Healthcare Management

Trends in oesophago-gastric surgery in Scotland

G.C. Oniscu 
S. Paterson-Brown
Department of Clinical and Surgical Science (Surgery), The Royal Infirmary of Edinburgh Lauriston Place, Edinburgh, EH3 9YW

Correspondence to: Mr Simon Paterson-Brown, Department of Surgery, The Royal Infirmary of Edinburgh, Lauriston Place, Edinburgh, EH3 9YW                

Introduction Methods Results

Discussion Acknowledgements References

Background: The last twenty years have seen significant changes in both the incidence and treatment of gastro-oesophageal disorders as well as a process of subspecialisation in general surgery. The aim of this study is to identify the changes 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=0.001,.2) in the number 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<0.001, .2). There was a 3-fold increase in the incidence of GORD with a significant increase (p<0.001, .2) of those treated surgically. Since 1977, there has also been a significant shift of workload from thoracic to general surgical units. Conclusions: Scotland has seen a consistent increase in the surgical workload generated by gastro-oesophageal malignancies over the last three decades without any improvement in the operability rate. Surgically treated GORD has also increased, probably due to the introduction of minimally invasive techniques. These trends have implications on healthcare planning, resource allocation and surgical training. Appropriate resources and trainees should follow the patients to those units carrying out this activity. Further centralisation of these services is likely to follow

Keywords: Gastric cancer, oesophageal cancer, gastro-oesophageal reflux disease, oesophagogastric surgery, Scotland, trends 
Surg J R Coll Surg Edinb Irel., 1 February 2003, 51-57

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.^1-3 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.^4-6 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.^7-9 Since the 1970s, Scotland has consistently shown a high incidence of oesophageal cancer rising to 20 per 100,000 in the 1990s.¹⁰ However, unlike other UK regions, there has been no decline in the incidence of gastric cancer.^11-14

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 of GORD due to its suggested association with oesophageal cancer may have contributed.^15,16 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 extent of subspecialisation in general surgery and whether highly specialised procedures such as oesophageal resection should only be performed in specialist units, be they general or thoracic.^17-20 This study, therefore, was set up to observe the changes in gastro-oesophageal surgery in Scotland.

METHODS
Three sets of 12 month data, 10 years apart (1977, 1987, and 1997), consisting of the workload of general and thoracic surgical units across Scotland were analysed. There were six thoracic units performing oesophago-gastric surgery in 1977, eight in 1987 and five in 1997. Throughout the study period there were 41 general surgical units performing various oesophago-gastric procedures. Information regarding the total number of patients with oesophageal disorders, oesophageal cancer, gastric disorders, gastric cancer and GORD discharged from all general and thoracic surgical departments in Scotland was retrieved from the Information and Statistics Division of the Scottish National Health Service. Patient numbers were identified by the discharge diagnoses according to the ICD-8 and ICD-9 codes. The resections carried out for malignant disorders and all the procedures performed for GORD were identified using OPCS3 and OPCS4 codes. Mid-year population and age group estimates for the three years were obtained from the Office of the Registrar General Scotland.

The trends in the incidence and treatment of oesophageal and gastric cancers and GORD were analysed and statistical differences calculated with SPSS version 9.0 software using Chi-square or Chisquare for trend, where appropriate.

RESULTS
During the last 30 years, the Scottish population has been relatively stable, with no significant change in the ageing process (Table 1).

Oesophageal cancer 
The number of patients with oesophageal disorders admitted to general and thoracic surgical units in Scotland increased from 2200 in 1977 to 5363 in 1987 and 7813 in 1997. The workload distribution had two different patterns. While there was a continuous increase for the general surgical units, the number of patients admitted to thoracic units dropped by 29% between 1987 and 1997 after an initial increase in the first decade, as shown in Figure 1. Both trends were statistically significant (p<0.001, Chi-square for trend). There was a 3.3-fold increase in the number of oesophageal cancers seen by general surgeons, from 448 in 1977 to 1482 in 1997, while the number of patients managed in thoracic units decreased by 27% since 1987 (Figure 2). Overall, there was a significant increase (2.5-fold) in the incidence of patients with oesophageal cancer seen by both specialties since 1977 (Chi square, p < 0.001) and in the relative incidence of cancer between the three study decades (Table 2).

Figure 1: Number of patients with oesophageal disorders admitted to surgical units in Scotland

The number of resections performed for 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).

Figure 2: Number of oesophageal cancer in patients admitted to surgical units in Scotland

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<0.001) as shown in Table 2. In the same period, there was a 1.4-fold increase in the number of patients with gastric cancer admitted to surgical units, from 1273 in 1977 to 1791 in 1997, as illustrated in Figure 4, and this trend too, was statistically significant (p=0.0017, Chi square) (Table 2).

The resection rates relative to the number of admissions for patients with gastric cancer has decreased significantly since 1977 (21% in 1997 vs. 57% in 1977, p<0.001,Chi-square). There was also a 57% reduction in the number of partial gastrectomies and a 10% reduction in the number of total gastrectomies performed in the last decade, as shown in Table 4.

Figure 3: Number of patients with gastric disorders admitted to surgical units in Scotland 

Oesophageal reflux disease
There was a 3-fold increase in the number of patients admitted to surgical units with GORD, from 1112 in 1977 to 3392 in 1997 (Table 2), the majority of patients being managed in general surgical units (Figure 5). In the last decade, there has been a significant increase (p<0.001, Chi-square) in the proportion of surgically treated GORD (Figure 6). These changes in the workload of the surgical units were paralleled by an increase in the number of cases with oesophageal cancer, gastric cancer and GORD treated in medical units as shown in Table 2.

DISCUSSION
This study examines the workload in general and thoracic surgical units, as collected in the national statistics and expressed by the number of discharged patients and surgical procedures. Although these figures give an accurate indicator of the total workload in these units, they do not represent the true incidence of the disease in the general population. In addition, the classification of oesophago-gastric tumours, in particular those situated at the cardia, was refined over the last 20 years and the subsequent changes in the coding system could have raised some methodological difficulties. However, detailed equivalent coding was available to allow correct comparisons between similar groups of patients in the three study periods.

Since 1977, there has been a 3-fold increase in the incidence of oesophageal disorders admitted to surgical units in Scotland with a 2.5-fold increase in the oesophageal cancer workload alone. This is consistent with previous data from Scotland and is in-keeping with world-wide reports.^1,2,21 Although the data have been taken from individual years within the 20-year study period, the stability of the population and the large numbers involved suggest that they can be considered as fairly representative. Several factors could of course account for the trends observed: firstly, increased awareness of upper gastro-intestinal symptoms and refinements in diagnostic techniques; secondly, as surgical and anaesthetic techniques have improved, more patients are being assessed by surgeons; and finally, the true incidence of these disorders appears to be rising. While these data only reflect a small proportion of the true incidence of these diseases in the general population (as it relates only to those patients admitted under the care of general or thoracic surgeons), it is probably a reasonable indicator of the overall trend. One of the most disappointing results from this study is the failure to improve the percentage of patients undergoing resectional surgery for oesophago-gastric cancer over the past 20 years.

Although these rates do not represent true resectability rates (as the denominator only includes those patients seen by general surgeons and thoracic surgeons and does not include only new cases), a similar proportion of patients admitted under the care of general or thoracic surgical teams throughout the study period underwent resection. In addition, there is a suggestion of a different clinical practice between general surgical and thoracic units. A higher proportion of all patients admitted under the care of thoracic surgeons underwent resection, suggesting either a philosophy that resection is good palliation or that any subsequent follow-up or admissions which may not require surgery are under the care of different medical or surgical specialities.

Although this study has demonstrated a reduction in the overall surgical workload for gastric disorders since 1987, there has been a significant increase in the number of gastric cancers managed in surgical units since 1977. While previous reports were contradictory, these data suggest that the incidence of gastric cancer is not declining in Scotland.^13,21

However, unlike oesophageal cancer, the resection rate for gastric cancer has decreased since 1977 with only 20% of patients admitted in 1997 to surgical wards undergoing resection. This is obviously of concern, but may be partly explained by the associated number of partial gastrectomies which have halved and the total gastrectomies which have only decreased by 10% (Table 4). This is in keeping with data from other UK regions, which have demonstrated a reduction in distally located cancer, with a significant increase in the frequency of more aggressive proximal cancers.^13,14 Improvements in staging, and an increasing reluctance of surgeons to operate on patients who have little hope of a cure and with other forms of palliative therapy available, will also have contributed to these results.^22,23 In addition, the reduction in benign gastric ulcer surgery has lead to a situation whereby gastric surgery is now represented by more complex procedures, mainly for gastro-oesophageal malignancies.

The number of patients with GORD  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.^15,16

Figure 4: Number of patients with gastric cancer admitted to surgical units in Scotland

Figure 5: Number of patients with gastro-oesophageal reflux disease (GORD) admitted to surgical units in Scotland

Figure 6: Number of patients with gastro-oesophageal reflux disease treated surgically in Scotland (1977/1987/1997)

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.²⁰

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.²⁴ 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 turn, will reduce the experience in those units and hospitals which previously carried out oesophago-gastric surgery. They, in turn, 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.

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Copyright: 29 November 2002

ROYAL COLLEGE OF SURGEONS OF EDINBURGH

One Day Symposium

Myocardial Revascularisation 2003

24th 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

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