Esophageal Cancer

Esophageal cancer involves the eleven inch long tube that connects the throat to the stomach. The esophagus carries swallowed food to the stomach to be digested. Esophageal cancer can occur anywhere along the esophagus, but in people in the United States, it occurs most often in the lower portion of the esophagus. The causes of esophageal cancer are not well understood. Factors that contribute to the risk of esophageal cancer include alcohol, smoking, obesity and gastroesophageal reflux (GERD).

At Michigan Medicine, each patient with esophageal cancer undergoes a multidisciplinary assessment by the Thoracic Tumor Board, which brings together specialists from thoracic surgery, oncology, radiation therapy, radiology, nuclear medicine, and pathology to arrive at a consensus about the best course of treatment. Learn more about diagnosis and treatment of esophageal cancer at the University of Michigan.

When esophageal cancer limited to the esophagus and has not spread, surgery is the treatment of choice. Transhiatal esophagectomy (THE) is an operation developed and refined at Michigan Medicine that involves removing the diseased esophagus and rebuilding it, generally using the stomach. The procedure is performed through an incision in the neck and the abdomen and eliminates the need to open the chest (transthoracic esophagectomy). The cancerous esophagus is removed. In most cases, the stomach is then pulled up from the abdomen and connected to the remaining esophagus in the neck. This allows the patient to eat and drink again.

In evaluating our performance providing transhiatal esophagectomy (THE), it is important to consider several types of measures, including the volume of procedures, adherence to best practices (or care process) and the success (or outcome) of the procedure. The Society of Thoracic Surgeons (STS) provides national benchmarks for this procedure to help hospitals evaluate their performance. As you review the graphs below, you will see that Michigan Medicine consistently surpasses the STS national benchmarks.

Procedure volume is the number of times a procedure was performed in a year. This measure is often used to assess experience and expertise of both the surgeon and the team caring for the patient. Studies have linked higher volumes with more successful outcomes for some types of procedures, and esophagectomy is one of these. The following graphs display the total number of major esophageal operations and the number of transhiatal esophagectomy operations.

Total Number of Major Esophageal Operations

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Why is This Measure Important?

Michigan Medicine performs a large number of major esophageal operations. Many patients from around the world are referred here. Michigan Medicine performs many types of major esophageal operations, including transthoracic esophagectomy (esophagectomy through the chest), colon interpositions (using the colon to replace a diseased esophagus), sliding and paraesophageal hiatal hernia repairs, resection of esophageal diverticula (weak parts of the esophagus that pouch outward), esophagomyotomy for achalasia (a swallowing disorder), robotic esophageal procedures, laparoscopic esophageal procedures (procedures using a camera), etc. This is a measure of the volume, or number of major esophageal operations.

How is Michigan Medicine Performing?

Thoracic surgeons at the University of Michigan perform a substantial and increasing number of complex esophageal operations each year. Michigan Medicine has one of the largest esophageal surgery programs in the nation.

U-M Source: University of Michigan, Section of Thoracic Surgery Annual Report.

Number of Transhiatal Esophagectomy Operations

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Why is This Measure Important?

Health systems that perform a large number of esophagectomies are likely to have better outcomes, such as shorter hospitalizations for the procedure and higher survival rates. Both the surgeon, and the team helping to care for the patient, develop greater expertise with more experience. A variety of publications have defined a "high volume" esophageal center as one performing 5-15 esophagectomies per year. This is a measure of the volume, or number of esophagectomies operations.

How is Michigan Medicine Performing?

Thoracic surgeons at the University of Michigan performed an average of 100 transhiatal esophagectomies (THEs) annually for the past five years. About 84% of these operations are performed for treatment of esophageal cancer.

Having developed and refined this surgical approach, the University of Michigan has more experience with this operation and the multidisciplinary care of esophageal cancer than any other health system in the nation. In 2007, when we last published our results for this operation in a medical journal, we had the largest reported patient volume in the world (2,007 patients) who had undergone transhiatal esophagectomy. The results generated at the Michigan Medicine are often included among the "benchmark" standards for the surgical treatment of esophageal cancer.


U-M Source: University of Michigan, Section of Thoracic Surgery Annual Report.

This section describes the performance of the Michigan Medicine by measuring the extent to which we follow best practices when performing esophagectomy. When followed, these practices lead to better outcomes.

We have a program of preoperative preparation to ensure that patients are in the best possible shape for their operation. This program has lead to substantially lower complications and less need for postoperative intensive (ICU) care after transhiatal esophagectomy (See "Outcomes").

Current Smokers Undergoing Esophagectomy
Lower Value = Better Performance

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Why is This Measure Important?

Patients who are active smokers prior to major chest surgery tend to have more lung secretions and difficulty breathing after their operation. Insuring that a patient's lung function is as strong as possible before a transhiatal esophagectomy (THE) reduces lung complications such as pneumonia, which in turn shortens hospitalization and mortality (death rate). This is a measure of the percentage of patients who are current smokers prior to undergoing THE. Current smokers include patients who stopped smoking within 2 weeks prior to their operation. For this measure, a lower percentage means better performance.

How is Michigan Medicine Performing?

The University of Michigan results are substantially better than the national average reported in the Society of Thoracic Surgeons (STS) national database for the number of active cigarette smokers undergoing an esophagectomy. Of Michigan Medicine patients undergoing transhiatal esophagectomy, 2.0% are "current smokers" compared with an average of 14.3% nationally. In other words, 98% of our patients undergoing esophagectomy have stopped cigarette smoking for more than two weeks compared with 85.7% nationally.

U-M Source: University of Michigan, Section of Thoracic Surgery Database.
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report - January 2011

In this Section, we evaluate the success of transhiatal esophagectomy (THE) at the University of Michigan by measuring the occurrence of complications within 30 days of the operation. The risk of developing complications differs from patient to patient. These graphs compare our performance to the results for similar patients provided by the Society of Thoracic Surgeons (STS) from 2002-2010. In each of the following graphs, a lower number means fewer complications and better performance. The graphs show that most patients who underwent a THE procedure at Michigan Medicine rarely experience complications and our complication, and death rates are consistently lower than the STS national average.

Poor Lung Function within 30 Days After Operation
Higher Value = Better Performance

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Why is This Measure Important?

A poorly inflating lung, also called atalectasis, can occur after surgery because the patient is not breathing sufficiently deeply or coughing enough to raise secretions from the lung. Atelectasis and pneumonia are among the most deadly complications after any chest surgery. Bronchoscopy (passing a lighted tube down the airway) is frequently performed to suction away secretions in patients who develop atelectasis after a transhiatal esophagectomy (THE). This is a measure of the percentage of patients who underwent THE and experienced atelectasis requiring a bronchoscopy within 30 days after their operation. For this measure, a lower percentage means better performance.

How is Michigan Medicine Performing?

At the University of Michigan, we require that our patients discontinue cigarette smoking for 2-3 weeks before surgery. We also instruct our patients to use an incentive inspirometer (a portable device to practice deep breathing at home) each day for a minimum of 2-3 weeks prior to surgery and to walk 2-3 miles a day so that they are conditioned to resume walking shortly after their operation. The attention we pay to preoperative preparation is responsible for the lower rate of atelectasis requiring bronchoscopy - 0.8% in our patients compared to the STS national average of 6.4 %.

U-M Source: Database and/or Medical Record Review
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report

Mechanical Ventilator Needed within 30 Days After Operation
Higher Value = Better Performance

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Why is This Measure Important?

Patients with esophageal cancer undergoing an esophagectomy are often weak, lack the strength to breathe sufficiently after such major chest surgery, and must be supported on a mechanical ventilator (respirator) in the Intensive Care Unit (ICU) for several days after operation. This is a measure of the percentage of patients who underwent THE and required a mechanical ventilator within 30 days after their operation. For this measure, a lower percentage means better performance.

How is Michigan Medicine Performing?

At the University of Michigan, we require that our patients discontinue cigarette smoking for 2-3 weeks before surgery. We also instruct our patients to use an incentive inspirometer (a portable device to practice deep breathing at home) each day for a minimum of 2-3 weeks prior to surgery and to walk 2-3 miles a day so that they are conditioned to resume walking shortly after their operation. The attention we pay to preoperative preparation and our experience performing THE are responsible for the lower rate of mechanical ventilator use - 3.7% in our patients compared to the STS national average of 12.4%.

In addition, 96% of THE patients at Michigan Medicine never receive post-operative treatment in an ICU, the vast majority being hospitalized on our Thoracic Surgery general care floor, where walking the day after surgery is the rule.

U-M Source: Database and/or Medical Record Review
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report

Length of Hospitalization
Lower Value = Better Performance

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Why is This Measure Important?

The number of days spent in the hospital after transhiatal esophagectomy (THE) is influenced by several factors, including the patient's overall strength, the ease with which the operation was performed, the condition of her/her lungs, the development of infections, etc. A shorter length of hospitalization is desirable because it means that the patient has recovered and can return home sooner. This is a measure of the average number of days of hospitalization for patients who underwent THE. For this measure, a lower number means better performance.

How is Michigan Medicine Performing?

With a relatively large patient volume and our long experience with THE (nearly 3,000 patients), the entire team involved with pre-operative, intraoperative, and post-operative care function as a unit and ensure a smoother transition of the patient through their operation and recovery. At the University of Michigan, the average length hospitalization after THE is 12.6 days compared to the STS national average of 14.7 days.

U-M Source: Database and/or Medical Record Review
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report

Pneumonia within 30 Days After Operation
Higher Value = Better Performance

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Why is This Measure Important?

Pneumonia often accompanies or follows atelectasis (a poorly inflating lung) and historically has been one of the leading causes of death after an esophagectomy. It is frequently attributed to abnormal lung function caused by smoking and emphysema and excessive pulmonary secretions due to failure to breathe deeply after surgery. This is a measure of the percentage of patients who underwent THE and developed pneumonia within 30 days after their operation. For this measure, a lower percentage means better performance.

How is Michigan Medicine Performing?

At the University of Michigan, we require that our patients discontinue cigarette smoking for 2-3 weeks before surgery. We also instruct our patients to use an incentive inspirometer (a portable device to practice deep breathing at home) each day for a minimum of 2-3 weeks prior to surgery and to walk 2-3 miles a day so that they are conditioned to resume walking shortly after their operation. The attention we pay to preoperative preparation is responsible for the lower rate of pneumonia after transhiatal esophagectomy - 7.1% in our patients compared to the STS nations average of 12.0%.

U-M Source: Database and/or Medical Record Review
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report

Blood Transfusion Needed within 30 Days After Operation
Higher Value = Better Performance

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Why is This Measure Important?

The need for blood transfusion in operations for cancer always exists because tumors have a large blood supply, and bleeding complications can occur during procedures to remove them. Studies have shown that patients with cancer who require blood transfusions during operations to remove the tumors may have poorer survival rates. Blood transfusions are costly and also carry the risk of infections, allergic reactions, and increased length of hospitalization. There is a strong current trend to avoid transfusions whenever possible in patients undergoing transhiatal esophagectomy (THE) for cancer. This is a measure of the percentage of patients who underwent THE and required a blood transfusion within 30 days after their operation. For this measure, a lower percentage means better performance.

How is Michigan Medicine Performing?

Refinements in the technique of THE have resulted in substantially less blood loss than in the past and a lower transfusion rate. At the University of Michigan, 92% of THE patients receive no blood transfusion. In our patients, 7.4% receive a blood transfusion compared to the STS national average of 19.3%.

U-M Source: Database and/or Medical Record Review
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report

Death within 30 Days After Operation
Lower Value = Better Performance

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Why is This Measure Important?

Esophagectomy is a relatively high risk operation, particularly when performed in weakened patients with esophageal cancer. Post-operative deaths are typically reported as occurring within 30 days of the operation. As with other outcome measures reported here, mortality after transhiatal esophagectomy (THE) is often a reflection of how well the patient has been prepared for the operation, the skill of the surgeon, and the expertise of the team caring for the patient in the hospital. This is a measure of the percentage of patients who died within 30 days after undergoing THE. For this measure, a lower percentage means better performance.

How is Michigan Medicine Performing?

At the University of Michigan, THE patients fare better than the national averages. Our 30-day mortality is 1.0% compared to the national averages of 2.7%.

U-M Source: Database and/or Medical Record Review
Comparison Group Source: Society of Thoracic Surgeons General Thoracic Surgery Database Report