Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
권호 표지
DOI QR코드

DOI QR Code

Emergent Esophagectomy in Patients with Esophageal Malignancy Is Associated with Higher Rates of Perioperative Complications but No Independent Impact on Short-Term Mortality

  • Yahya Alwatari (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Devon C. Freudenberger (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Jad Khoraki (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Lena Bless (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Riley Payne (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Walker A. Julliard (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Rachit D. Shah (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University) ;
  • Carlos A. Puig (Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University)
  • Received : 2023.10.25
  • Accepted : 2023.12.07
  • Published : 2024.03.05
Download PDF
⟨ Previous Next ⟩

Abstract

Background: Data on perioperative outcomes of emergent versus elective resection in esophageal cancer patients requiring esophagectomy are lacking. We investigated whether emergent resection was associated with increased risks of morbidity and mortality. Methods: Data on patients with esophageal malignancy who underwent esophagectomy from 2005 to 2020 were retrospectively analyzed from the American College of Surgeons National Surgical Quality Improvement Program database. Thirty-day complication and mortality rates were compared between emergent esophagectomy (EE) and non-emergent esophagectomy. Logistic regression assessed factors associated with complications and mortality. Results: Of 10,067 patients with malignancy who underwent esophagectomy, 181 (1.8%) had EE, 64% had preoperative systemic inflammatory response syndrome, sepsis, or septic shock, and 44% had bleeding requiring transfusion. The EE group had higher American Society of Anesthesiologists (ASA) class and functional dependency. More transhiatal esophagectomies and diversions were performed in the EE group. After EE, the rates of 30-day mortality (6.1% vs. 2.8%), overall complications (65.2% vs. 44.2%), bleeding, pneumonia, prolonged intubation, and positive margin (17.7% vs. 7.4%) were higher, while that of anastomotic leak was similar. On adjusted logistic regression, older age, lower albumin, higher ASA class, and fragility were associated with increased complications and mortality. McKeown esophagectomy and esophageal diversion were associated with a higher risk of postoperative complications. EE was associated with 30-day postoperative complications (odds ratio, 2.39; 95% confidence interval, 1.66-3.43; p<0.0001). Conclusion: EE was associated with a more than 2-fold increase in complications compared to elective procedures, but no independent increase in short-term mortality. These findings may help guide data-driven critical decision-making for surgery in select cases of complicated esophageal malignancy.

Keywords

References

  1. Sharma P. Barrett esophagus: a review. JAMA 2022;328:663-71. https://doi.org/10.1001/jama.2022.13298 
  2. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019;69:7-34. https://doi.org/10.3322/caac.21551 
  3. Meredith KL, Maramara T, Blinn P, Lee D, Huston J, Shridhar R. Comparative perioperative outcomes by esophagectomy surgical technique. J Gastrointest Surg 2020;24:1261-8. https://doi.org/10.1007/s11605-019-04269-y 
  4. Raymond DP, Seder CW, Wright CD, et al. Predictors of major morbidity or mortality after resection for esophageal cancer: a Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model. Ann Thorac Surg 2016;102:207-14. https://doi.org/10.1016/j.athoracsur.2016.04.055 
  5. Godin A, Liberman M. The modern approach to esophageal palliative and emergency surgery. Ann Transl Med 2021;9:905. https://doi.org/10.21037/atm.2020.03.107 
  6. Konig AM, Hofmann BT, Groth S, Izbicki JR. Emergency interventions for perforation and bleeding in esophageal cancer patients. Chirurg 2012;83:719, 722-5. https://doi.org/10.1007/s00104-011-2266-6 
  7. Nirula R. Esophageal perforation. Surg Clin North Am 2014;94:35-41. https://doi.org/10.1016/j.suc.2013.10.003 
  8. Ohsawa M, Hamai Y, Ibuki Y, Emi M, Okada M. Successful management of esophageal cancer with perforation using bypass surgery followed by definitive chemoradiotherapy. In Vivo 2020;34:2169-72. https://doi.org/10.21873/invivo.12025 
  9. Seo YD, Lin J, Chang AC, Orringer MB, Lynch WR, Reddy RM. Emergent esophagectomy for esophageal perforations: a safe option. Ann Thorac Surg 2015;100:905-9. https://doi.org/10.1016/j.athoracsur.2015.04.055 
  10. Schweigert M, Solymosi N, Dubecz A, et al. Emergency oesophagectomy for oesophageal perforation after chemoradiotherapy for oesophageal cancer. Ann R Coll Surg Engl 2015;97:140-5. https://doi.org/10.1308/003588414X14055925060631 
  11. Schneider L, Hartwig W, Aulmann S, et al. Quality of life after emergency vs. elective esophagectomy with cervical reconstruction. Scand J Surg 2010;99:3-8. https://doi.org/10.1177/145749691009900102 
  12. Subramaniam S, Aalberg JJ, Soriano RP, Divino CM. New 5-factor modified frailty index using American College of Surgeons NSQIP data. J Am Coll Surg 2018;226:173-81. https://doi.org/10.1016/j.jamcollsurg.2017.11.005 
  13. Driedger MR, Puig CA, Thiels CA, et al. Emergent pancreatectomy for neoplastic disease: outcomes analysis of 534 ACS-NSQIP patients. BMC Surg 2020;20:169. https://doi.org/10.1186/s12893-020-00822-8 
  14. Wilkinson JD, Mamas MA, Kontopantelis E. Logistic regression frequently outperformed propensity score methods, especially for large datasets: a simulation study. J Clin Epidemiol 2022;152:176-84. https://doi.org/10.1016/j.jclinepi.2022.09.009 
  15. Peponis T, Bohnen JD, Sangji NF, et al. Does the emergency surgery score accurately predict outcomes in emergent laparotomies? Surgery 2017;162:445-52. https://doi.org/10.1016/j.surg.2017.03.016 
  16. Ingraham AM, Cohen ME, Bilimoria KY, et al. Comparison of hospital performance in nonemergency versus emergency colorectal operations at 142 hospitals. J Am Coll Surg 2010;210:155-65. https://doi.org/10.1016/j.jamcollsurg.2009.10.016 
  17. Havens JM, Peetz AB, Do WS, et al. The excess morbidity and mortality of emergency general surgery. J Trauma Acute Care Surg 2015;78:306-11. https://doi.org/10.1097/TA.0000000000000517 
  18. Sheetz KH, Waits SA, Krell RW, Campbell DA Jr, Englesbe MJ, Ghaferi AA. Improving mortality following emergent surgery in older patients requires focus on complication rescue. Ann Surg 2013;258:614-8. https://doi.org/10.1097/SLA.0b013e3182a5021d 
  19. Castillo-Angeles M, Cooper Z, Jarman MP, Sturgeon D, Salim A, Havens JM. Association of frailty with morbidity and mortality in emergency general surgery by procedural risk level. JAMA Surg 2021;156:68-74. https://doi.org/10.1001/jamasurg.2020.5397 
  20. Bolger JC, Zaidi A, Fuentes-Bonachera A, et al. Emergency surgery in octogenarians: outcomes and factors affecting mortality in the general hospital setting. Geriatr Gerontol Int 2018;18:1211-4. https://doi.org/10.1111/ggi.13456 
  21. Goeteyn J, Evans LA, De Cleyn S, et al. Frailty as a predictor of mortality in the elderly emergency general surgery patient. Acta Chir Belg 2017;117:370-5. https://doi.org/10.1080/00015458.2017.1337339 
  22. Chiang JM, Chang CJ, Jiang SF, et al. Pre-operative serum albumin level substantially predicts post-operative morbidity and mortality among patients with colorectal cancer who undergo elective colectomy. Eur J Cancer Care (Engl) 2017;26:e12403. https://doi.org/10.1111/ecc.12403 
  23. Shin R, Lee SM, Sohn B, et al. Predictors of morbidity and mortality after surgery for intestinal perforation. Ann Coloproctol 2016;32:221-7. https://doi.org/10.3393/ac.2016.32.6.221 
  24. Li G, Walco JP, Mueller DA, Wanderer JP, Freundlich RE. Reliability of the ASA Physical Status Classification System in predicting surgical morbidity: a retrospective analysis. J Med Syst 2021;45:83. https://doi.org/10.1007/s10916-021-01758-z 
  25. Schizas D, Michalinos A, Syllaios A, et al. Staged esophagectomy: surgical legacy or a bailout option? Surg Today 2020;50:1323-31. https://doi.org/10.1007/s00595-019-01894-7 
  26. Sabra MJ, Alwatari YA, Wolfe LG, et al. Ivor Lewis vs Mckeown esophagectomy: analysis of operative outcomes from the ACS NSQIP database. Gen Thorac Cardiovasc Surg 2020;68:370-9. https://doi.org/10.1007/s11748-020-01290-w 
  27. Zheng R, Tham EJ, Rios-Diaz AJ, et al. A 10-year ACS-NSQIP analysis of trends in esophagectomy practices. J Surg Res 2020;256:103-11. https://doi.org/10.1016/j.jss.2020.06.008 
  28. Saddoughi SA, Mitchell KG, Antonoff MB, et al. Analysis of esophagectomy margin practice and survival implications. Ann Thorac Surg 2022;113:209-16. https://doi.org/10.1016/j.athoracsur.2021.01.028 
  29. Raval MV, Pawlik TM. Practical guide to surgical data sets: National Surgical Quality Improvement Program (NSQIP) and Pediatric NSQIP. JAMA Surg 2018;153:764-5. https://doi.org/10.1001/jamasurg.2018.0486 
  30. Lam TC, Fok M, Cheng SW, Wong J. Anastomotic complications after esophagectomy for cancer: a comparison of neck and chest anastomoses. J Thorac Cardiovasc Surg 1992;104:395-400. https://doi.org/10.1016/S0022-5223(19)34794-4