitals with a low volume of work.

ACKNOWLEDGEMENTS We wish to thank Dr. Marion Baines and her team at the Information and Statistics Division of the Scottish National Health Service for providing the data. Copyright: 29November 2002

ROYAL COLLEGE OF SURGEONS OF EDINBURGH

One Day Symposinm

Myocardial Revascularisation 2003 24 TH April 2003 Convenor - Mr R R Jeffrey

Speakers Include Dr Lawrence Bonchek, Pennsylvania Mr Alex Cale, Hull Dr Marcus Flather, London Dr Keith Oldroyd, Glasgow Mr Andrew Ritchie, Pappworth Mr David Taggart, Oxford Mr Vipen Zamvar, Edinburgh

This Symposium will be of interest to all cardiothoracic surgeons and trainees. Physicians with an interest in cardiology and all cardiologists. The Registration Fee is £ 175 for Consultants and £130.00 for trainees Please contact Mrs Maureen Lowrie for an application form and detailed programme. 44 (0) 131 6689209 [email protected]

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REFERENCES 1. Parkin M, Muir CS, Wheelan SL, et al., eds. Cancer Incidence in Five Continents, vol. VI (IARC Scientific Publication No 120). Lyon: Internationa/ Agency for Research On Cancer, 1992 2. Jensen OM, Esteve J, Moller H, et al. Cancer in the European Community and its Member States. Eur J Cancer 1990; 26: 1167-256 3. Blot WJ, Devesa SS, Kneller RW, et at. Rising incidence of adenocarcinoma of the oesophagus and gastric cardia. JAMA 1991; 265: 1287-89 4. Dolan K, Sutton R, Walker SJ, et at. New classification of oesophageal and gastric carcinomas derived from changing patterns in epidemiology. Br J Cancer 1999; 80: 834-42 5. Wijnhoven BPL, Siersema PD, Hop WCJ, et at. Adenocarcinomas of the distal oesophagus and gastric cardia are one clinical entity. Br J Surg 1999; 86: 529-35 6. Heidl G, Langhans P, Mellin W, et at. Adenocarcinomas of oesophagus and cardia in comparison with gastric carcinoma. J Cancer Res Clin Onco/1993; 120: 95-99 7. Antonioli DA, Cady B. Changing aspects of gastric adenocarcinoma [letter]. N Eng/ J Med 1984; 310: 1538 8. Devesa SS, Blot WJ, Fraumeni JF Jr. Changing patterns in the incidence of oesophageal and gastric carcinoma in the United States. Cancer 1998; 83: 2049-53 9. Allum WH, Powell DJ, McConkey CC, et at. Gastric cancer: a 25-year review. Br J Surg 1989; 76: 53540 10. Anderson JR. Incidences of gastric and oesophageal cancer in Europe [letter]. Scott Med J 1998; 43: 41 11. Powell J, McConkey cc. Increasing incidence of adenocarcinoma of the gastric cardia and adjacent sites. Br J Cancer 1990; 62: 440-43 12. Rios-Castellanos E, Sitas F, Sheperd NA, et at. Changing patterns in gastric cancer in Oxfordshire.

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Gut 1992; 33: 1312-17 13. Sedgwick DM, Akoh JA, Macintyre IMC. Gastric cancer in Scotland: changing epidemiology, unchanging workload. Br Med J 1991; 302: 1305-07 14. Akoh JA, Sedgwick DM, Macintyre IMC. Improving results in gastric cancer - an 11 year audit. Br J Surg 1991; 78: 349-51 15. Watson A. Surgical management of gastrooesophageal reflux disease. Br J Surg 1996; 83: 1313-15 16. Lagergren J, Bergstrom R, Lindgren A, et at. Symptomatic gastroesophageal reflux as a risk factor for esophageal adenocarcinoma. N Eng/ J Med 1999; 340: 825-31 17. Kelly K. New directions in gastrointestinal surgery. Am JSurg 1994; 167: 2-7 18. Jordan GL Jr. The future of general surgery. Am J Surg 1991; 161: 194-202 19. Nambiar RM. General surgery in an era of superspecialisation - what is the future? Ann Acad Med Singapore 1995; 24: 180-87 20. McCulloch P. Should general surgeons treat gastric carcinoma? An audit of practice and results, 19801985. BrJ Surg 1994; 81: 417-20 21. McKinney PA, Sharp L, Macfarlane GJ, et at. Oesophageal and gastric cancer in Scotland 19601990. Br J Cancer 1995; 71: 411-15 22. Smith A, Finch MD, John TG, et at. Role of laparoscopic ultrasonography in the management of patients with oesophagogastric cancer. Br J Surg 1999; 86: 1083-87 23. Blazeby JM, Alderson D, Farndon JR. Quality of life in patients with oesophageal cancer. In: Recent results in cancer research - Esophageal carcinoma, vol. 55 J Lange J and JR Siewert (eds.) Berlin: Springer-Verlag, 2000: 193-204 24. Guidance on Commissioning Cancer Services. Improving outcomes in upper gastro-intestinal cancers. NHS Executive; Jan.2001

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