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J Chest Surg

Published online February 7, 2024

Copyright © Journal of Chest Surgery.

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 , M.D., Devon C. Freudenberger , M.D., Jad Khoraki , M.D., Lena Bless , M.D., Riley Payne , B.S., Walker A. Julliard , M.D., Rachit D. Shah , M.D., Carlos A. Puig , M.D.

Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA

Correspondence to:Yahya Alwatari
Tel 1-804-628-9789
Fax 1-804-827-1016
E-mail alwatari.yahya@mayo.edu
ORCID
https://orcid.org/0000-0002-0219-3251

Received: October 25, 2023; Revised: December 4, 2023; Accepted: December 7, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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: Emergent, Esophagectomy, Perioperative outcomes, National Surgical Quality Improvement Program

Article

ahead

J Chest Surg

Published online February 7, 2024

Copyright © Journal of Chest Surgery.

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 , M.D., Devon C. Freudenberger , M.D., Jad Khoraki , M.D., Lena Bless , M.D., Riley Payne , B.S., Walker A. Julliard , M.D., Rachit D. Shah , M.D., Carlos A. Puig , M.D.

Section of Thoracic & Foregut Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA

Correspondence to:Yahya Alwatari
Tel 1-804-628-9789
Fax 1-804-827-1016
E-mail alwatari.yahya@mayo.edu
ORCID
https://orcid.org/0000-0002-0219-3251

Received: October 25, 2023; Revised: December 4, 2023; Accepted: December 7, 2023

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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: Emergent, Esophagectomy, Perioperative outcomes, National Surgical Quality Improvement Program

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