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Original Investigation
June 23, 2021

Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer

Author Affiliations
  • 1Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
  • 2Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
  • 3Department of Oesophago-Gastric Cancer Surgery, Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, United Kingdom
  • 4Center for Esophageal Diseases, Elisabeth Hospital Essen, University Medicine Essen, Essen, Germany
  • 5Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
  • 6Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
  • 7Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
  • 8Department of Digestive Surgery, Guy’s & St Thomas’ National Health Service Foundation Trust, London, United Kingdom
  • 9Department of Digestive and Oncological Surgery, Hirslanden Medical Center, Zurich, Switzerland
  • 10Department of Digestive Surgery, Hospital Universitario del Mar, Barcelona, Spain
  • 11Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
  • 12Department of Digestive Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
  • 13Department of Thoracic Surgery, Keio University, Tokyo, Japan
  • 14Department of Surgery, Massachusetts General Hospital, Boston
  • 15Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas
  • 16Department of Thoracic and Cardiovascular Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
  • 17Department of Thoracic Surgery, National University Hospital, Singapore, Singapore
  • 18Department of Surgery, Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
  • 19Department of Upper Gastrointestinal Surgery, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
  • 20Department of Surgery, Odense University Hospital, Odense, Denmark
  • 21Digestive Health Center, Oregon Health and Science University, Portland
  • 22Oesophagogastric Cancer Multidisciplinary Team, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
  • 23Department of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
  • 24Department of Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom
  • 25Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
  • 26Department of Gastrointestinal Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
  • 27Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Chengdu, China
  • 28Department of Surgery, St James’s Hospital Trinity College, Dublin, Ireland
  • 29Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
  • 30Department of Thoracic Surgery, The University of Chicago Medicine, Chicago, Illinois
  • 31Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
  • 32Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
  • 33Department of Gastrointestinal Surgery, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
  • 34Department of Surgery, University Medical Center, Utrecht, the Netherlands
  • 35Department of Thoracic Surgery, University of Michigan Health System, Ann Arbor
  • 36Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
  • 37Department of Upper Gastrointestinal Surgery, University of Verona, Verona, Italy
  • 38Department of Upper Gastrointestinal Surgery, Vita-Salute San Raffaele University, Milan, Italy
  • 39Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
JAMA Surg. Published online June 23, 2021. doi:10.1001/jamasurg.2021.2376
Key Points

Question  Can death within 90 days be accurately predicted before esophagectomy for cancer?

Findings  In this diagnostic/prognostic study, a scoring system that predicted death within 90 days based on logistic regression β coefficients was developed for 8403 patients randomly assigned to development (n = 4172) and validation (n = 4231) cohorts. On the basis of 10 preoperative variables, the final score allowed stratification into 5 risk groups: very low risk (1.8%), low risk (3.0%), medium risk (5.8%), high risk (8.9%), and very high risk (18.2%) of death within 90 days.

Meaning  The International Esodata Study Group risk prediction model allowed for stratification of an individual patient’s risk of death within 90 days after esophagectomy and may aid decision-making and the consent process between patients and surgeons.


Importance  Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions.

Objective  To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes.

Design, Setting, and Participants  In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts.

Exposures  Esophageal resection for cancer of the esophagus and gastroesophageal junction.

Main Outcomes and Measures  All-cause postoperative 90-day mortality.

Results  A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, –1 to –2; 90-day mortality, 5.8%), high risk (score, −3 to −4: 90-day mortality, 8.9%), and very high risk (score, ≤−5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort.

Conclusions and Relevance  In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient’s risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.

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