Retrospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 14, 2016; 22(22): 5246-5253
Published online Jun 14, 2016. doi: 10.3748/wjg.v22.i22.5246
Post-discharge complications after esophagectomy account for high readmission rates
Sophia Y Chen, Daniela Molena, Miloslawa Stem, Benedetto Mungo, Anne O Lidor
Sophia Y Chen, Miloslawa Stem, Benedetto Mungo, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD 21287, United States
Daniela Molena, Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, United States
Anne O Lidor, Section of Minimally Invasive, Foregut and Bariatric Surgery, Division of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, United States
Author contributions: Chen SY, Molena D, Stem M, Mungo B and Lidor AO designed the study, wrote the manuscript and made the decision to submit; Chen SY, Stem M and Lidor AO contributed to the data collection, analysis, interpretation.
Institutional review board statement: This study was reviewed, approved, and deemed exempt by the Institutional Review Board of the Johns Hopkins University School of Medicine.
Conflict-of-interest statement: Daniela Molena is a speaker for Novadaq Corporation; the remaining authors have no conflicts of interest.
Data sharing statement: No additional data are available. American College of Surgeons National Surgical Quality Improvement Program and the hospitals participating in the ACS-NSQIP are the source of the data used herein; they have not verified and are not responsible for the statistical validity of the data analysis or the conclusions derived by the authors.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Daniela Molena, MD, Associate Attending, Director of Esophageal Surgery, Thoracic Surgery Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, United States.
Telephone: +1-212-6393870 Fax: +1-646-2277106
Received: February 17, 2016
Peer-review started: February 19, 2016
First decision: March 9, 2016
Revised: April 5, 2016
Accepted: April 15, 2016
Article in press: April 15, 2016
Published online: June 14, 2016

AIM: To identify rates of post-discharge complications (PDC), associated risk factors, and their influence on early hospital outcomes after esophagectomy.

METHODS: We used the 2005-2013 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify patients ≥ 18 years of age who underwent an esophagectomy. These procedures were categorized into four operative approaches: transhiatal, Ivor-Lewis, 3-holes, and non-gastric conduit. We selected patient data based on clinical relevance to patients undergoing esophagectomy and compared demographic and clinical characteristics. The primary outcome was PDC, and secondary outcomes were hospital readmission and reoperation. The patients were then divided in 3 groups: no complication (Group 1), only pre-discharge complication (Group 2), and PDC patients (Group 3). A modified Poisson regression analysis was used to identify risk factors associated with developing post-discharge complication, and risk ratios were estimated.

RESULTS: 4483 total patients were identified, with 8.9% developing PDC within 30-d after esophagectomy. Patients who experienced complications post-discharge had a median initial hospital length of stay (LOS) of 9 d; however, PDC occurred on average 14 d following surgery. Patients with PDC had greater rates of wound infection (41.0% vs 19.3%, P < 0.001), venous thromboembolism (16.3% vs 8.9%, P < 0.001), and organ space surgical site infection (17.1% vs 11.0%, P = 0.001) than patients with pre-discharge complication. The readmission rate in our entire population was 12.8%. PDC patients were overwhelmingly more likely to have a reoperation (39.5% vs 22.4%, P < 0.001) and readmission (66.9% vs 6.6%, P < 0.001). BMI 25-29.9 and BMI ≥ 30 were associated with increased risk of PDC compared to normal BMI (18.5-25).

CONCLUSION: PDC after esophagectomy account for significant number of reoperations and readmissions. Efforts should be directed towards optimizing patient’s health pre-discharge, with possible prevention programs at discharge.

Keywords: Reoperation, Hospital readmission, Post-discharge complications, Esophagectomy, Outcomes research

Core tip: In this study, we used the 2005-2013 ACS-NSQIP database to identify the rate of post-discharge complications, their associated risk factors, and their influence on early hospital readmission after esophagectomy. This report demonstrates that post-discharge complications after esophagectomy account for a significant number of reoperations and readmissions. We believe that implementing prevention strategies to decrease common post-discharge complications like venous thromboembolism and infection should be considered, and that directing our energies toward optimizing patient health prior to discharge may improve overall surgical outcomes.