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Kalata S, Singh B, Graham N, Fan Z, Chang AC, Lynch WR, Lagisetty KH, Lin J, Yeung J, Reddy RM, Wakeam E. Epidemiology of Postoperative Complications After Esophagectomy: Implications for Management. Ann Thorac Surg 2023; 116:1168-1175. [PMID: 37704003 DOI: 10.1016/j.athoracsur.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND Despite advances in operative techniques and postoperative care, esophagectomy remains a morbid operation. Leveraging complication epidemiology and the correlation of these complications may improve rescue and refine early recovery pathways. METHODS This study retrospectively reviewed all esophagectomies performed at a tertiary academic center from 2014 to 2021 and quantified the timing of the most common complications. Daily incidence values for index complications were calculated, and a covariance matrix was created to examine the correlation of the complications with each other. Study investigators performed a Cox proportional hazards analysis to clarify the association between early diagnosis of postoperative atrial fibrillation and pneumonia with subsequent anastomotic leak. RESULTS The study analyzed 621 esophagectomies, with 580 (93.4%) cervical anastomoses and 474 (76%) patients experiencing complications. A total of 159 (25.6%) patients had postoperative atrial fibrillation, and 155 (25.0%) had an anastomotic leak. The median (interquartile range [IQR]) postoperative day of these complications was day 2 (IQR, days 2-3) and day 8 (IQR, days 7-11), respectively. Our covariance matrix found significant associations in the variance of the most common postoperative complications, including pneumonia, atrial fibrillation, anastomotic leak, and readmissions. Early postoperative atrial fibrillation (hazard ratio, 8.1; 95% CI, 5.65-11.65) and postoperative pneumonia (hazard ratio, 3.8; 95% CI, 1.98-7.38) were associated with anastomotic leak. CONCLUSIONS Maintaining a high index of suspicion for early postoperative complications is crucial for rescuing patients after esophagectomy. Early postoperative pneumonia and atrial fibrillation may be sentinel complications for an anastomotic leak, and their occurrence may be used to prompt further clinical investigation. Early recovery protocols should consider the development of early complications into postoperative feeding and imaging algorithms.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Bilawal Singh
- College of Medicine, Central Michigan University, Mt. Pleasant, Michigan
| | - Nathan Graham
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Zhaohui Fan
- Center for Healthcare Outcomes and Policy, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
| | - Andrew C Chang
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - William R Lynch
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kiran H Lagisetty
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jules Lin
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Jonathan Yeung
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Rishindra M Reddy
- Department of Surgery, University of Michigan, Ann Arbor, Michigan; Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Elliot Wakeam
- Division of Thoracic Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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2
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Phillips JD, Fay KA, Wakeam E, Graham NJ, Godfrey CM, Marmor HN, Grogan EL, Meguid RA, Madsen HJ, Stuart CM, Sachdeva UM, Wang D, Abou Chaar MK, Blackmon SH, Maeder ME, Emond JA, Hasson RM, Millington TM, Finley DJ. Food Deserts Increase Readmission After Esophagectomy for Cancer: A Multi-institutional Study. Ann Thorac Surg 2023; 116:246-253. [PMID: 37080374 PMCID: PMC10631468 DOI: 10.1016/j.athoracsur.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/24/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Food deserts are low-income census tracts with poor access to supermarkets and are associated with worse outcomes in breast, colon, and a small number of esophageal cancer patients. This study investigated residency in food deserts on readmission rates in a multi-institutional cohort of esophageal cancer patients undergoing trimodality therapy. METHODS A retrospective review of patients who underwent trimodality therapy at 6 high-volume institutions from January 2015 to July 2019 was performed. Food desert status was defined by the United States Department of Agriculture by patient ZIP Code. The primary outcome was 30-day readmission after esophagectomy. Multilevel, multivariable logistic regression was used to model readmission on food desert status adjusted for diabetes, insurance type, length of stay, and any complication, treating the institution as a random factor. RESULTS Of the 453 records evaluated, 425 were included in the analysis. Seventy-three patients (17.4%) resided in a food desert. Univariate analysis demonstrated food desert patients had significantly increased 30-day readmission. No differences were seen in length of stay, complications, or 30-day mortality. In the adjusted logistic regression model, residing in a food desert remained a significant risk factor for readmission (odds ratio, 2.11; 95% CI, 1.07-4.15). There were no differences in 30-day, 90-day, or 1-year mortality based on food desert status, although readmission was associated with worse 90-day and 1-year mortality. CONCLUSIONS Food desert residence was associated with 30-day readmission after esophagectomy in patients undergoing trimodality treatment for esophageal cancer in this multi-institutional population. Identification of patients residing in a food desert may allow surgeons to focus preventative interventions during treatment and postoperatively to improve outcomes.
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Affiliation(s)
- Joseph D Phillips
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
| | - Kayla A Fay
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Elliot Wakeam
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Caroline M Godfrey
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hannah N Marmor
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric L Grogan
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert A Meguid
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Helen J Madsen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina M Stuart
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Uma M Sachdeva
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Danny Wang
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | | | | | - Matthew E Maeder
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jennifer A Emond
- Department of Biomedical Data Sciences, Geisel School of Medicine, Hanover, New Hampshire
| | - Rian M Hasson
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Timothy M Millington
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - David J Finley
- Section of Thoracic Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Fowler AJ, Wahedally MAH, Abbott TEF, Prowle JR, Cromwell DA, Pearse RM. Long-term disease interactions amongst surgical patients: a population cohort study. Br J Anaesth 2023:S0007-0912(23)00237-4. [PMID: 37400340 PMCID: PMC10375505 DOI: 10.1016/j.bja.2023.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 04/20/2023] [Accepted: 04/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND The average age of the surgical population continues to increase, as does prevalence of long-term diseases. However, outcomes amongst multi-morbid surgical patients are not well described. METHODS We included adults undergoing non-obstetric surgical procedures in the English National Health Service between January 2010 and December 2015. Patients could be included multiple times in sequential 90-day procedure spells. Multi-morbidity was defined as presence of two or more long-term diseases identified using a modified Charlson comorbidity index. The primary outcome was 90-day postoperative death. Secondary outcomes included emergency hospital readmission within 90 days. We calculated age- and sex-adjusted odds ratios (OR) with 95% confidence intervals (CI) using logistic regression. We compared the outcomes associated with different disease combinations. RESULTS We identified 20 193 659 procedure spells among 13 062 715 individuals aged 57 (standard deviation 19) yr. Multi-morbidity was present among 2 577 049 (12.8%) spells with 195 965 deaths (7.6%), compared with 17 616 610 (88.2%) spells without multi-morbidity with 163 529 deaths (0.9%). Multi-morbidity was present in 1 902 859/16 946 808 (11.2%) elective spells, with 57 663 deaths (2.7%, OR 4.9 [95% CI: 4.9-4.9]), and 674 190/3 246 851 (20.7%) non-elective spells, with 138 302 deaths (20.5%, OR 3.0 [95% CI: 3.0-3.1]). Emergency readmission followed 547 399 (22.0%) spells with multi-morbidity compared with 1 255 526 (7.2%) without. Multi-morbid patients accounted for 57 663/114 783 (50.2%) deaths after elective spells, and 138 302/244 711 (56.5%) after non-elective spells. The rate of death varied five-fold from lowest to highest risk disease pairs. CONCLUSION One in eight patients undergoing surgery have multi-morbidity, accounting for more than half of all postoperative deaths. Disease interactions amongst multi-morbid patients is an important determinant of patient outcome.
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Affiliation(s)
- Alexander J Fowler
- School of Medicine and Dentistry, Queen Mary University of London, London, UK; Royal College of Surgeons of England, London, UK.
| | | | - Tom E F Abbott
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - John R Prowle
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - David A Cromwell
- Royal College of Surgeons of England, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - Rupert M Pearse
- School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Chanbour H, Suryateja Gangavarapu L, Chen JW, Bendfeldt GA, Younus I, Ahmed M, Roth SG, Luo LY, Chotai S, Abtahi AM, Stephens BF, Zuckerman SL. Unplanned Readmission After Surgery for Cervical Spine Metastases. World Neurosurg 2023; 171:e768-e776. [PMID: 36584895 DOI: 10.1016/j.wneu.2022.12.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/25/2022] [Accepted: 12/25/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Patients undergoing surgery for cervical spine metastases are at risk for unplanned readmission due to comorbidities and chemotherapy/radiation. Our objectives were to: 1) report the incidence of unplanned readmission, 2) identify risk factors associated with unplanned readmission, and 3) determine the impact of an unplanned readmission on long-term outcomes. METHODS A single-center, retrospective, case-control study was undertaken of patients undergoing cervical spine surgery for metastatic disease between 02/2010 and 01/2021. The primary outcome of interest was unplanned readmission within 6 months. Survival analysis was performed for overall survival (OS) and local recurrence (LR). RESULTS A total of 61 patients underwent cervical spine surgery for metastatic disease with the following approaches: 11 (18.0%) anterior, 28 (45.9%) posterior, and 22 (36.1%) combined. Mean age was 60.9 ± 11.2 years and 38 (62.3%) were males. A total of 9/61 (14.8%) patients had an unplanned readmission, 3 for surgical reasons and 6 for medical reasons. No difference was found in demographics, preoperative Karnofsky Performance Scale (P = 0.992), motor strength (P = 0.477), or comorbidities (P = 0.213) between readmitted patients versus not. Readmitted patients had a higher rate of preoperative radiation (P = 0.009). No statistical differences were found in operative time (P = 0.893), estimated blood loss (P = 0.676), length of stay (P = 0.720), discharge disposition (P = 0.279), and operative approach (P = 0.450). Furthermore, no difference was found regarding complications (P = 0.463), postoperative Karnofsky Performance Scale (P = 0.535), and postoperative Modified McCormick Scale (P = 0.586). Lastly, unplanned readmissions were not associated with OS (log-rank; P = 0.094) or LR (log-rank; P = 0.110). CONCLUSIONS In patients undergoing cervical spine metastasis surgery, readmission occurred in 15% of patients, 33% for surgical reasons, and 67% for medical reasons. Preoperative radiotherapy was associated with an increased rate of unplanned readmissions, yet readmission had no association with OS or LR.
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Affiliation(s)
- Hani Chanbour
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jeffrey W Chen
- Vanderbilt University, School of Medicine, Nashville, Tennessee, USA
| | | | - Iyan Younus
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mahmoud Ahmed
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Steven G Roth
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Leo Y Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Silky Chotai
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir M Abtahi
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Byron F Stephens
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Scott L Zuckerman
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Ge QY, Wu YH, Cong ZZ, Qiang Y, Wang YQ, Zheng C, Shen Y. Comparison of the clinical outcomes after esophagectomy between intrathoracic anastomosis and cervical anastomosis: a systematic review and meta-analysis. BMC Surg 2022; 22:417. [PMID: 36476138 PMCID: PMC9730664 DOI: 10.1186/s12893-022-01875-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Esophageal cancer is a high-mortality disease. Esophagectomy is the most effective method to treat esophageal cancer, accompanied with a high incidence of post-operation complications. The anastomosis has a close connection to many severe post-operation complications. However, it remains controversial about the choice of intrathoracic anastomosis (IA) or cervical anastomosis (CA). The study was conducted to compare the clinical outcomes between the two approaches. METHODS We searched databases for both randomized controlled trials (RCTs) and cohort studies comparing post-operation outcomes between IA and CA. Primary outcomes were the incidences of anastomotic leakage and mortality. Secondary outcomes were the incidences of anastomotic stenosis, pneumonia and re-operation. RESULTS Twenty studies with a total of 7,479 patients (CA group: n = 3,183; IA group: n = 4296) were included. The results indicated that CA group had a higher incidence of anastomotic leakage than IA group (odds ratio [OR] = 2.05, 95% confidence intervals [CI] = 1.61-2.60, I2 = 53.31%, P < 0.01). Subgroup analyses showed that CA group had higher incidences of type I (OR = 2.19, 95%CI = 1.05-4.57, I2 = 0.00%, P = 0.04) and type II (OR = 2.75, 95%CI = 1.95-3.88, I2 = 1.80%, P < 0.01) anastomotic leakage than IA group. No difference was found in type III anastomotic leakage (OR = 1.23, 95%CI = 0.82-1.86, I2 = 20.92%, P = 0.31). The 90-day mortality (OR = 1.66, 95%CI = 1.11-2.47, I2 = 0.0%, P = 0.01) in IA group were lower than that in CA group. No difference was found in in-hospital mortality (OR = 1.31, 95%CI = 0.91-1.88, I2 = 0.00%, P = 0.15) and 30-day mortality (OR = 1.08, 95%CI = 0.69-1.70, I2 = 0.00%, P = 0.74). CONCLUSIONS IA might be a better anastomotic approach than CA, with a lower incidence of anastomosis leakage and no increase in short-term mortality. Significant heterogeneity and publication bias might limit the reliability of the results. More high-quality studies are needed to verify and update our findings.
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Affiliation(s)
- Qi-Yue Ge
- grid.263826.b0000 0004 1761 0489Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yu-Heng Wu
- grid.263826.b0000 0004 1761 0489Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Zhuang-Zhuang Cong
- grid.41156.370000 0001 2314 964XDepartment of Cardiothoracic Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Yong Qiang
- grid.263826.b0000 0004 1761 0489Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yan-Qing Wang
- grid.41156.370000 0001 2314 964XDepartment of Cardiology, Jinling Hospital, School of Medicine, Medical School of Nanjing University, Nanjing, China
| | - Chao Zheng
- grid.506261.60000 0001 0706 7839Department of Thoracic Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021 China
| | - Yi Shen
- grid.263826.b0000 0004 1761 0489Department of Cardiothoracic Surgery, Jinling Hospital, School of Medicine, Southeast University, Nanjing, China
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Fay KA, Maeder ME, Emond JA, Hasson RM, Millington TM, Finley DJ, Phillips JD. Residing in a food desert is associated with an increased risk of readmission following esophagectomy for cancer. J Thorac Dis 2022; 14:1854-1868. [PMID: 35813712 PMCID: PMC9264063 DOI: 10.21037/jtd-21-1637] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 05/19/2022] [Indexed: 11/06/2022]
Abstract
Background Nutritional status is related to treatment outcomes for esophageal cancer. Residing in a food desert (FD) has been associated with worse outcomes in breast and colon cancer. We assessed the association of residing in a FD on 30-day outcomes of esophageal cancer patients who received tri-modality therapy. Methods A retrospective review of patients who underwent esophagectomy (1/2015 to 7/2020, in New Hampshire, USA) was performed. Patients were excluded if they did not undergo neo-adjuvant treatment, required treatment outside of standard Chemoradiotherapy for Oesophageal Cancer Followed by Surgery Study (CROSS) protocol, or lacked both pre and post neo-adjuvant treatment computed tomography (CT) scans for review. Demographics, nutrition parameters, treatment characteristics, 30-day complications and 90-day mortality were reviewed. FD status was defined by the United States Department of Agriculture (USDA) Food Access Research Atlas and cross-referenced with patients' home zip code. Readmission was defined as readmission to any hospital for any reason within 30-day of discharge. Univariable analysis was conducted using Student's t-test or Wilcoxon rank-sum for continuous variables, and Fisher's exact test for categorical variables. Multivariable logistic regression was then used to model readmission status on FD status adjusted for measures statistically associated with readmission status at the P<0.10 in univariable analyses. Results Seventy-eight patients were included in the analysis. Overall pre-treatment prevalence of sarcopenia was 11.5% (9/78) and did not vary by FD status. Univariable analysis, demonstrated few significant differences between those who were readmitted and those who were not. On unadjusted analysis, patients who lived in a FD were 5 times more likely to be readmitted [5.16; 95% confidence interval (CI): 1.70-15.67] compared to those who did not. Residing in a FD remained a significant risk factor for readmission after adjustment for operative time, discharge to a rehabilitation facility and development of a grade III/IV complication [adjusted odds ratio (OR): 6.38; 95% CI: 1.45-28.08]. Conclusions Our data suggest that residing in a FD is a prognostic factor for readmission after tri-modality therapy for esophageal cancer. Clinicians need to be aware that previously established nutritional markers may not completely capture nutritional status and living in a FD may significantly increase the risk of readmission in these patients.
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Affiliation(s)
- Kayla A Fay
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Matthew E Maeder
- Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jennifer A Emond
- Department of Biomedical Data Sciences, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Rian M Hasson
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA
| | - Timothy M Millington
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - David J Finley
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Joseph D Phillips
- Department of Surgery, Section of Thoracic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Kuppusamy MK, Low DE. Evaluation of International Contemporary Operative Outcomes and Management Trends Associated With Esophagectomy: A 4-Year Study of >6000 Patients Using ECCG Definitions and the Online Esodata Database. Ann Surg 2022; 275:515-525. [PMID: 33074888 DOI: 10.1097/sla.0000000000004309] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aims to verify the utility of international online datasets to benchmark and monitor treatment and outcomes in major oncologic procedures. BACKGROUND The Esophageal Complication Consensus Group (ECCG) has standardized the reporting of complications after esophagectomy within the web-based Esodata.org database. This study will utilize the Esodata dataset to update contemporary outcomes and to monitor trends in practice in an era of rapid technical change. METHODS This observational study, based on a prospectively developed specific database, updates esophagectomy outcomes collected between 2015 and 2018. Evolution in patient and operative demographics, treatment, complications, and quality outcome measures were compared between patients undergoing surgery in 2015 to 2016 and 2017 to 2018. RESULTS Between 2015 and 2018, 6022 esophagectomies from 39 centers were entered into Esodata. Most patients were male (78.3%) with median age 63. Patients having minimally invasive esophagectomy constituted 3177 (52.8%), a chest anastomosis 3838 (63.7%), neoadjuvant chemoradiotherapy 2834 (48.7%), and R0 resections 5441 (93.5%). For quality measures, 30- and 90-day mortality was 2.0% and 4.5%, readmissions 9.7%, transfusions 12%, escalation in care 22.1%, and discharge home 89.4%. Trends in quality measures between 2015 and 2016 (2407 patients) and 2017 and 2018 (3318 patients) demonstrated significant (P < 0.05) improvements in readmissions 11.1% to 8.5%, blood transfusions 14.3% to 10.2%, and escalation in care from 24.5% to 20% A significantly (P < 0.05) reduced incidence in pneumonia (15.3%-12.8%) and renal failure (1.0%-0.4%) was observed. Anastomotic leak rates increased from 11.7% to 13.1%, whereas leaks requiring surgery decreased 3.3% and 3.0%, respectively. CONCLUSIONS The Esodata database provides a valuable resource for assessing contemporary international outcomes. This study highlights an increased application of minimally invasive approaches, a high percentage of complications, improvements in pneumonia and key quality metrics, but with anastomotic leak rates still >10%.
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Affiliation(s)
- Madhan K Kuppusamy
- Agaplesion Markus Krankenhaus, Frankfurt, Germany
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, UK
- Claude Huriez University Hospital, Lille, France; Erasmus Medical Center, Rotterdam
- Netherlands; Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
- Guy's & St Thomas' NHS Foundation Trust, London, UK
- Hirslanden Medical Center, Zürich, Switzerland; Hôpital Nord, Aix-Marseille Université, Marseille, France
- Hospital Universitario del Mar, Barcelona, Spain
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Katholieke Universiteit Leuven, Leuven, Belgium; Keio University, Tokyo, Japan
- Massachusetts General Hospital, Boston, MA
- MD Anderson Cancer Center, Houston, TX
- Memorial Sloan Kettering Cancer Center, New York City, NY
- National University Hospital, Singapore, Singapore
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Odense University Hospital, Odense, Denmark
- Oregon Health and Science University, Portland, OR
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
- Queen Elizabeth Hospital University of Birmingham, Birmingham, UK
- Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Royal Victoria Hospital, Belfast, Northern Ireland
- Sichuan Cancer Hospital & Institute, Chengdu, China
- St. James's Hospital Trinity College, Dublin, Ireland
- Tata Memorial Center, Mumbai, India
- The University of Chicago Medicine, Chicago, IL
- Toronto General Hospital, Toronto, Canada
- University Hospital of Cologne, Cologne, Germany
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Medical Center, Utrecht, Netherlands
- University of Michigan Health System, Ann Arbor, MI
- University of São Paulo School of Medicine, São Paulo, Brazil
- University of Verona, Verona, Italy
- Virginia Mason Medical Center, Seattle, WA
- Vita-Salute San Raffaele University, Milan, Italy
| | - Donald E Low
- Agaplesion Markus Krankenhaus, Frankfurt, Germany
- Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
- Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, UK
- Claude Huriez University Hospital, Lille, France; Erasmus Medical Center, Rotterdam
- Netherlands; Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, PA
- Guy's & St Thomas' NHS Foundation Trust, London, UK
- Hirslanden Medical Center, Zürich, Switzerland; Hôpital Nord, Aix-Marseille Université, Marseille, France
- Hospital Universitario del Mar, Barcelona, Spain
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
- Katholieke Universiteit Leuven, Leuven, Belgium; Keio University, Tokyo, Japan
- Massachusetts General Hospital, Boston, MA
- MD Anderson Cancer Center, Houston, TX
- Memorial Sloan Kettering Cancer Center, New York City, NY
- National University Hospital, Singapore, Singapore
- Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
- Nottingham University Hospitals NHS Trust, Nottingham, UK
- Odense University Hospital, Odense, Denmark
- Oregon Health and Science University, Portland, OR
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
- Queen Elizabeth Hospital University of Birmingham, Birmingham, UK
- Queen Mary Hospital, The University of Hong Kong, Hong Kong SAR, China
- Royal Victoria Hospital, Belfast, Northern Ireland
- Sichuan Cancer Hospital & Institute, Chengdu, China
- St. James's Hospital Trinity College, Dublin, Ireland
- Tata Memorial Center, Mumbai, India
- The University of Chicago Medicine, Chicago, IL
- Toronto General Hospital, Toronto, Canada
- University Hospital of Cologne, Cologne, Germany
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
- University Medical Center, Utrecht, Netherlands
- University of Michigan Health System, Ann Arbor, MI
- University of São Paulo School of Medicine, São Paulo, Brazil
- University of Verona, Verona, Italy
- Virginia Mason Medical Center, Seattle, WA
- Vita-Salute San Raffaele University, Milan, Italy
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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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9
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D'Journo XB, Boulate D, Fourdrain A, Loundou A, van Berge Henegouwen MI, Gisbertz SS, O'Neill JR, Hoelscher A, Piessen G, van Lanschot J, Wijnhoven B, Jobe B, Davies A, Schneider PM, Pera M, Nilsson M, Nafteux P, Kitagawa Y, Morse CR, Hofstetter W, Molena D, So JBY, Immanuel A, Parsons SL, Larsen MH, Dolan JP, Wood SG, Maynard N, Smithers M, Puig S, Law S, Wong I, Kennedy A, KangNing W, Reynolds JV, Pramesh CS, Ferguson M, Darling G, Schröder W, Bludau M, Underwood T, van Hillegersberg R, Chang A, Cecconello I, Ribeiro U, de Manzoni G, Rosati R, Kuppusamy M, Thomas PA, Low DE. Risk Prediction Model of 90-Day Mortality After Esophagectomy for Cancer. JAMA Surg 2021; 156:836-845. [PMID: 34160587 PMCID: PMC8223144 DOI: 10.1001/jamasurg.2021.2376] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/13/2021] [Indexed: 02/06/2023]
Abstract
Importance Ninety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions. Objective To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. Design, Setting, and Participants In this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts. Exposures Esophageal resection for cancer of the esophagus and gastroesophageal junction. Main Outcomes and Measures All-cause postoperative 90-day mortality. Results A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, ≥1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, -3 to -4: 90-day mortality, 8.9%), and very high risk (score, ≤-5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. Conclusions and Relevance In this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.
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Affiliation(s)
- Xavier Benoit D'Journo
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - David Boulate
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Anderson Loundou
- Department of Thoracic Surgery, Aix-Marseille University, North Hospital, Marseille, France
| | - Mark I van Berge Henegouwen
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Suzanne S Gisbertz
- Department of Gastrointestinal Surgery, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - J Robert O'Neill
- Department of Oesophago-Gastric Cancer Surgery, Cambridge Oesophago-Gastric Centre, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Arnulf Hoelscher
- Center for Esophageal Diseases, Elisabeth Hospital Essen, University Medicine Essen, Essen, Germany
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez University Hospital, Lille, France
| | - Jan van Lanschot
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Bas Wijnhoven
- Department of Digestive Surgery, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Blair Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Andrew Davies
- Department of Digestive Surgery, Guy's & St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Paul M Schneider
- Department of Digestive and Oncological Surgery, Hirslanden Medical Center, Zurich, Switzerland
| | - Manuel Pera
- Department of Digestive Surgery, Hospital Universitario del Mar, Barcelona, Spain
| | - Magnus Nilsson
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Philippe Nafteux
- Department of Digestive Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Yuko Kitagawa
- Department of Thoracic Surgery, Keio University, Tokyo, Japan
| | | | - Wayne Hofstetter
- Department of Thoracic Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Daniela Molena
- Department of Thoracic and Cardiovascular Surgery, Memorial Sloan Kettering Cancer Center, New York City, New York
| | - Jimmy Bok-Yan So
- Department of Thoracic Surgery, National University Hospital, Singapore, Singapore
| | - Arul Immanuel
- Department of Surgery, Northern Oesophagogastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom
| | - Simon L Parsons
- Department of Upper Gastrointestinal Surgery, Nottingham University Hospitals National Health Service Trust, Nottingham, United Kingdom
| | | | - James P Dolan
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Stephanie G Wood
- Digestive Health Center, Oregon Health and Science University, Portland
| | - Nick Maynard
- Oesophagogastric Cancer Multidisciplinary Team, Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
| | - Mark Smithers
- Department of Surgery, Princess Alexandra Hospital, University of Queensland, Brisbane, Australia
| | - Sonia Puig
- Department of Gastrointestinal Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham Foundation Trust, Birmingham, United Kingdom
| | - Simon Law
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Wong
- Department of Gastrointestinal Surgery, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Andrew Kennedy
- Department of Gastrointestinal Surgery, Royal Victoria Hospital, Belfast, Northern Ireland
| | - Wang KangNing
- Department of Thoracic Surgery, Sichuan Cancer Hospital & Institute, Chengdu, China
| | - John V Reynolds
- Department of Surgery, St James's Hospital Trinity College, Dublin, Ireland
| | - C S Pramesh
- Department of Surgical Oncology, Tata Memorial Centre, Mumbai, India
| | - Mark Ferguson
- Department of Thoracic Surgery, The University of Chicago Medicine, Chicago, Illinois
| | - Gail Darling
- Department of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Wolfgang Schröder
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Marc Bludau
- Department of Digestive Surgery, University Hospital of Cologne, Cologne, Germany
| | - Tim Underwood
- Department of Gastrointestinal Surgery, University Hospital Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | | | - Andrew Chang
- Department of Thoracic Surgery, University of Michigan Health System, Ann Arbor
| | - Ivan Cecconello
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Ulysses Ribeiro
- Department of Digestive Surgery, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - Giovanni de Manzoni
- Department of Upper Gastrointestinal Surgery, University of Verona, Verona, Italy
| | - Riccardo Rosati
- Department of Upper Gastrointestinal Surgery, Vita-Salute San Raffaele University, Milan, Italy
| | | | | | - Donald E Low
- Department of Thoracic Surgery, Virginia Mason Medical Center, Seattle, Washington
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10
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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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11
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Commentary: Surgical risk assessment in 2020: Is a handshake and a walking test really the best we've got? J Thorac Cardiovasc Surg 2020; 161:834-835. [PMID: 33422318 DOI: 10.1016/j.jtcvs.2020.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 12/16/2022]
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12
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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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13
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Resio BJ, Gonsalves L, Canavan M, Mueller L, Phillips C, Sathe T, Swett K, Boffa DJ. Where the Other Half Dies: Analysis of Mortalities Occurring More Than 30 Days After Complex Cancer Surgery. Ann Surg Oncol 2020; 28:1278-1286. [PMID: 32885398 DOI: 10.1245/s10434-020-09080-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 07/15/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Nearly half of operative mortalities occur outside the traditionally studied 30-day period after surgery. To identify additional opportunities to improve surgical safety, the circumstances of deaths occurring 31-90 days after complex cancer surgery are analyzed. PATIENTS AND METHODS Patients aged ≥ 65 years who died within 90 days of complex cancer surgery for nonmetastatic cancer were analyzed in the Surveillance, Epidemiology, and End Results (SEER)-Medicare and the Connecticut Tumor Registry (CTR) databases. RESULTS Of the 36,114 patients undergoing complex cancer surgery from 2004 to 2013 in SEER-Medicare, 1367 (3.8%) died within 31-90 days ("late mortalities"). Seventy-eight percent of late mortalities were readmitted prior to death. The highest proportion of late mortalities occurred during a readmission (49%), and 11% were never discharged from their index admission. Cause of death (COD) was largely attributed to the malignancy itself (56%), which is unlikely to be the underlying cause. Of the noncancer COD, cardiac causes were most frequent (34%), followed by pulmonary causes (18%). Death was rarely attributed to thromboembolic disease (< 1%). The CTR provided location of death, which was most commonly in a hospital (65%) or nursing facility (20%); death at home was rare (6%). CONCLUSIONS The vast majority of patients dying between 31 and 90 days of surgery were admitted to a hospital or nursing facility at the time of their death after initially being discharged, and few patients died at home. Greater clarity in death documentation is needed to identify specific opportunities to rescue patients from fatal complications arising in the later postoperative period.
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Affiliation(s)
- Benjamin J Resio
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Maureen Canavan
- Department of Internal Medicine, Cancer Outcomes and Public Policy and Effectiveness Research (COPPER), Yale School of Medicine, New Haven, CT, USA
| | | | | | | | | | - Daniel J Boffa
- Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
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14
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González-Montero J, Valenzuela G, Ahumada M, Barajas O, Villanueva L. Management of cancer patients during COVID-19 pandemic at developing countries. World J Clin Cases 2020; 8:3390-3404. [PMID: 32913846 PMCID: PMC7457113 DOI: 10.12998/wjcc.v8.i16.3390] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/09/2020] [Accepted: 08/12/2020] [Indexed: 02/05/2023] Open
Abstract
Cancer patient care requires a multi-disciplinary approach and multiple medical and ethical considerations. Clinical care during a pandemic health crisis requires prioritising the use of resources for patients with a greater chance of survival, especially in developing countries. The coronavirus disease 2019 crisis has generated new challenges given that cancer patients are normally not prioritised for admission in critical care units. Nevertheless, the development of new cancer drugs and novel adjuvant/neoadjuvant protocols has dramatically improved the prognosis of cancer patients, resulting in a more complex decision-making when prioritising intensive care in pandemic times. In this context, it is essential to establish an effective and transparent communication between the oncology team, critical care, and emergency units to make the best decisions, considering the principles of justice and charity. Concurrently, cancer treatment protocols must be adapted to prioritise according to oncologic response and prognosis. Communication technologies are powerful tools to optimise cancer care during pandemics, and we must adapt quickly to this new scenario of clinical care and teaching. In this new challenging pandemic scenario, multi-disciplinary work and effective communication between clinics, technology, science, and ethics is the key to optimising clinical care of cancer patients.
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Affiliation(s)
- Jaime González-Montero
- Basic and Clinical Oncology Department, Faculty of Medicine, University of Chile, Santiago 70058, Chile
| | - Guillermo Valenzuela
- Basic and Clinical Oncology Department, Faculty of Medicine, University of Chile, Santiago 70058, Chile
| | - Mónica Ahumada
- Basic and Clinical Oncology Department, Faculty of Medicine, University of Chile, Santiago 70058, Chile
- Basic and Clinical Oncology Department, Hospital Clinico Universidad de Chile and Clínica Dávila, Chile
| | - Olga Barajas
- Basic and Clinical Oncology Department, Faculty of Medicine, University of Chile, Santiago 70058, Chile
- Basic and Clinical Oncology Department, Hospital Clinico Universidad de Chile and Fundación Arturo López-Pérez, Chile
| | - Luis Villanueva
- Oncology Department, Hospital Clínico Universidad de Chile and Fundación Arturo López-Perez, Chile
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15
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Zheng R, Rios-Diaz AJ, Liem S, Devin CL, Evans NR, Rosato EL, Palazzo F, Berger AC. Is the placement of jejunostomy tubes in patients with esophageal cancer undergoing esophagectomy associated with increased inpatient healthcare utilization? An analysis of the National Readmissions Database. Am J Surg 2020; 221:141-148. [PMID: 32828519 DOI: 10.1016/j.amjsurg.2020.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/19/2020] [Accepted: 06/20/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Patients undergoing esophagectomy often receive jejunostomy tubes (j-tubes) for nutritional supplementation. We hypothesized that j-tubes are associated with increased post-esophagectomy readmissions. STUDY DESIGN We identified esophagectomies for malignancy with (EWJ) or without (EWOJ) j-tubes using the 2010-2015 Nationwide Readmissions Database. Outcomes include readmission, inpatient mortality, and complications. Outcomes were compared before and after propensity score matching (PSM). RESULTS Of 22,429 patients undergoing esophagectomy, 16,829 (75.0%) received j-tubes. Patients were similar in age and gender but EWJ were more likely to receive chemotherapy (24.2% vs. 15.1%, p < 0.01). EWJ was associated with decreased 180-day inpatient mortality (HR 0.72 [0.52-0.99]) but not with higher readmissions at 30- (15.2% vs. 14.0%, p = 0.16; HR 0.9 [0.77-1.05]) or 180 days (25.2% vs. 24.3%, p = 0.37; HR 0.94 [0.79-1.10]) or increased complications (p = 0.37). These results were confirmed in the PSM cohort. CONCLUSION J-tubes placed in the setting of esophagectomy do not increase inpatient readmissions or mortality.
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Affiliation(s)
- Richard Zheng
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA.
| | - Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Spencer Liem
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Nathaniel R Evans
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Ernest L Rosato
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Sidney Kimmel Medical College, Philadelphia University and Thomas Jefferson University, Philadelphia, PA, USA
| | - Adam C Berger
- Department of Surgery, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
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16
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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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17
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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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18
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Nelson DB, Mitchell KG, Weston BR, Betancourt S, Maru D, Rice DC, Mehran RJ, Sepesi B, Antonoff MB, Walsh GL, Swisher SG, Roth JA, Vaporciyan AA, Blum M, Hofstetter WL. Should endoscopic mucosal resection be attempted for cT2N0 esophageal cancer? Dis Esophagus 2019; 32:1-6. [PMID: 30888418 DOI: 10.1093/dote/doz016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 02/11/2019] [Accepted: 02/21/2019] [Indexed: 12/11/2022]
Abstract
Endoscopic mucosal resection (EMR) can be an effective therapy for superficial esophageal cancer. Many patients with cT2 invasion by endoscopic ultrasound (EUS) receive surgery but are subsequently found to have superficial disease. The purpose of this study was to investigate the safety profile and the added value of attempting EMR for EUS-staged cT2N0 esophageal cancer. A retrospective review was performed at a single institution from 2008 to 2017. Patients who were staged cT2N0 by EUS were identified from a prospectively maintained surgical database. Among 75 patients identified for analysis, 30 underwent an attempt at EMR. No perforations or other immediate complications occurred. EMR was more likely to be attempted among older patients (P = 0.001) with smaller tumor size (P < 0.001) and diminished SUVmax (P = 0.001). At the time of treatment, EMR was successful in clearing all known disease among 17/30 patients, with 12 representing pT1a or less and 5 representing pT1b with negative margins. Among the 17 patients for whom EMR was able to clear all known disease, there were no recurrences or cancer-related deaths. Although all the patients were staged as cT2N0 by EUS, many patients were identified by EMR to have superficial disease. There were no perforations or other adverse events related to EMR. Furthermore, EMR cleared all known disease among 17 patients with no known recurrences or cancer-related deaths. The results indicate that EMR for cT2N0 esophageal cancer is a safe diagnostic option that is therapeutic for some.
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Affiliation(s)
| | | | - Brian R Weston
- Department of GastroenterologyThe University of Texas MD Anderson Cancer Center
| | - Sonia Betancourt
- Department of Diagnostic ImagingThe University of Texas MD Anderson Cancer Center
| | - Dipen Maru
- Department of PathologyThe University of Texas MD Anderson Cancer Center
| | - David C Rice
- Department of Thoracic and Cardiovascular Surgery
| | | | - Boris Sepesi
- Department of Thoracic and Cardiovascular Surgery
| | | | | | | | - Jack A Roth
- Department of Thoracic and Cardiovascular Surgery
| | | | - Mariela Blum
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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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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Erdem S, Troxler E, Warschkow R, Tsai C, Yerokun B, Schmied B, Stettler C, Blazer DG, Hartwig M, Worni M, Gloor B. Is There a Role for Surgery in Patients with Neuroendocrine Tumors of the Esophagus? A Contemporary View from the NCDB. Ann Surg Oncol 2019; 27:671-680. [PMID: 31605338 DOI: 10.1245/s10434-019-07847-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Esophageal neuroendocrine tumors (eNETs) are exceedingly rare, aggressive and have a poor prognosis. Treatment guidelines are ill-defined and mainly based on evidence from case reports and analogous experiences drawn from similar disease sites. METHODS The NCDB was reviewed for histologically confirmed stage I-III, primary eNETs from 2006 to 2014. Patients were grouped into whether or not they underwent primary tumor resection. Univariate, multivariable, and full bipartite propensity score (PS) adjusted Cox regression analyses were used to assess overall and relative survival differences. RESULTS A total of 250 patients were identified. Mean age was 65.0 (standard deviation [SD] 11.9) years, and 174 (69.6%) patients were male. Most patients had stage III disease (n = 136, 54.4%), and the most common type of NET was small cell eNET (n = 111, 44.4%). Chemotherapy was used in 186 (74.4%), radiation therapy in 178 (71.2%), and oncological resection was performed in 69 (27.6%) patients. Crude 2-year survival rates were higher in the operated (57.3%) compared with the nonoperated group (35.2%; p < 0.001). The survival benefit held true after multivariable adjustment (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.32-0.69, p < 0.001). After full bipartite PS adjustment analysis, survival was longer for patients who received a surgical resection compared with those who did not (HR 0.48, 95% CI 0.31-0.75, p = 0.003) with a corresponding 2-year overall survival rate of 63.3% (95% CI 52.0-77.2) versus 38.8% (95% CI 30.9-48.8), respectively. CONCLUSIONS Multimodal treatment that includes surgery is associated with better overall survival for eNETs. Additional research is needed to more definitively identify patients who benefit from esophagectomy and to establish an appropriate treatment algorithm.
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Affiliation(s)
- Suna Erdem
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Esther Troxler
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - René Warschkow
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Catherine Tsai
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | | | - Bruno Schmied
- Department of Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christoph Stettler
- Department of Diabetes, Endocrinology, Nutritional Medicine and Metabolism, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Mathias Worni
- Duke University Medical Center, Durham, NC, USA. .,Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Basel, Switzerland.
| | - Beat Gloor
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
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Hirji SA, Shah RM, Fields A, Orhurhu V, Bhulani N, White A, Mody GN, Swanson SJ. The Impact of Hospital Size on National Trends and Outcomes Following Open Esophagectomy. ACTA ACUST UNITED AC 2019; 55:medicina55100669. [PMID: 31623325 PMCID: PMC6843198 DOI: 10.3390/medicina55100669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/20/2019] [Accepted: 09/30/2019] [Indexed: 01/29/2023]
Abstract
Background and Objectives: Previous studies have demonstrated superior patient outcomes for thoracic oncology patients treated at high-volume surgery centers compared to low-volume centers. However, the specific role of overall hospital size in open esophagectomy morbidity and mortality remains unclear. Materials and Methods: Patients aged >18 years who underwent open esophagectomy for primary malignant neoplasia of the esophagus between 2002 and 2014 were identified using the National Inpatient Sample. Minimally invasive procedures were excluded. Discharges were stratified by hospital size (large, medium, and small) and analyzed using trend and multivariable regression analyses. Results: Over a 13-year period, a total of 69,840 open esophagectomy procedures were performed nationally. While the proportion of total esophagectomies performed did not vary by hospital size, in-hospital mortality trends decreased for all hospitals (large (7.2% to 3.7%), medium (12.8% vs. 4.9%), and small (12.8% vs. 4.9%)), although this was only significant for large hospitals (P < 0.01). After controlling for patient demographics, comorbidities, admission, and hospital-level factors, hospital length of stay (LOS), total inflation-adjusted costs, in-hospital mortality, and complications (cardiac, respiratory, vascular, and bleeding) did not vary by hospital size (all P > 0.05). Conclusions: After risk adjustment, patient morbidity and in-hospital mortality appear to be comparable across all institutions, including small hospitals. While there appears to be an increased push for referring patients to large hospitals, our findings suggest that there may be other factors (such as surgeon type, hospital volume, or board status) that are more likely to impact the results; these need to be further explored in the current era of episode-based care.
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Affiliation(s)
- Sameer A Hirji
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Rohan M Shah
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Adam Fields
- T. H. Chan Harvard School of Public Health, Boston, MA 02115, USA.
| | - Vwaire Orhurhu
- T. H. Chan Harvard School of Public Health, Boston, MA 02115, USA.
| | - Nizar Bhulani
- T. H. Chan Harvard School of Public Health, Boston, MA 02115, USA.
| | - Abby White
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
| | - Gita N Mody
- Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC 27599-7065, USA.
| | - Scott J Swanson
- Division of Thoracic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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22
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Gupta V, Bubis L, Kidane B, Mahar AL, Ringash J, Sutradhar R, Darling GE, Coburn NG. Readmission rates following esophageal cancer resection are similar at regionalized and non-regionalized centers: A population-based cohort study. J Thorac Cardiovasc Surg 2019; 158:934-942.e2. [DOI: 10.1016/j.jtcvs.2019.04.061] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 03/28/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
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White A, Kucukak S, Lee DN, Mazzola E, Zhang Y, Swanson SJ. Ivor Lewis minimally invasive esophagectomy for esophageal cancer: An excellent operation that improves with experience. J Thorac Cardiovasc Surg 2019; 157:783-789. [DOI: 10.1016/j.jtcvs.2018.10.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 09/10/2018] [Accepted: 10/07/2018] [Indexed: 12/20/2022]
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Arnold BN, Chiu AS, Hoag JR, Kim CH, Salazar MC, Blasberg JD, Boffa DJ. Spontaneous regionalization of esophageal cancer surgery: an analysis of the National Cancer Database. J Thorac Dis 2018; 10:1721-1731. [PMID: 29707326 DOI: 10.21037/jtd.2018.02.12] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Esophagectomy patients are up to three times more likely to die after surgery when cared for at low-volume hospitals (LVHs). Increased awareness by patients and clinicians of the hazards of esophagectomy at LVHs, may inspire a "spontaneous regionalization" away from LVHs, yet the extent to which this has taken place is unclear. Methods Retrospective analysis of patients undergoing esophagectomy for esophageal cancer in the National Cancer Database (NCDB) across two eras: 2004-2006 (Era 1) and 2010-2012 (Era 2). Primary outcomes included the proportion of patients at high-volume hospitals (HVHs) (≥13/year per Leapfrog Group), adjusted, and unadjusted 90-day mortality. Results The NCDB captured 5,968 esophagectomy patients in Era 1 and 5,580 in Era 2, a 6.5% decrease (P<0.001). Fewer hospitals performed esophagectomies in Era 2 (756 vs. 663, P=0.014), yet the proportion of patients treated at LVHs declined slightly between eras (73% vs. 70%, P<0.001). Patients with high-risk attributes (e.g., advanced age, multiple comorbidities, etc.) were disproportionately treated at LVHs in both eras (77% Era 1, P<0.001, 73% Era 2, P=0.017). However, the 90-day mortality rate for patients with high-risk attributes decreased considerably between Eras at LVHs (19.3% to 12.3%, P<0.001). Conclusions Spontaneous regionalization of esophageal cancer surgery has not occurred on a large scale, yet for high-risk patients, the hazards of being cared for at LVHs have dissipated. Further study is needed to optimize alignment of esophagectomy patients and hospitals.
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Affiliation(s)
- Brian N Arnold
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Alexander S Chiu
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jessica R Hoag
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, New Haven, CT, USA
| | - Clara H Kim
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Michelle C Salazar
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Justin D Blasberg
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Daniel J Boffa
- Section of Thoracic Surgery, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT, USA
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25
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Readmissions With Multidrug-Resistant Infection in Patients With Prior Multidrug Resistant Infection. Infect Control Hosp Epidemiol 2017; 39:12-19. [PMID: 29248023 DOI: 10.1017/ice.2017.254] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To determine incidence of and risk factors for readmissions with multidrug-resistant organism (MDRO) infections among patients with previous MDRO infection. DESIGN Retrospective cohort of patients admitted between January 1, 2006, and October 1, 2015. SETTING Barnes-Jewish Hospital, a 1,250-bed academic tertiary referral center in St Louis, Missouri. METHODS We identified patients with MDROs obtained from the bloodstream, bronchoalveolar lavage (BAL)/bronchial wash, or other sterile sites. Centers for Disease Control and prevention (CDC) and European CDC definitions of MDROs were utilized. All readmissions ≤1 year from discharge from the index MDRO hospitalization were evaluated for bloodstream, BAL/bronchial wash, or other sterile site cultures positive for the same or different MDROs. RESULTS In total, 4,429 unique patients had a positive culture for an MDRO; 3,453 of these (78.0%) survived the index hospitalization. Moreover, 2,127 patients (61.6%) were readmitted ≥1 time within a year, for a total of 5,849 readmissions. Furthermore, 512 patients (24.1%) had the same or a different MDRO isolated from blood, BAL/bronchial wash, or another sterile site during a readmission. Bone marrow transplant, end-stage renal disease, lymphoma, methicillin-resistant Staphylococcus aureus, or carbapenem-resistant Pseudomonas aeruginosa during index hospitalization were factors associated with increased risk of having an MDRO isolated during a readmission. MDROs isolated during readmissions were in the same class of MDRO as the index hospitalization 9%-78% of the time, with variation by index pathogen. CONCLUSIONS Readmissions among patients with MDRO infections are frequent. Various patient and organism factors predispose to readmission. When readmitted patients had an MDRO, it was often a pathogen in the same class as that isolated during the index admission, with the exception of Acinetobacter (~9%). Infect Control Hosp Epidemiol 2018;39:12-19.
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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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27
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Mortality and Graft Loss Attributable to Readmission After Kidney Transplantation: Immediate and Long-term Risk. Transplantation 2017; 101:2520-2526. [PMID: 27941434 DOI: 10.1097/tp.0000000000001609] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND After kidney transplantation, early readmission is independently associated with graft loss and mortality. The mechanism of this association is poorly understood. Understanding the timeline of risk, that is, during the readmission hospitalization versus periods postreadmission, will provide additional insights. METHODS We used national registry data to study 56 076 adult Medicare-primary first-time kidney transplant recipients from December 1999 to October 2011. Piecewise Cox proportional hazard models were used to estimate the association between graft loss, mortality, and readmission for 2 periods: readmission hospitalization and postreadmission. RESULTS During the readmission hospitalization, graft loss was substantially higher (deceased donor kidney transplant [DDKT] without delayed graft function [DGF] hazard ratio: 24.634.447.9, P < 0.001; with DGF: 10.815.221.4, P < 0.001; live donor kidney transplant [LDKT]: 18.136.774.2, P < 0.001) and mortality was substantially higher (DDKT without DGF: 14.120.830.7, P < 0.001; with DGF: 9.0312.818.0, P < 0.001; LDKT: 9.0018.241.3, P < 0.001). Immediately after readmission discharge, graft loss (DDKT without DGF: 2.082.402.77, P < 0.001; with DGF: 1.832.142.51, P < 0.001; LDKT: 2.002.503.13, P < 0.001), and mortality (DDKT without DGF: 2.162.432.73, P < 0.001; with DGF: 1.832.162.88, P < 0.001; LDKT: 1.902.342.88, P < 0.001) remained elevated, but much less so. After readmission, the hazard of graft loss remained, but decreased 19% per year for DDKT recipients (time varying coefficient 0.780.810.85, P < 0.001) and 14% per year for LDKT recipients (0.790.860.93, P < 0.001). The hazard of mortality remained, but decreased 14% per year for DDKT recipients (0.830.860.89, P < 0.001) and 9% per year for LDKT recipients (0.850.910.98, P < 0.001). CONCLUSIONS In conclusion, readmission is most strongly associated with graft loss and mortality during the readmission hospitalization, but also portends a lasting, albeit attenuated, risk postreadmission.
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Choe YR, Joh JY, Kim YP. Association between frailty and readmission within one year after gastrectomy in older patients with gastric cancer. J Geriatr Oncol 2017; 8:185-189. [PMID: 28259489 DOI: 10.1016/j.jgo.2017.02.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/25/2016] [Accepted: 02/07/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The incidence of gastric cancer in older people is increasing. Because older patients are at increased risk of postoperative complications and mortality, preoperative risk assessment in this population is important. This study explored whether preoperative assessment of frailty could be useful for predicting the postoperative outcome in patients with gastric cancer. MATERIALS AND METHODS We investigated 223 patients (136 men and 87 women) over 65years of age who underwent gastric cancer surgery from April 2012 to March 2015 at a single institution in Korea. Frailty was assessed using the Study of Osteoporotic Fractures (SOF) frailty index. Logistic regression was used to identify factors predicting readmission within one year of discharge following gastrectomy. RESULTS Twenty six (11.7%) patients were readmitted within one year after gastrectomy. Patients in the "robust" and "pre-frail and frail" group had a readmission rate of 6.7% and 19.1%, respectively. After adjusting age, gender, Eastern Cooperative Oncology Group performance status (ECOG PS) (score≥1), histological type and stage (III, IV), frailty (pre-frail and frail) was a predictive factor for readmission within one year of discharge after gastrectomy (Odds Ratio, 5.74, 95%; Confidence Interval, 1.78-18.48; p=0.003). CONCLUSIONS Preoperative risk assessment including frailty evaluation can predict the readmission within one year of discharge after gastrectomy. Frailty assessment can help physicians to identify the risk and inform patients and their families of the risk, which should improve decision making in gastric cancer treatment.
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Affiliation(s)
- Yu-Ri Choe
- Department of Family Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro, Hwasun-eup, Hwasun-gun, Chonnam, South Korea.
| | - Ju-Youn Joh
- Department of Family Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro, Hwasun-eup, Hwasun-gun, Chonnam, South Korea.
| | - Yeon-Pyo Kim
- Department of Family Medicine, Chonnam National University Hwasun Hospital, 322, Seoyang-ro, Hwasun-eup, Hwasun-gun, Chonnam, South Korea; Chonnam National University School of Medicine, 160, Baekseo-ro, Dong-gu, Gwangju, South Korea.
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30
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Goense L, van Dijk WA, Govaert JA, van Rossum PSN, Ruurda JP, van Hillegersberg R. Hospital costs of complications after esophagectomy for cancer. Eur J Surg Oncol 2016; 43:696-702. [PMID: 28012715 DOI: 10.1016/j.ejso.2016.11.013] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 11/15/2016] [Accepted: 11/21/2016] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to estimate the economic burden of postoperative complications after esophagectomy for cancer, in order to optimally allocate resources for quality improvement initiatives in the future. METHODS A retrospective analysis of prospectively collected clinical and financial outcomes after esophageal cancer surgery in a tertiary referral center in the Netherlands was performed. Data was extracted from consecutive patients registered in the Dutch Upper GI Cancer Audit between 2011 and 2014 (n = 201). Costs were measured up to 90-days after hospital discharge and based on Time-Driven Activity-Based Costing. The additional costs were estimated using multiple linear regression models. RESULTS The average total cost for one patient after esophagectomy was €37,581 (±31,372). The estimated costs of an esophagectomy without complications were €23,476 (±6496). Mean costs after minor (47%) and severe complications (29%) were €31,529 (±23,359) and €59,167 (±42,615) (p < 0.001), respectively. The 5% most expensive patients were responsible for 20.3% of the total hospital costs assessed in this study. Patient characteristics associated with additional costs in multivariable analysis included, age >70 (+€2,922, p = 0.036), female gender (+€4,357, p = 0.005), COPD (+€5,415, p = 0.002), and a history of thromboembolic events (+€6,213, p = 0.028). Complications associated with a significant increase in costs in multivariable analysis included anastomotic leakage (+€4,123, p = 0.008), cardiac complications (+€5,711, p = 0.003), chyle leakage (+€6,188, p < 0.001) and postoperative bleeding (+€31,567, p < 0.001). CONCLUSIONS Complications and severity of complications after esophageal surgery are associated with a substantial increase in costs. Although not all postoperative complications can be prevented, implementation of preventive measures to reduce complications could result in a considerable cost reduction and quality improvement.
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Affiliation(s)
- L Goense
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands.
| | | | - J A Govaert
- Department of Surgery, Leiden University Medical Center, The Netherlands
| | - P S N van Rossum
- Department of Surgery, University Medical Center Utrecht, The Netherlands; Department of Radiation Oncology, University Medical Center Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgery, University Medical Center Utrecht, The Netherlands
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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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