, Volume 16, Issue 4, pp 386–394 | Cite as

A low surgical Apgar score is a predictor of anastomotic leakage after transthoracic esophagectomy, but not a prognostic factor

  • Masato Hayashi
  • Hirofumi KawakuboEmail author
  • Shuhei Mayanagi
  • Rieko Nakamura
  • Koichi Suda
  • Norihito Wada
  • Yuko Kitagawa
Original Article



The surgical Apgar score (SAS) has been a useful predictor of postoperative complications in several types of cancer. However, there are few reports about the correlation of SAS and esophageal cancer. This study aimed to examine the utility of SAS as a predictor of major complications, particularly anastomotic leakage, in patients who underwent transthoracic esophagectomy, and investigate the correlation between SAS and patient prognosis.


This is a single-center, retrospective observational study. A total of 190 patients who underwent esophagectomy for esophageal cancer in 2012–2016 were reviewed to find the correlation between SAS and postoperative complications (Clavien–Dindo classification III or higher). SAS was calculated based on intraoperative estimated blood loss, lowest mean arterial pressure, and lowest heart rate. Major complications included anastomotic leakage, respiratory, cardiac, recurrent nerve palsy, chylothorax, and other complications. We also reviewed how SAS was correlated with 3 year overall survival (OS) and recurrence-free survival (RFS). A high SAS was defined as ≥ 6, and a low SAS as < 6.


On univariate analysis, SAS showed a statistical significance in all major complications and anastomotic leakage. On multiple logistic regression analysis, a low SAS was detected as a risk factor of the major complications and anastomotic leakage, with a significant difference. Moreover, we conducted survival analysis with SAS; however, we could not detect that a low SAS had a negative impact on OS and RFS.


A low SAS can be a predictor of postoperative complications, especially anastomotic leakage. However, SAS was not correlated with OS or RFS.


Esophageal cancer Complication Risk assessment 



The authors thank Kumiko Motooka, who belongs to the staff at the Department of Surgery in Keio University School of Medicine, for her help in the preparation of this report.

Compliance with ethical standards

Ethical Statement

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for being included in the study.

Conflict of interest

Author Masato Hayashi, Corresponding Author Hirofumi Kawakubo, Author Shuhei Mayanagi, Author Rieko Nakamura, Author Koichi Suda, Author Norihito Wada, and Author Yuko Kitagawa state that they have no conflict of interest.


  1. 1.
    Gawande AA, Kwaan MR, Regenbogen SE, Lipsitz SA, Zinner MJ. An Apgar Score for surgery. J Am Coll Surg. 2007;204:201–8.CrossRefGoogle Scholar
  2. 2.
    Regenbogen SE, Lancaster RT, Lipsitz SR, Greenberg CC, Hutter MM, Gawande AA. Does the Surgical Apgar score measure intraoperative performance? Ann Surg. 2008;248:320–8.CrossRefGoogle Scholar
  3. 3.
    Hsu SY, Ou CY, Ho YN, Huang YH. Application of Surgical Apgar score in intracranial meningioma surgery. PLoS One. 2017;12:e0174328.CrossRefGoogle Scholar
  4. 4.
    Urrutia J, Valdes M, Zamora T, Canessa V, Briceno J. Can the Surgical Apgar Score predict morbidity and mortality in general orthopaedic surgery? Int Orthop. 2012;36:2571–6.CrossRefGoogle Scholar
  5. 5.
    Reynolds PQ, Sanders NW, Schildcrout JS, Mercaldo ND, St Jacques PJ. Expansion of the Surgical Apgar Score across all surgical subspecialties as a means to predict postoperative mortality. Anesthesiology. 2011;114:1305–12.CrossRefGoogle Scholar
  6. 6.
    Clark RM, Lee MS, Rauh-Hain JA, et al. Surgical Apgar Score and prediction of morbidity in women undergoing hysterectomy for malignancy. Gynecol Oncol. 2015;136:516–20.CrossRefGoogle Scholar
  7. 7.
    Ito T, Abbosh PH, Mehrazin R, et al. Surgical Apgar Score predicts an increased risk of major complications and death after renal mass excision. J Urol. 2015;193:1918–22.CrossRefGoogle Scholar
  8. 8.
    Wied C, Fross NB, Kristensen MT, Holm G, Kallemose T, Troelsen A. Surgical Apgar Score predicts early complication in transfemoral amputees: retrospective study of 170 major amputations. World J Orthop. 2016;7:832–8.CrossRefGoogle Scholar
  9. 9.
    La Torre M, Ramacciato G, Nigri G, Balducci G, Cavallini M, Rossi M, Ziparo V. Post-operative morbidity and mortality in pancreatic surgery. the role of surgical Apgar Score. Pancreatology. 2013;13:175–9.CrossRefGoogle Scholar
  10. 10.
    Miki Y, Tokunaga M, Tanizawa Y, Bando E, Kawamura T, Terashima M. Perioperative risk assessment for gastrectomy by surgical Apgar score. Ann Surg Oncol. 2014;21:2601–7.CrossRefGoogle Scholar
  11. 11.
    Regenbogen SE, Bordeianou L, Hutter MM, Gawande AA. The intraoperative surgical Apgar score predicts postdischarge complications after colon and rectal resection. Surgery. 2010;148:559–66.CrossRefGoogle Scholar
  12. 12.
    Takeuchi H, Miyata H, Ozawa S, et al. Comparison of short-term outcomes between open and minimally invasive esophagectomy for esophageal cancer using a nationwide database in Japan. Ann Surg Oncol. 2017;24:1821–7.CrossRefGoogle Scholar
  13. 13.
    Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet. 2012;379:1887–92.CrossRefGoogle Scholar
  14. 14.
    Strøyer S, Mantoni T, Svendsen LB. Evaluation of the surgical Apgar Score in patients undergoing ivor-lewis esophagectomy. J Surg Oncol. 2017;115:186–91.CrossRefGoogle Scholar
  15. 15.
    Griffin SM, Shaw IH, Dresner SM. Early complications after ivor lewis subtotal esophagectomy with two-field lymphadenectomy: risk factors and management. J Am Coll Surg. 2002;194:285–97.CrossRefGoogle Scholar
  16. 16.
    Takesue T, Takeuchi H, Fukuda K, et al. Postoperative hyperbilirubinemia suggests the occurrence of complications after esophagectomy for esophageal cancer. World J Surg. 2015;39:1111–8.CrossRefGoogle Scholar
  17. 17.
    Ferguson MK, Martin TR, Reeder LB, Olak J. Mortality after esophagectomy: risk factor analysis. World J Surg. 1997;21:599–604.CrossRefGoogle Scholar
  18. 18.
    Giugliano DN, Morgan A, Palazzo F, Leiby BE, Evans NR, Rosato EL, Berger AC. Surgical Apgar Score (SAS) predicts perioperative morbidity, mortality, and length of stay in patients undergoing esophagectomy at a high-volume center. J Surg Oncol. 2017;116:359–64.CrossRefGoogle Scholar
  19. 19.
    Xing XZ, Wang HJ, Qu SN, et al. The value of esophagectomy Surgical Apgar Score (eSAS) in predicting the risk of major morbidity after open esophagectomy. J Thorac Dis. 2016;8:1780–7.CrossRefGoogle Scholar
  20. 20.
    Booka E, Takeuchi H, Nishi T, et al. The impact of postoperative complications on survivals after esophagectomy for esophageal cancer. Medicine. 2015;94:e1369.CrossRefGoogle Scholar
  21. 21.
    Matsuda S, Takeuchi H, Kawakubo H, et al. Correlation between intense postoperative inflammatory response and survival of esophageal cancer patients who underwent transthoracic esophagectomy. Ann Surg Oncol. 2015;22:4453–60.CrossRefGoogle Scholar
  22. 22.
    Kaburagi T, Takeuchi H, Kawakubo H, Omori T, Ozawa S, Kitagawa Y. Clinical utility of a novel hybrid position combining the left lateral decubitus and prone positions during thoracoscopic esophagectomy. World J Surg. 2014;38:410–8.CrossRefGoogle Scholar
  23. 23.
    Shoji Y, Takeuchi H, Kitagawa Y. Air bubble sign: a new screening method for anastomotic leakage after esophagectomy for esophageal cancer. Ann Surg Oncol. 2018;25(Suppl 3):713–4.CrossRefGoogle Scholar
  24. 24.
    Goense L, van Rossum PS, Tromp M, et al. Intraoperative and postoperative risk factors for anastomotic leakage and pneumonia after esophagectomy for cancer. Dis Esophagus. 2017;30(1):1–10. Scholar
  25. 25.
    Melis M, Pinna A, Okochi S, et al. Validation of the Surgical Apgar Score in a veteran population undergoing general surgery. J Am Coll Surg. 2014;218:218–25.CrossRefGoogle Scholar
  26. 26.
    Urschel JD. Esophagogastrostomy Anastomotic Leaks Complicating Esophagectomy: a Review. Am J Surg. 1995;169:634–40.CrossRefGoogle Scholar
  27. 27.
    Ejaz A, Gani F, Frank SM, Pawlik TM. Improvement of the surgical Apgar score by addition of intraoperative blood transfusion among patients undergoing major gastrointestinal surgery. J Gastrointest Surg. 2016;20:1752–9.CrossRefGoogle Scholar
  28. 28.
    Aoyama T, Kazama K, Murakawa M, et al. The surgical Apgar score is an independent prognostic factor in patients with pancreatic cancer undergoing pancreatoduodenectomy followed by adjuvant chemotherapy. Anticancer Res. 2016;36:2497–503.Google Scholar
  29. 29.
    Matsuda S, Takeuchi H, Kawakubo H, et al. Prognostic impact of change in the fibrinogen and albumin score during preoperative treatment in esophageal cancer patients. World J Surg. 2017;41:2788–95.CrossRefGoogle Scholar

Copyright information

© The Japan Esophageal Society and Springer 2019

Authors and Affiliations

  1. 1.Department of SurgeryKeio University School of MedicineTokyoJapan

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