Textbook Outcomes After Esophagectomy with Gastric Conduit for Cancer
*James J. Park 1, *Allison Crawford MS3, Giles F. Whalen MD2, *Isabel Cristina M. Emmerick PhD3, Karl F. Uy MD3, Mark W. Maxfield MD3, Feiran Lou MD3
1UMass Chan Medical School, Worcester, MA; 2Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA; 3Division of Thoracic Surgery, Department of Surgery, UMass Memorial Medical Center, UMass Chan Medical School, Worcester, MA
Introduction: Textbook outcome (TO) is a composite measure designed to assess the overall short-term outcome of an operation. TO after esophagectomy with gastric conduit using the NSQIP database has not yet been defined.
Methods: Records in the NSQIP esophagectomy-specific database from 2016-2021 were analyzed. Patients who underwent elective esophagectomies with gastric conduit for resectable esophageal cancer were included. TO was defined as absence of anastomotic leak, major complications, positive surgical margins, reintervention ? 30 days post-surgery, prolonged hospital stay (> 21 days), postoperative mortality ? 30 days after surgery, and readmission ? 30 days after discharge. Major complications were organ/space SSI, wound disruption, unplanned intubation, pulmonary embolism, acute renal failure, stroke/CVA, cardiac arrest requiring CPR, myocardial infarction, and septic shock.
Results: Of the 6813 patients in the 2016-2021 dataset who underwent esophagectomy, 3755 met study criteria. A total of 2534 (67%) patients had TO. The majority of patients who failed to achieve TO only missed one parameter (41%, 496/1221), and among these patients, positive surgical margin (35%, 176/496) and major complication (24%) were the most missed parameters.
Major complication was the most frequently missed parameter overall (57%, 694/1221), followed by reintervention ? 30 days post-surgery (50%), anastomotic leak (42%), prolonged hospital stay (32%), and positive surgical margins (22%). Most patients who had major complications only had one (60%, 413/694), and the most common major complications were organ/space surgical site infection (54%, 372/694) and unplanned intubation (53%), followed by septic shock (26%). Stroke/CVA was the least common major complication (0.4%, 3/694).
In a multivariable analysis, N2/N3 disease, COPD, ASA 4, low BMI, Asian race, long operation time, preoperative WBC, and age had statistically significant association with failure to achieve TO. Increased operation time had the strongest association with failure to achieve TO (OR 0.88, 95% CI 0.85-0.92, p < 0.0001). Patients who underwent esophagectomy with a minimally invasive approach of the abdominal portion only, minimally invasive approach of both abdominal and thoracic components, and who received chemotherapy within 90 days were more likely to achieve TO. Chemotherapy within 90 days had the strongest association with achieving TO (OR 1.38, 95% CI 1.18-1.63, p < 0.0001).
Conclusions: In an analysis of the NSQIP database, 67% of the cases resulted in TO. Several factors were associated with failure to achieve TO. Further investigations are needed to test if modifying variables like preoperative weight can lead to improved outcomes.
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