Is Esophagectomy for Benign Conditions Benign?

When Is Intensive Care Unit Admission Needed After an Esophagectomy?

INTRODUCTION

Due to the high morbidity associated with esophagectomies, patients are often directly admitted to intensive care units (ICUs) for postoperative monitoring. However, critical complications can arise after this initial ICU stay. We hypothesized that the timing of ICU stay was not optimal for the care of patients after esophagectomy and aimed to determine when patients are at risk for developing critical complications.

METHODS

We searched the National Safety and Quality Improvement Program for patients who underwent an esophagectomy between 2016 and 2021. The outcome of interest was the interval between surgery and first critical complication. A critical complication was defined as one likely to require intensive care, including respiratory failure, septic shock, etc. Multivariate regression was performed to identify the risks of complications.

RESULTS

This study included 6813 patients from more than 70 institutions. Within the first 30 d postesophagectomy, 21.59% of patients experienced at least one critical complication. Half of first critical complications occurred after postoperative day 5, and 85.05% of them occurred after postoperative day 2. Risk factors for critical complications included age greater than 60 y, preoperative comorbidities, and open surgical approach. Malignancies were associated with a significantly lower incidence of critical complications.

CONCLUSIONS

Critical complications occurred beyond the immediate postesophagectomy period. Therefore, low-risk patients undergoing minimally invasive esophagectomies can be safely monitored outside the ICU, allowing for better patient care and resource utilization.

Morbidity After Esophagectomy Is Higher for Benign Than Malignant Disease

BACKGROUND

Esophagectomy carries a high risk of morbidity and mortality. The most common indication for esophagectomy is esophageal cancer, with fewer than 5% of esophagectomies performed for benign disease. We hypothesized that esophagectomy for benign disease is associated with a higher risk of operative and postoperative complications.

METHODS

A retrospective study of The Society of Thoracic Surgeons database was performed to identify all patients who had an esophagectomy from 2010 to 2018. Patients who had an emergent or palliative esophagectomy were excluded. Patients were compared based on the indication for operation, malignant vs benign disease. A 1:1 propensity score matching of The Society of Thoracic Surgeons risk factors was performed and outcomes compared between the matched cohorts.

RESULTS

Of 16,392 patients, 14,871 (91%) had malignant disease and 1521 (9%) had benign disease that met inclusion criteria. Patients with malignant disease were older (P < .001), more likely to be male (83% vs 56%, P < .001), and had more comorbidities (P < .001). There were 1362 propensity-matched pairs. Malignant esophagectomies were more likely to be performed with a minimally invasive vs an open approach (P < .001). Benign operations had more intraoperative blood transfusions (P < .001). Patients undergoing esophagectomy for benign disease had more prolonged intubations (P = .02) and postoperative blood transfusions (P = .001). Benign disease had more major morbidities (P = .001) but similar postoperative mortality (P = .62).

CONCLUSIONS

Esophagectomy for benign disease is associated with worse perioperative morbidity compared with esophagectomy for malignant disease. Given these findings patients should be counseled on expected outcomes, and this variable should be considered for inclusion in the composite score for risk assessment.

Salvage Options for Fundoplication Failure

PURPOSE OF REVIEW

Gastroesophageal reflux disease (GERD) affects millions of people worldwide. Many patients with medically refractory symptoms ultimately undergo antireflux surgery, most often with a laparoscopic fundoplication. Symptoms related to GERD may persist or recur. Revisional surgery is necessary in some patients.

RECENT FINDINGS

A reoperative fundoplication is the most commonly performed salvage procedure for failed fundoplication. Although redo fundoplication has been reported to have increased risk of morbidity compared with primary cases, increasing experience with the minimally invasive approach to reoperative surgery has significantly improved patient outcome with acceptable resolution of reflux symptoms in the majority of patients. Recurrence of reflux symptoms after an initial fundoplication requires a thorough work-up and a thoughtful approach. While reoperative fundoplication is the most common procedure performed, there are other options and the treatment should be tailored to the patient, their history, and the mechanism of fundoplication failure.