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Liatsou E, Bellos I, Katsaros I, Michailidou S, Karela NR, Mantziari S, Rouvelas I, Schizas D. Sex differences in survival following surgery for esophageal cancer: A systematic review and meta-analysis. Dis Esophagus 2024:doae063. [PMID: 39137391 DOI: 10.1093/dote/doae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 06/25/2024] [Accepted: 08/03/2024] [Indexed: 08/15/2024]
Abstract
The impact of sex on the prognosis of patients with esophageal cancer remains unclear. Evidence supports that sex- based disparities in esophageal cancer survival could be attributed to sex- specific risk exposures, such as age at diagnosis, race, socioeconomic status, smoking, drinking, and histological type. The aim of our study is to investigate the role of sex disparities in survival of patients who underwent surgery for esophageal cancer. A systematic review and meta-analysis of the existing literature in PubMed, EMBASE, and CENTRAL from December 1966 to February 2023, was held. Studies that reported sex-related differences in survival outcomes of patients who underwent esophagectomy for esophageal cancer were identified. A total of 314 studies were included in the quantitative analysis. Statistically significant results derived from 1-year and 2-year overall survival pooled analysis with Relative Risk (RR) 0.93 (95% Confidence Interval (CI): 0.90-0.97, I2 = 52.00) and 0.90 (95% CI: 0.85-0.95, I2 = 0.00), respectively (RR < 1 = favorable for men). In the postoperative complications analysis, statistically significant results concerned anastomotic leak and heart complications, RR: 1.08 (95% CI: 1.01-1.16) and 0.62 (95% CI: 0.52-0.75), respectively. Subgroup analysis was performed among studies with <200 and > 200 patients, histology types, study continent and publication year. Overall, sex tends to be an independent prognostic factor for esophageal carcinoma. However, unanimous results seem rather obscure when multivariable analysis and subgroup analysis occurred. More prospective studies and gender-specific protocols should be conducted to better understand the modifying role of sex in esophageal cancer prognosis.
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Affiliation(s)
- Efstathia Liatsou
- Department of Clinical Therapeutics, Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Bellos
- Department of Hygiene, Epidemiology and Medical Statistics, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Katsaros
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Styliani Michailidou
- First Department of Paediatric Surgery, Panagiotis & Aglaia Kyriakou Children's Hospital, Athens, Greece
| | - Nina-Rafailia Karela
- Second Department of Internal Medicine, Elpis General Hospital of Athens, Athens, Greece
| | - Styliani Mantziari
- Department of Visceral Surgery, Lausanne University Hospital (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Ioannis Rouvelas
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Upper Abdominal Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Dimitrios Schizas
- First Department of Surgery, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
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Edwards MA, Hussain MWA, Spaulding AC, Brennan E, Bowers SP, Elli EF, Thomas M. Can Risk-Based Thromboprophylaxis Practice Guidelines be Safely Used in Esophagectomy Cases? Experience of an Academic Health System. J Gastrointest Surg 2023; 27:2045-2056. [PMID: 37670109 DOI: 10.1007/s11605-023-05815-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/13/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) occurs in 3-11% of esophagectomy patients and is associated with increased mortality and morbidity. The use of validated VTE risk assessment tools and compliance with recommended practice guidelines remains unclear. In this study, we seek to determine the use of Caprini guideline indicated VTE prophylaxis and its effect on VTE and bleeding complications following esophagectomy. METHODS Esophagectomy cases were identified from the Mayo Clinic electronic health records. Caprini score and VTE prophylaxis regimen received were determined retrospectively. VTE prophylaxis was identified as appropriate or inappropriate based on the Caprini score and prophylaxis received preoperative, during hospitalization, and after hospital discharge. Study cohorts were compared by Pearson Chi-square test, Fisher's Exact test, Kruskal-Wallis test, and logistic regression models. Stata/MP 16.1 was used for analysis. Odds ratios and 95% confidence intervals were reported for logistic regression models. A p-value < 0.05 was considered significant. RESULTS Four hundred and fifty-six esophagectomy cases were analyzed. The median Caprini score was thirteen. Appropriate prophylaxis resulted in a 6.9-fold reduction in inpatient VTE. All 30- and 90-day post-discharge VTEs occurred in those not receiving Caprini guideline-indicated VTE prophylaxis. Inpatient, 30- and 90-day post-discharge bleeding rates were 7.68%, 0.91%, and 2.11%, respectively; however, bleeding was not increased with receipt of appropriate prophylaxis. CONCLUSION In this esophagectomy cohort, Caprini guideline indicated VTE prophylaxis resulted in reduced inpatient VTE events without increasing bleeding complications. Risk-based VTE prevention measures should be considered in this patient cohort known to be at heightened risk for postoperative VTE.
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Affiliation(s)
- Michael A Edwards
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA.
- Department Surgery, Mayo Clinic Alix School of Medicine, 4500 San Pablo Rd S, Jacksonville, FL, 32224, USA.
| | | | - Aaron C Spaulding
- Mayo Clinic, Division of Health Care Delivery Research, Jacksonville, FL, 32224, USA
| | - Emily Brennan
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Steven P Bowers
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Enrique Fernando Elli
- Division of Advanced GI and Bariatric Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
| | - Mathew Thomas
- Department of Cardio/Thoracic Surgery, Mayo Clinic, Jacksonville, FL, 32224, USA
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3
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Wang Y, Yang CFJ, He H, Buchan JM, Patel DC, Liou DZ, Lui NS, Berry MF, Shrager JB, Backhus LM. Short-term and intermediate-term readmission after esophagectomy. J Thorac Dis 2021; 13:4678-4689. [PMID: 34527309 PMCID: PMC8411130 DOI: 10.21037/jtd-21-637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/25/2021] [Indexed: 11/06/2022]
Abstract
Background The objective of this study was to characterize short- and intermediate-term readmissions following esophagectomy and to identify predictors of readmission in these two groups. Methods Patients who underwent esophagectomy in the National Readmissions Database (2013–2014) were grouped according to whether first readmission was “short-term” (readmitted <30 days) or “intermediate-term” (readmitted 31–90 days) following index admission for esophagectomy. Predictors of readmission were evaluated using multivariable logistic regression modeling. Results Of the 3,005 patients who underwent esophagectomy, 544 (18.1%) had a short-term readmission and 305 (10.1%) had an intermediate-term readmission. The most frequent reasons for short-term readmission were post-operative infection (7.5%), dysphagia (6.3%) and pneumonia (5.1%). The most common intermediate-term complications were pneumonia (7.2%), gastrointestinal stricture/stenosis (6.9%) and dysphagia (5.9%). In multivariable analysis, being located in a micropolitan area, increasing number of comorbidities and higher severity of illness score were associated with an increased likelihood of having a short-term readmission while being discharged to a facility (as opposed to directly home) was associated with increased likelihood of both short- and intermediate-term readmission (all P<0.05). Conclusions In this analysis, postoperative infection was the most common reason for short-term readmission. Dysphagia and pneumonia were common reasons for both short- and intermediate-term readmission of patients following esophagectomy. Interventions focused on reducing the risk of postoperative infection and pneumonia may reduce hospital readmissions. Gastrointestinal stricture and dysphagia were associated with increased risk of intermediate readmission and should be examined in the context of morbidity associated with pyloric procedures (e.g., pyloromyotomy) at the time of esophagectomy.
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Affiliation(s)
- Yoyo Wang
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Chi-Fu Jeffrey Yang
- Department of Surgery, Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Hao He
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA
| | | | - Deven C Patel
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA
| | - Douglas Z Liou
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA
| | - Natalie S Lui
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA
| | - Mark F Berry
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA.,Department of Cardiothoracic Surgery, Division of Thoracic Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA.,Department of Cardiothoracic Surgery, Division of Thoracic Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Leah M Backhus
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Building, Stanford, CA, USA.,Department of Cardiothoracic Surgery, Division of Thoracic Surgery, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Chen YT, Wang CT, Chiu CH, Chao YK. Salvage surgery, chylothorax and pneumonia are the main drivers of unplanned readmissions after oesophagectomy for cancer. Eur J Cardiothorac Surg 2021; 59:1021-1029. [PMID: 33367507 DOI: 10.1093/ejcts/ezaa451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 10/28/2020] [Accepted: 11/15/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Unplanned readmissions after surgery can be cumbersome to patients and costly on healthcare resources. The aim of this single-centre study was to identify the independent risk factors for unplanned readmissions in patients who had undergone oesophagectomy for cancer. METHODS We retrospectively reviewed the clinical records of 526 consecutive patients with oesophageal cancer who received transthoracic oesophagectomy and were discharged home between 2006 and 2017. Risk factors for unplanned readmission within the first 30 days from discharge were identified by multivariable competing risk analysis. RESULTS The mean age of the study patients was 55.14 years and 93.7% were men. Squamous cell carcinoma was identified in 94.1% of the participants, and 68.0% received chemoradiotherapy. There were 299 (56.8%) patients who experienced at least 1 postoperative complication. Fifty-five patients (10.5%) experienced an unplanned readmission. The postoperative 90-day mortality rate among patients who experienced an unplanned readmission was significantly higher than that of cases who did not (9.1% vs 0.2%, respectively, P < 0.001). Multivariable analysis identified chylothorax [hazard ratio (HR): 3.86, 95% confidence interval (CI): 1.89-7.91, P < 0.001], pneumonia (HR: 1.98, 95% CI 1.03-3.82, P = 0.042) and salvage surgery (HR: 2.27, 95% CI: 1.10-4.69, P = 0.027) as independent risk factors for unplanned readmissions. CONCLUSIONS Salvage surgery, postoperative chylothorax and pneumonia are the main drivers of 30-day unplanned readmissions in patients who had undergone oesophagectomy for cancer. Patients who required unplanned readmissions showed increased early mortality rates.
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Affiliation(s)
- Yu-Ting Chen
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Chen-Ti Wang
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chiu
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
| | - Yin-Kai Chao
- Department of Thoracic Surgery, Chang Gung Memorial Hospital-Linko, Chang Gung University, Taoyuan, Taiwan
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5
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Kidane B, Higgins S, Hirpara DH, Kaaki S, Shen YC, Allison F, Waddell TK, Darling GE. From Emergency Department Visit to Readmission After Esophagectomy: Analysis of Burden and Risk Factors. Ann Thorac Surg 2020; 112:379-386. [PMID: 33310147 DOI: 10.1016/j.athoracsur.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 10/24/2020] [Accepted: 11/16/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Frequent emergency department (ED) visits occur after esophagectomy. We aimed to identify the incidence of and risk factors for conversion from ED visit to inpatient admission. METHODS A retrospective cohort study was performed of consecutive esophagectomies at a tertiary Canadian center (1999 to 2014). Multivariable regression analyses identified factors associated with conversion from ED visit to admission. RESULTS There were 520 esophagectomies with 6% inhospital mortality (n = 31). Of those discharged, 29.7% (n = 145) had one or more emergency visit and 43.4% (n = 63) of these patients were readmitted to the hospital. First-time ED visits resulted in inpatient conversion 23.4% of the time (n = 34); successive ED visits resulted in increasing conversion. On multivariable analysis, anastomotic leak (adjusted odds ratio 2.45; 95% confidence interval, 1 to 6.01; P = .05) was independently associated with higher odds of conversion to admission. Sensitivity analysis using Poisson regression to model conversion as a rate identified that living in regions further away was associated with lower conversion rate to admission (risk ratio 0.35; 95% confidence interval, 0.13 to 0.94; P = .04). CONCLUSIONS Although postesophagectomy ED utilization is high, the majority of visits do not convert to admission. With each increasing ED visit, likelihood of converting to admission increases. Anastomotic leakage was associated with higher odds of conversion to admission, possibly related to development of strictures. Access to urgent outpatient endoscopy may help reduce the incidence of ED visits and admission. Although living in regions further away is associated with lower conversion rates to admission at the index hospital, that may be due to patients utilizing closer local hospitals.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Sean Higgins
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dhruvin H Hirpara
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Suha Kaaki
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yu Cindy Shen
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Frances Allison
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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6
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Singhal S, Mittal SK. Readmission after esophageal resection for esophageal cancer: incidence and risk factors. J Thorac Dis 2020; 12:4608-4611. [PMID: 33145033 PMCID: PMC7578455 DOI: 10.21037/jtd-20-1670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Saurabh Singhal
- Department of GI-HPB Surgery and Liver Transplantation, Indraprastha Apollo Hospital, New Delhi, India
| | - Sumeet K Mittal
- Department of Esophageal Surgery, Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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7
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Length of hospital stay after uncomplicated esophagectomy. Hospital variation shows room for nationwide improvement. Surg Endosc 2020; 35:6344-6357. [PMID: 33104919 PMCID: PMC8523439 DOI: 10.1007/s00464-020-08103-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/16/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Within the scope of value-based health care, this study aimed to analyze Dutch hospital performance in terms of length of hospital stay after esophageal cancer surgery and its association with 30-day readmission rates. Since both parameters are influenced by the occurrence of complications, this study only included patients with an uneventful recovery after esophagectomy. METHODS All patients registered in the Dutch Upper Gastrointestinal Cancer Audit (DUCA) who underwent a potentially curative esophagectomy between 2015 and 2018 were considered for inclusion. Patients were excluded in case of an intraoperative/post-operative complication, readmission to the intensive care unit, or any re-intervention. Length of hospital stay was dichotomized around the national median into 'short admissions' and 'long admissions'. Hospital variation was evaluated using a case-mix-corrected funnel plot based on multivariable logistic regression analyses. Association of length of hospital stay with 30-day readmission rates was investigated using the χ2-statistic. RESULTS A total of 1007 patients was included. National median length of hospital stay was 9 days, ranging from 6.5 to 12.5 days among 17 hospitals. The percentage of 'short admissions' per hospital ranged from 7.7 to 93.5%. After correction for case-mix variables, 3 hospitals had significantly higher 'short admission' rates and 4 hospitals had significantly lower 'short admission' rates. Overall, 6.2% [hospital variation (0.0-13.2%)] of patients were readmitted. Hospital 30-day readmission rates were not significantly different between patients with a short length of hospital stay and those with a long length of hospital stay (5.5% versus 7.6%; p = 0.19). CONCLUSIONS Based on these nationwide audit data, median length of hospital stay after an uncomplicated esophagectomy was 9 days ranging from 6.5 to 12.5 days among Dutch hospitals. There was no association between length of hospital stay and readmission rates. Nationwide improvement might lead to a substantial reduction of hospital costs.
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Rozeboom PD, Dyas AR, Bronsert MR, Bhagat R, Meguid RA. Improving postoperative outcomes in esophagectomy for cancer-what is the role of institutional data? J Thorac Dis 2020; 12:1750-1753. [PMID: 32642077 PMCID: PMC7330285 DOI: 10.21037/jtd-20-1681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Paul D Rozeboom
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam R Dyas
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rohun Bhagat
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,University of Rochester, School of Medicine, Rochester, NY, USA
| | - Robert A Meguid
- Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.,Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO, USA
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Yoshida N, Adachi Y, Morinaga T, Eto K, Tokunaga R, Harada K, Hiyoshi Y, Nagai Y, Iwatsuki M, Ishimoto T, Baba Y, Iwagami S, Miyamoto Y, Imamura Y, Watanabe M, Baba H. Wives as Key Persons Positively Impacting Prognosis for Male Patients Undergoing Esophagectomy for Esophageal Cancer: A Retrospective Study from a Single Japanese Institute. Ann Surg Oncol 2020; 27:2402-2411. [PMID: 32215755 DOI: 10.1245/s10434-020-08378-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Identification of a key person for supporting patients with activities of daily living after esophagectomy can contribute to patients' nutrition, rehabilitation, mental status, and determination of treatments for cancer. It may also affect the patients' prognostic outcomes. PATIENTS AND METHODS This retrospective study included 504 patients who underwent three-incisional esophagectomy for esophageal cancer between June 2005 and June 2018 at the Kumamoto University Hospital. The association between the type of key person identified and overall survival (OS) was investigated. The impact of the key person on postoperative nutrition and survival after recurrence was also examined. RESULTS Clinical backgrounds in patients with and without wife as their key person were equivalent. OS among male patients who identified their wife as their key person was significantly better than that in those without their wife as key person (P = 0.0035). Cox regression analysis showed that absence of a wife was an independent risk factor for worse survival outcomes (hazard ratio, 0.62; 95% confidence interval, 0.393-0.987; P = 0.044) along with age, clinical stage, severe postoperative morbidity, and pathological curability. Presence of a wife did not affect postoperative nutritional status. Incidence of death due to other causes and OS after recurrence were better in male patients with a wife than in those without; however, this difference was not significant. CONCLUSIONS Among males with esophageal cancer, their wives may be a significant contributor to extension of survival after surgery, via various support mechanisms.
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Affiliation(s)
- Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Translational Research and Advanced Treatment Against Gastrointestinal Gancer, Kumamoto University, Kumamoto, Japan
| | - Yuki Adachi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takeshi Morinaga
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kojiro Eto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ryuma Tokunaga
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuto Harada
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yohei Nagai
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Takatsugu Ishimoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.,Division of Translational Research and Advanced Treatment Against Gastrointestinal Gancer, Kumamoto University, Kumamoto, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shiro Iwagami
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Koto-ku, Tokyo, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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10
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Early Readmissions after Esophagectomy for Esophageal Adenocarcinoma: Does Facility Case-Volume Matter? Surg Res Pract 2020; 2020:8072682. [PMID: 32083166 PMCID: PMC7008254 DOI: 10.1155/2020/8072682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 01/06/2020] [Indexed: 11/17/2022] Open
Abstract
Increased esophagectomy procedures over the past four decades have correlated with the rise in incidence of esophageal adenocarcinoma. Despite advances in technology and procedural expertise, esophagectomy remains a high-risk surgical procedure. Higher volume facilities have more experience with esophagectomy and would be expected to have a lower incidence of surgical complications and attendant morbidity and mortality. By analyzing information from a nationwide United States hospital database, we sought to find out if there is a significant difference between facilities stratified by case volume, with regards to 30-day readmission after esophagectomy. The findings of this study indicated that even with a large applied differential, early readmissions did not differ significantly between high- and low-volume centers. Also, analyzed and discussed were any associated demographic and comorbidity factors as they relate to early readmissions after esophagectomy for esophageal adenocarcinoma across the country. This is the first study to specifically address these variables.
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11
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Goel NJ, Iyengar A, Kelly JJ, Mavroudis C, Lancaster C, Williams NN, Dempsey DT, Kucharczuk J. Nationwide Analysis of 30-Day Readmissions After Esophagectomy: Causes, Costs, and Risk Factors. Ann Thorac Surg 2020; 109:185-193. [DOI: 10.1016/j.athoracsur.2019.08.035] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 07/27/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
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Park SY, Kim DJ, Byun GE. Incidence and risk factors of readmission after esophagectomy for esophageal cancer. J Thorac Dis 2019; 11:4700-4707. [PMID: 31903259 DOI: 10.21037/jtd.2019.10.34] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The Esophageal Complications Consensus Group (ECCG) recommends that readmission to a primary or secondary hospital within 30 days of discharge after esophagectomy is an important quality outcome indicator for esophagectomy. This retrospective study was performed to investigate the incidence and risk factors for readmission after esophagectomy. Methods We retrospectively reviewed 291 patients who received an esophagectomy and mediastinal lymphadenectomy for curative purposes from January 2006 to June 2017. Results The mean age was 63.02±8.02 years, and there were 264 (90.7%) male patients. Thirty-nine (13.4%) patients were re-admitted within 30 days after discharge. The mean interval from discharge to the readmission was 13.46±9.36. Common causes of readmission were anastomotic stricture that required ballooning (12, 30.7%), wound problem (7, 17.9%), pneumonia (6, 15.4%), and poor oral intake (4, 10.2%). Other causes of readmission were delayed gastric emptying [3], jejunostomy tube problem [2], ileus [2], pain [1], pneumothorax [1], and pleural effusion [1]. On multivariable analysis, anastomotic leakage (odd ratio =2.884, P=0.026) was significantly related to readmission, whereas age, pathologic stage, vocal cord palsy, and neoadjuvant therapy were not related to readmission. Conclusions Readmission within 30 days after esophagectomy was determined to be related to postoperative anastomotic leakage and wound problems whereas the vocal cord palsy was not.
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Affiliation(s)
- Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Joon Kim
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Go Eun Byun
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kidane B, Jacob B, Gupta V, Peel J, Saskin R, Waddell TK, Darling GE. Medium and long-term emergency department utilization after oesophagectomy: a population-based analysis. Eur J Cardiothorac Surg 2019; 54:683-688. [PMID: 29648637 DOI: 10.1093/ejcts/ezy155] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 03/14/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Oesophagectomy is a complex operation with the potential for prolonged recovery. The aim of this study was to evaluate healthcare resource utilization, specifically emergency department (ED) visits within 1 year of oesophagectomy, and to identify risk factors for ED visits and frequent ED use (FEDU). METHODS A retrospective cohort study of consecutive oesophagectomies for cancer in all Ontario hospitals was conducted using linked health data (2000-2012) including the ability to identify ED visits at non-index hospitals. Ontario has a single-payer healthcare system with a population of 13.8-million people. Multivariable regression was used to identify independent factors associated with ED visits and FEDU (≥3 ED visits) within 1 year after oesophagectomy. RESULTS There were 3344 oesophagectomies with in-hospital mortality of 5.8% (n = 193). Of those discharged, 16.4% (n = 549), 36.0% (n = 1203) and 55.8% (n = 1866) had ED visits within 30 days, 90 days and 1 year, respectively. Higher comorbidity [adjusted odds ratio (aOR) = 1.08, 95% confidence interval (CI): 1.05-1.11, P < 0.0001], rurality (aOR = 1.40, 95% CI: 1.10-1.78, P = 0.006) and receipt of chemotherapy and/or radiation therapy (aOR = 2.55, 95% CI: 2.12-3.08, P < 0.0001) were independent risk factors for ED visits within 1 year of oesophagectomy. Thoracoscopic-assisted surgery was independently associated with decreased ED visits (aOR = 0.67, 95% CI: 0.45-0.99, P = 0.049). Eight hundred and thirteen (24.3%) patients had FEDU. Higher comorbidity (aOR = 1.11, 95% CI: 1.08-1.14, P < 0.0001), rurality (aOR = 1.66, 95% CI: 1.31-2.10, P < 0.0001) and receipt of chemotherapy and/or radiation therapy (aOR = 2.38, 95% CI: 1.93-2.93, P < 0.0001) were independent risk factors for FEDU. One health region had more ED visits (P = 0.04) and more FEDU (P = 0.001) when compared with the other regions. There were higher ED visits and FEDU in the later years of the study period (both P < 0.0001). CONCLUSIONS ED visits are common after oesophagectomy with almost 25% of patients having ≥3 visits and >50% having ≥1 visit within 1 year of oesophagectomy. We have identified demographic, surgical and regional risk factors for the potential targeted quality improvement.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, MB, Canada.,Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Binu Jacob
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Vaibhav Gupta
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - John Peel
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, ON, Canada.,Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
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Geller AD, Zheng H, Gaissert H, Mathisen D, Muniappan A, Wright C, Lanuti M. Relative Incremental Cost of Postoperative Complications of Esophagectomy. Semin Thorac Cardiovasc Surg 2019; 31:290-299. [DOI: 10.1053/j.semtcvs.2018.10.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/26/2018] [Indexed: 11/11/2022]
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15
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Yoshida N, Baba H. ASO Author Reflections: Venous Thromboembolism After Esophagectomy-The Importance of an Optimal Strategy for Thromboprophylaxis. Ann Surg Oncol 2018; 25:952-953. [PMID: 30306374 DOI: 10.1245/s10434-018-6883-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Indexed: 11/18/2022]
Affiliation(s)
- Naoya Yoshida
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Hideo Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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16
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Kidane B, Kaaki S, Hirpara DH, Shen YC, Bassili A, Allison F, Waddell TK, Darling GE. Emergency department use is high after esophagectomy and feeding tube problems are the biggest culprit. J Thorac Cardiovasc Surg 2018; 156:2340-2348. [PMID: 30309674 DOI: 10.1016/j.jtcvs.2018.07.100] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 06/16/2018] [Accepted: 07/09/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Esophagectomy is a complex operation with potential for prolonged recovery. We aimed to identify the incidence of and risk factors for any and frequent emergency department visits within 1 year of esophagectomy. METHODS A retrospective cohort study was performed looking at consecutive esophagectomies at a tertiary Canadian center (1999-2014). Multivariable analyses identified factors associated with any emergency department visits and frequent emergency department use (≥3 visits) within 1 year postesophagectomy. RESULTS There were 520 esophagectomies with in-hospital mortality of 6% (n = 31). Of those discharged, 29.7% (n = 145) had ≥ 1 emergency department visit. Most common causes were feeding tube problems (39.3%; n = 57) and dysphagia/stricture (13.1%; n = 19). Higher income (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.04-1.42 per $10,000) and use of hybrid/minimally invasive esophagectomy (aOR, 3.24; 95% CI, 1.71-6.11) were independently associated with having emergency department visits. Patients with hybrid/minimally invasive esophagectomy were discharged earlier than others (P < .0001). Living outside of our metropolitan area (aOR, 0.36; 95% CI, 0.27-0.49) and having surgery in the later years of the study period (aOR, 0.91; 95% CI, 0.86-0.97; P = .006) were both independently associated with lower odds of emergency department visits. Forty-three patients (8.8%) were frequent emergency department users, with the most common causes of repeat emergency visits being feeding tube problems. Living outside of our metropolitan area was associated with lower odds of frequent emergency visits (aOR, 0.25; 95% CI, 0.14-0.45). CONCLUSIONS There is high emergency department use within 1 year postesophagectomy. Patients living farther away from our hospital had a lower rate of emergency department use. It is possible that they are utilizing emergency departments nearer to home; this needs further study. Feeding tube problems are the biggest culprits and are potentially modifiable.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Suha Kaaki
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dhruvin H Hirpara
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Yu Cindy Shen
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Adam Bassili
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Frances Allison
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Thomas K Waddell
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Gail E Darling
- Division of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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17
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Liu YJ, Fan J, He HH, Zhu SS, Chen QL, Cao RH. Anastomotic leakage after intrathoracic versus cervical oesophagogastric anastomosis for oesophageal carcinoma in Chinese population: a retrospective cohort study. BMJ Open 2018; 8:e021025. [PMID: 30181184 PMCID: PMC6129039 DOI: 10.1136/bmjopen-2017-021025] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE To investigate the characteristics and predictors for anastomotic leakage after oesophagectomy for oesophageal carcinoma from the perspective of anastomotic level. DESIGN Retrospective cohort study. SETTINGS A single tertiary medical centre in China. PARTICIPANTS From January 2010 to December 2016, all patients with oesophageal cancer of the distal oesophagus or gastro-oesophageal junction undergoing elective oesophagectomy with a curative intent for oesophageal carcinoma with intrathoracic oesophagogastric anastomosis (IOA) versus cervical oesophagogastric anastomosis (COA) were included. We investigated anastomotic level and perioperative confounding factors as potential risk factors for postoperative leakage by univariate and multivariate logistic regression. PRIMARY OUTCOME MEASURES The primary outcome was the odds of anastomotic leakage by different confounding factors. Secondary outcome was the association of IOA versus COA with other postoperative outcomes. RESULTS Of 458 patients included, 126 underwent cervical anastomosis and 332 underwent intrathoracic anastomosis. Anastomotic leakage developed in 55 patients (12.0%), with no statistical differences between COA and IOA (16.6% vs 10.2%; p=0.058). Multivariable analysis identified active diabetes mellitus (OR 2.001, p=0.047), surgical procedure (open: reference; minimally invasive: OR 1.770, p=0.049) and anastomotic method (semimechanical: reference; stapled: OR 1.821; handsewn: OR 2.271, p=0.048) rather than anastomotic level (IOA: reference; COA: OR 1.622, p=0.110) were independent predictors of leakage. CONCLUSIONS Surgical and anastomotic techniques rather than the level of anastomotic site were independent predictors of postoperative anastomotic leakage in patients undergoing oesophageal cancer surgery.
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Affiliation(s)
- Yin-jiang Liu
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
| | - Jun Fan
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Huang-he He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Shu-sheng Zhu
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
| | - Qiu-lan Chen
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
| | - Rong-hua Cao
- Department of Thoracic Surgery, Taizhou City Hospital of Traditional Chinese Medicine, Taizhou, China
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18
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Yoshida N, Baba Y, Miyamoto Y, Iwatsuki M, Hiyoshi Y, Ishimoto T, Imamura Y, Watanabe M, Baba H. Prophylaxis of Postoperative Venous Thromboembolism Using Enoxaparin After Esophagectomy: A Prospective Observational Study of Effectiveness and Safety. Ann Surg Oncol 2018; 25:2434-2440. [PMID: 29876696 DOI: 10.1245/s10434-018-6552-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) after esophagectomy is higher than in other gastroenterological cancer surgery. Although the effectiveness and safety of thromboprophylaxis using enoxaparin have been established in orthopedic, abdominal, and pelvic surgeries, no studies regarding esophagectomy are available. METHODS A prospective observational study was conducted to elucidate the usefulness of enoxaparin for VTE prophylaxis after esophagectomy. The study enrolled 30 patients who underwent elective esophagectomy for esophageal cancer between April 2015 and October 2016. During postoperative days 2-11, the patients received a subcutaneous injection of enoxaparin (2000 IU) twice daily. The primary end point for the study was the incidence of postoperative VTE. In addition, the incidence of all enoxaparin treatment- and operation-related adverse events was investigated. The study identified VTE by VTE protocol-enhanced computed tomography, performed routinely during and after enoxaparin treatment. RESULTS One pulmonary embolism (PE) (3.3%) and two deep vein thromboses (DVTs) (6.7%) were observed during enoxaparin treatment. In addition, one PE (3.6%) and four DVTs (14.3%) (one patient experienced both) were observed after treatment. All VTEs were asymptomatic. Regarding enoxaparin-related adverse events, four minor bleeds occurred but did not require discontinuation of enoxaparin. The incidence of postoperative morbidity was acceptable. In blood tests related to coagulation, no significant differences were observed between patients with and without VTE. CONCLUSIONS The authors believe that thromboprophylaxis using enoxaparin is safe and can prevent VTE after esophagectomy. However, its effectiveness is limited to the period of treatment, so additional prophylaxis may be recommended.
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Affiliation(s)
- Naoya Yoshida
- Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University Hospital, Kumamoto, Japan.,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yoshifumi Baba
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yuji Miyamoto
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Masaaki Iwatsuki
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yukiharu Hiyoshi
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Takatsugu Ishimoto
- Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University Hospital, Kumamoto, Japan.,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan
| | - Yu Imamura
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan.,Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Masayuki Watanabe
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan.,Department of Gastroenterological Surgery, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hideo Baba
- Division of Translational Research and Advanced Treatment Against Gastrointestinal Cancer, Kumamoto University Hospital, Kumamoto, Japan. .,Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Chuoku, Kumamoto, 860-8556, Japan.
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19
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Bhagat R, Bronsert MR, Juarez-Colunga E, Weyant MJ, Mitchell JD, Glebova NO, Henderson WG, Fullerton D, Meguid RA. Postoperative Complications Drive Unplanned Readmissions After Esophagectomy for Cancer. Ann Thorac Surg 2018; 105:1476-1482. [DOI: 10.1016/j.athoracsur.2017.12.024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 09/27/2017] [Accepted: 12/18/2017] [Indexed: 02/07/2023]
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20
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Dreznik Y, Hoffman A, Hamburger T, Ben-Yaacov A, Dux Y, Jacoby H, Berger Y, Nissan A, Gutman M. Hospital readmission rates and risk factors for readmission following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal surface malignancies. Surgeon 2018; 16:278-282. [PMID: 29429947 DOI: 10.1016/j.surge.2018.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 01/05/2018] [Accepted: 01/05/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Cytoreductive surgery and Hyperthermic intra-peritoneal chemotherapy (CRS/HIPEC) for peritoneal surface malignancies is associated with high morbidity. The increased numbers of patients undergoing CRS/HIPEC in recent years mandates risk analysis and quality assurance. However, only scarce data exist regarding causative parameters for readmission. The aim of this study was to assess readmission rates and risk factors associated with readmission. METHODS A retrospective-cohort study including patients from two high-volume centers who underwent CRS/HIPEC surgery between the years 2007-2016 was performed. Patients' demographics, peri-operative data and readmission rates were recorded. RESULTS 223 patients were included in the study. The 7 and 30-day readmission rates were 3.5% (n = 8) and 11% (n = 25), respectively. Late readmission rates (up to 90 days) were 11% (n = 25). The most common causes of readmission were surgical related infections (35%), small bowel obstruction (17.5%) and dehydration (14%). Post-operative complications were associated with higher readmission rates (p = 0.0001). PCI score was not associated with higher rates of readmission. CONCLUSION Readmissions following CRS/HIPEC occur mainly due to infectious complications and dehydrations. Patients following CRS/HIPEC should be discharged after careful investigation to a community based continuing care with access for IV fluid replacement or antibiotics administration when required.
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Affiliation(s)
- Yael Dreznik
- Department of Surgery B, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
| | - Aviad Hoffman
- Department of Surgery B, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamar Hamburger
- Division of Clinical Research, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Almog Ben-Yaacov
- Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Yossi Dux
- Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Harel Jacoby
- Department of Surgery B, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaniv Berger
- Department of Surgery B, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Aviram Nissan
- Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Department of General and Oncological Surgery-Surgery C, Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - Mordechai Gutman
- Department of Surgery B, Chaim Sheba Medical Center, Tel-Hashomer, Israel; Affiliated to the Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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21
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Makiura D, Ono R, Inoue J, Fukuta A, Kashiwa M, Miura Y, Oshikiri T, Nakamura T, Kakeji Y, Sakai Y. Impact of Sarcopenia on Unplanned Readmission and Survival After Esophagectomy in Patients with Esophageal Cancer. Ann Surg Oncol 2017; 25:456-464. [PMID: 29214454 DOI: 10.1245/s10434-017-6294-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Although sarcopenia increases postoperative complications following esophagectomy, its effects on prognosis remain unclear. This study was performed to identify the effect of sarcopenia on 90-day unplanned readmission and overall survival (OS) after esophagectomy. METHODS Ninety-eight patients with esophageal cancer who underwent esophagectomy were enrolled in this study. Unplanned readmission was defined as any emergent hospitalization within 90 days after discharge. Sarcopenia, defined as low muscle mass plus low muscle strength and/or low physical performance according to the Asian consensus definition, was assessed prior to esophagectomy. Multivariate logistic regression analysis was performed to identify factors that contributed to 90-day unplanned readmission. OS was estimated using the Kaplan-Meier method, and a Cox proportional hazards model was used to assess the relationship between sarcopenia and OS. RESULTS Thirty-one patients (31.6%) were diagnosed with sarcopenia. The 90-day unplanned readmission rate was significantly higher in patients with sarcopenia than those without (42.9% vs. 16.4%, respectively; p = 0.01). Multivariable logistic regression analysis showed that sarcopenia was an independent predictor of 90-day unplanned readmission [odds ratio 3.71, 95% confidence interval (CI) 1.29-11.05; p = 0.02], and the log-rank test showed that sarcopenia was associated with OS (p = 0.01). Moreover, sarcopenia was a significant predictor of OS after adjustment for age, sex, and pathological stage (hazard ratio 2.35, 95% CI 1.21-4.54; p = 0.01). CONCLUSIONS Sarcopenia is a risk factor for 90-day unplanned readmission and OS following esophagectomy. Assessment of sarcopenia could help to identify patients at higher risk of a poor prognosis after esophagectomy.
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Affiliation(s)
- Daisuke Makiura
- Division of Rehabilitation, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.
| | - Rei Ono
- Department of Community Health Sciences, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Junichiro Inoue
- Division of Rehabilitation, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Akimasa Fukuta
- Department of Community Health Sciences, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Miyuki Kashiwa
- Division of Rehabilitation, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Yasushi Miura
- Division of Rehabilitation, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.,Department of Rehabilitation Sciences, Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Taro Oshikiri
- Division of Gastrointestinal Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tetsu Nakamura
- Division of Gastrointestinal Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshihiro Kakeji
- Division of Gastrointestinal Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yoshitada Sakai
- Division of Rehabilitation, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan.,Division of Rehabilitation Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
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22
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Dalton BGA, Friedant AJ, Su S, Schatz TAP, Ruth KJ, Scott WJ. Benefits of Supplemental Jejunostomy Tube Feeding During Neoadjuvant Therapy in Patients with Locally Advanced, Potentially Resectable Esophageal Cancer. J Laparoendosc Adv Surg Tech A 2017; 27:1279-1283. [PMID: 28777676 DOI: 10.1089/lap.2017.0320] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Standard treatment for locally advanced esophageal cancer includes neoadjuvant therapy followed by surgical resection. However, many patients experience a period of decreased oral intake during neoadjuvant treatment and are at risk for malnutrition. We hypothesize that use of jejunostomy tube (j-tube) feedings during neoadjuvant therapy in selected patients may be associated with better perioperative outcomes. METHODS A prospectively collected database at a single institution was retrospectively analyzed. The study period was from 2005 to 2015. Patients who underwent j-tube placement before neoadjuvant therapy before definitive resection for esophageal cancer were included in the analysis. Perioperative outcomes were compared between patients who adhered to recommended tube feeds during neoadjuvant therapy (users) and patients who did not adhere (nonusers). RESULTS During the study period, 94/301 patients received a j-tube before or during neoadjuvant therapy for esophageal cancer. Seventy-three patients utilized tube feeds regularly during the neoadjuvant phase, while 21 patients did not. The groups did not differ significantly with respect to clinical factors such as dysphagia on presentation, postneoadjuvant therapy performance status, or Charlson Comorbidity Index. Perioperative pneumonia rates were lower in j-tube users compared to nonusers (6.8% [5 of 73] versus 23.8% [5 of 21]), respectively, P = .036); this difference remained significant with adjustment for type of surgery (odds ratio = 0.16, P = .018). CONCLUSIONS j-Tube users had a significantly lower incidence of pneumonia within 30 days of curative resection when compared to nonusers. j-Tube feedings during neoadjuvant therapy for selected patients with locally advanced esophageal cancer should be encouraged.
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Affiliation(s)
| | | | - Stacey Su
- Fox Chase Cancer Center , Philadelphia, Pennsylvania
| | | | - Karen J Ruth
- Fox Chase Cancer Center , Philadelphia, Pennsylvania
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23
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Wang W, Zhao G, Wu L, Dong Y, Zhang C, Sun L. Risk factors for anastomotic leakage following esophagectomy: Impact of thoracic epidural analgesia. J Surg Oncol 2017; 116:164-171. [PMID: 28384375 DOI: 10.1002/jso.24621] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/04/2017] [Indexed: 01/29/2023]
Affiliation(s)
- Wen Wang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Gefei Zhao
- Department of Thoracic Surgery, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Linxin Wu
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Yanpeng Dong
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Chaobin Zhang
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
| | - Li Sun
- Department of Anesthesiology, National Cancer Center/Cancer Hospital; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing China
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24
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Woodard GA, Crockard JC, Clary-Macy C, Zoon-Besselink CT, Jones K, Korn WM, Ko AH, Gottschalk AR, Rogers SJ, Jablons DM. Hybrid minimally invasive Ivor Lewis esophagectomy after neoadjuvant chemoradiation yields excellent long-term survival outcomes with minimal morbidity. J Surg Oncol 2016; 114:838-847. [PMID: 27569043 DOI: 10.1002/jso.24409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/31/2016] [Indexed: 01/21/2023]
Abstract
BACKGROUND There is a clear survival benefit to neoadjuvant chemoradiation prior to esophagectomy for patients with stages II-III esophageal cancer. A minimally invasive esophagectomy approach may decrease morbidity but is more challenging in a previously radiated field and therefore patients who undergo neoadjuvant chemoradiation may experience more postoperative complications. METHODS A prospective database of all esophageal cancer patients who underwent attempted hybrid minimally invasive Ivor Lewis esophagectomy was maintained between 2006 and 2015. The clinical characteristics, neoadjuvant treatments, perioperative complications, and survival outcomes were reviewed. RESULTS Overall 30- and 90-day mortality rates were 0.8% (1/131) and 2.3% (3/131), respectively. The majority of patients 58% (76/131) underwent induction treatment without significant adverse impact on mortality, major complications, or hospital stay. Overall survival at 1, 3, and 5 years was 85.9%, 65.3%, and 53.9%. Five-year survival by pathologic stage was stage I 68.9%, stage II 54.0%, and stage III 29.6%. CONCLUSIONS The hybrid minimally invasive Ivor Lewis esophagectomy approach results in low perioperative morbidity and mortality and is well tolerated after neoadjuvant chemoradiation. Good long-term overall survival rates likely resulted from combined concurrent neoadjuvant chemoradiation in the majority of patients, which did not impact the ability to safely perform the operation or postoperative complications rates. J. Surg. Oncol. 2016;114:838-847. © 2016 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Gavitt A Woodard
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jane C Crockard
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Carolyn Clary-Macy
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Clara T Zoon-Besselink
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Kirk Jones
- Department of Pathology, University of California San Francisco, San Francisco, California
| | - Wolfgang Michael Korn
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, California
| | - Andrew H Ko
- Division of Hematology and Oncology, University of California San Francisco, San Francisco, California
| | - Alexander R Gottschalk
- Department of Radiation Oncology, University of California San Francisco, San Francisco, California
| | - Stanley J Rogers
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - David M Jablons
- Department of Surgery, University of California San Francisco, San Francisco, California.
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Chen SY, Molena D, Stem M, Mungo B, Lidor AO. Post-discharge complications after esophagectomy account for high readmission rates. World J Gastroenterol 2016; 22:5246-5253. [PMID: 27298567 PMCID: PMC4893471 DOI: 10.3748/wjg.v22.i22.5246] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/05/2016] [Accepted: 04/15/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify rates of post-discharge complications (PDC), associated risk factors, and their influence on early hospital outcomes after esophagectomy.
METHODS: We used the 2005-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients ≥ 18 years of age who underwent an esophagectomy. These procedures were categorized into four operative approaches: transhiatal, Ivor-Lewis, 3-holes, and non-gastric conduit. We selected patient data based on clinical relevance to patients undergoing esophagectomy and compared demographic and clinical characteristics. The primary outcome was PDC, and secondary outcomes were hospital readmission and reoperation. The patients were then divided in 3 groups: no complication (Group 1), only pre-discharge complication (Group 2), and PDC patients (Group 3). A modified Poisson regression analysis was used to identify risk factors associated with developing post-discharge complication, and risk ratios were estimated.
RESULTS: 4483 total patients were identified, with 8.9% developing PDC within 30-d after esophagectomy. Patients who experienced complications post-discharge had a median initial hospital length of stay (LOS) of 9 d; however, PDC occurred on average 14 d following surgery. Patients with PDC had greater rates of wound infection (41.0% vs 19.3%, P < 0.001), venous thromboembolism (16.3% vs 8.9%, P < 0.001), and organ space surgical site infection (17.1% vs 11.0%, P = 0.001) than patients with pre-discharge complication. The readmission rate in our entire population was 12.8%. PDC patients were overwhelmingly more likely to have a reoperation (39.5% vs 22.4%, P < 0.001) and readmission (66.9% vs 6.6%, P < 0.001). BMI 25-29.9 and BMI ≥ 30 were associated with increased risk of PDC compared to normal BMI (18.5-25).
CONCLUSION: PDC after esophagectomy account for significant number of reoperations and readmissions. Efforts should be directed towards optimizing patient’s health pre-discharge, with possible prevention programs at discharge.
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Moore JM, Hooker CM, Molena D, Mungo B, Brock MV, Battafarano RJ, Yang SC. Complex Esophageal Reconstruction Procedures Have Acceptable Outcomes Compared With Routine Esophagectomy. Ann Thorac Surg 2016; 102:215-22. [PMID: 27217296 DOI: 10.1016/j.athoracsur.2016.02.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Complex esophageal reconstruction (CER) is defined as restoring esophageal continuity in a previously operated field, using a nongastric conduit, or after esophageal diversion. This study compares the outcomes of CER with non-CER (NCER), which uses an undisturbed stomach for reconstruction. METHODS This single-institution retrospective cohort study compares 75 CERs with 75 NCERs from 1995 to 2014 that were matched for cancer versus benign disease. Distributions of demographic characteristics, comorbidities, and complications were compared between CER and NCER. Odds of mortality at 30 and 90 days were calculated with logistic regression. Overall survival was illustrated with Kaplan-Meier method and Cox proportional hazards regression. RESULTS Although patients were similar in age, sex, and preoperative comorbidities, more non-white patients underwent CER (p = 0.04). Most NCER patients had adenocarcinoma (44%) or Barrett's high-grade dysplasia (39%); most CER patients had other benign disease (44%) or squamous cell carcinoma (24%, p < 0.01). CER had statistically significantly higher rates of reoperation, pneumonia, infection, and gastrointestinal complications, and longer median length of stay than NCER. Odds of mortality for CER and NCER at 30 days (odds ratio [OR] 1.0, 95% CI: 0.1 to 16.3), 90 days (OR 2.6, 95% CI: 0.5 to 13.9) and overall (adjusted hazard ratio 1.56, 95% CI: 0.9 to 2.7) were not statistically significantly different. CONCLUSIONS Compared with NCER, CER patients had higher rates of return to the operating room, more postoperative infections and gastrointestinal complications, and longer length of stay. However, 30-day, 90-day, and overall survival were similar. CER should be offered to patients with acceptable risks and anticipated long-term survival.
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Affiliation(s)
- Jessica M Moore
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Craig M Hooker
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Daniela Molena
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Benedetto Mungo
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Malcolm V Brock
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Richard J Battafarano
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland
| | - Stephen C Yang
- Department of Surgery, Division of Thoracic Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland.
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Plasma MicroRNA-21 Predicts Postoperative Pulmonary Complications in Patients Undergoing Pneumoresection. Mediators Inflamm 2016; 2016:3591934. [PMID: 27293316 PMCID: PMC4880696 DOI: 10.1155/2016/3591934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 04/16/2016] [Accepted: 04/19/2016] [Indexed: 11/17/2022] Open
Abstract
Postoperative pulmonary complication (PPC) remains the most common postoperative complication in patients undergoing noncardiac thoracic surgery. We conducted the clinical study to determine the diagnostic role of miRNA-21 in noncardiac thoracic surgery. 368 patients undergoing noncardiac thoracic surgery were recruited. Blood samples were collected before anesthesia and 2 hours after incision during surgery for RT-PCR measurement of miRNA-21. PPC occurrence, extrapulmonary complications, duration of ICU stay, and death within 1 year were evaluated. The overall rate of PPCs following surgery was 10.32%. A high relative miRNA-21 level was an independent risk factor for PPCs within 7 days (OR, 2.69; 95% CI, 1.25-5.66; and P < 0.001). High miRNA-21 was also associated with an increased risk of extrapulmonary complications (OR, 3.62; 95% CI, 2.26-5.81; and P < 0.001), prolonged ICU stay (OR, 6.54; 95% CI, 2.26-18.19; and P < 0.001), increased death within 30 days (OR, 6.17; 95% CI, 2.11-18.08; and P < 0.001), and death within 1 year (OR, 7.30; 95% CI, 2.76-19.28; and P < 0.001). In summary, plasma miRNA-21 may serve as a novel biomarker of PPCs for patients undergoing noncardiac thoracic surgery.
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Nason KS. Minimal or maximal surgery for esophageal cancer? J Thorac Cardiovasc Surg 2016; 151:633-635. [DOI: 10.1016/j.jtcvs.2015.09.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 02/07/2023]
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Martin AS, Abbott DE, Hanseman D, Sussman JE, Kenkel A, Greiwe P, Saeed N, Ahmad SH, Sussman JJ, Ahmad SA. Factors Associated with Readmission After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis. Ann Surg Oncol 2016; 23:1941-7. [DOI: 10.1245/s10434-016-5109-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Indexed: 01/02/2023]
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30
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Kim AW. Readmissions and the law of unintended consequences. J Thorac Cardiovasc Surg 2015; 150:1030-1. [PMID: 26546196 DOI: 10.1016/j.jtcvs.2015.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 09/05/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Anthony W Kim
- Section of Thoracic Surgery, School of Medicine, Yale University, New Haven, Conn.
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Now that reimbursement for readmission to the hospital is threatened, we are finally focused on readmissions after esophagectomy. J Thorac Cardiovasc Surg 2015; 149:1392-3. [PMID: 25816953 DOI: 10.1016/j.jtcvs.2015.02.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/23/2015] [Indexed: 11/23/2022]
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