Post-discharge complications after esophagectomy account for high readmission rates

Table 1 Baseline demographic and clinical characteristics of patients undergoing esophagectomy n (%)

Characteristic	Group 1	Group 2	Group 3	P value
	No complication	Pre-discharge complication	Post-discharge complication
	n = 2497 (55.70)	n = 1588 (35.42)	n = 398 (8.88)
Age, mean (median)	62.5 ± 11.2 (63)	63.9 ± 10.8 (65)	63.4 ± 10.9 (64)	0.001
Age group (yr)				0.048
< 60	921 (36.88)	513 (32.30)	143 (35.93)
60-69	862 (34.52)	579 (36.46)	126 (31.66)
70-79	602 (24.11)	407 (25.63)	109 (27.39)
≥ 80	112 (4.49)	89 (5.60)	20 (5.03)
Male1	2042 (81.88)	1220 (76.83)	325 (81.66)	< 0.001
Race				0.088
White	2135 (85.50)	1363 (85.83)	352 (88.44)
Black	76 (3.04)	62 (3.90)	6 (1.51)
Other/unknown	286 (11.45)	168 (10.26)	40 (10.05)
ASA classification1				< 0.001
No disturb/mild disturb	611 (24.50)	237 (14.92)	88 (22.17)
Serious disturb	1746 (70.01)	1161 (73.11)	269 (67.76)
Life threat/moribund	137 (5.49)	190 (11.96)	40 (10.08)
Body mass index, mean (median)	27.9 ± 6.4 (27)	27.7 ± 6.3 (26.9)	28.4 ± 6.2 (27.6)	0.132
Body mass index group1 (kg/m2)				0.013
< 18.5	68 (2.75)	59 (3.75)	9 (2.26)
18.5-24.9	761 (30.72)	522 (33.14)	100 (25.13)
25-29.9	905 (36.54)	532 (33.78)	159 (39.95)
≥ 30	743 (30.00)	462 (29.33)	130 (32.66)
Diabetes	341 (13.66)	300 (18.89)	75 (18.84)	< 0.001
Current smoker	616 (24.67)	434 (27.33)	86 (21.61)	0.033
Dyspnea	209 (8.37)	205 (12.91)	48 (12.06)	< 0.001
History of COPD	131 (5.25)	156 (9.82)	23 (5.78)	< 0.001
Weight loss	468 (18.74)	301 (18.95)	73 (18.34)	0.959
Steroid use	74 (2.96)	42 (2.64)	12 (3.02)	0.820
Emergency case	18 (0.72)	39 (2.46)	3 (0.75)	< 0.001
Diagnosis				0.002
Benign disease	355 (14.22)	289 (18.20)	56 (14.07)
Esophageal/gastric cancer	2142 (85.78)	1299 (81.80)	342 (85.93)
Year of operation				0.012
2005-2007	293 (11.73)	223 (14.04)	41 (10.30)
2008-2010	746 (29.88)	409 (25.76)	109 (27.39)
2011-2013	1458 (58.39)	956 (60.20)	248 (62.31)

¹Different denominator due to missing data: gender (Total n = 4480; Group 1 n = 2494; Group 2 n = 1588; Group 3 n = 398); functional status (n = 4481; 2497; 1586; 398); ASA class (n = 4479; 2494; 1588; 397); BMI (n = 4450; 2477; 1575; 398). ASA: American Society of Anesthesiology; COPD: Chronic obstructive pulmonary disease; BMI: Body mass index.

Table 2 Observed unadjusted rates of pre- and post-discharge outcomes after esophagectomy n (%)

Outcome	Total (n = 1986)	Group 2	Group 3	P value
		Pre-discharge complication	Post-discharge complication
		n = 1588 (79.96)	n = 398 (20.04)
30-d mortality1	140 (7.05)	104 (6.55)	36 (9.05)	0.082
Overall morbidity
Wound infection	470 (23.67)	307 (19.33)	163 (40.95)	< 0.001
Pneumonia	535 (26.94)	444 (27.96)	91 (22.86)	0.040
Urinary tract infection	112 (5.64)	91 (5.73)	21 (5.28)	0.725
Venous thromboembolism	207 (10.42)	142 (8.94)	65 (16.33)	< 0.001
Cardiac complication	108 (5.44)	92 (5.79)	16 (4.02)	0.163
Shock/sepsis	518 (26.08)	422 (26.57)	96 (24.12)	0.319
Unplanned intubation	420 (21.15)	368 (23.17)	52 (13.07)	< 0.001
Bleeding transfusion	584 (29.41)	526 (33.12)	58 (14.57)	< 0.001
Renal complication	59 (2.97)	50 (3.15)	9 (2.26)	0.351
On ventilator > 48 h	439 (22.10)	396 (24.94)	43 (10.80)	< 0.001
Organ space SSI	242 (12.19)	174 (10.96)	68 (17.09)	0.001
Reoperation 12-13	235 (25.97)	160 (22.38)	75 (39.47)	< 0.001
Serious Morbidity2	1102 (55.49)	901 (56.74)	201 (50.50)	0.025
Year of operation				0.142
2005-2007	264 (13.29)	223 (14.04)	41 (10.30)
2008-2010	518 (26.08)	409 (25.76)	109 (27.39)
2011-2013	1204 (60.62)	956 (60.20)	248 (62.31)
Length of stay, d (median)	11.7 ± 5.4 (10)	15.0 ± 6.3 (14)	10.3 ± 4.3 (9)	< 0.001
Prolonged length of stay3	765 (38.52)	707 (44.52)	58 (14.57)	< 0.001
Operative time, min (median)	342.3 ± 134.7 (328)	358.6 ± 145.6 (343)	350.4 ± 133.1 (335.5)	0.308
Prolonged operative time4	570 (28.70)	467 (29.41)	103 (25.88)	0.164
Readmission 2011-2013	226 (19.07)	62 (6.60)	164 (66.94)	< 0.001

¹In-hospital and post-discharge mortality among patients with pre or post-discharge complications. The overall mortality rate was 3.12% (140/4483);

²Serious morbidity: cardiac complication, shock/sepsis, unplanned intubation, on ventilator > 48 h, organ space SSI, and reoperation 2012-2013;

³Defined as length of stay > 75^th percentile;

⁴Defined as operative time > 75^th percentile. SSI: Surgical site infection.

Table 3 Unadjusted risk and risk ratio for post-discharge complications after esophagectomy

Risk factor	PDC risk (n/total)	RR (95%CI)
Overall PDC risk	398/4379 (9.09)	-
Procedure type
Ivor-Lewis	196/2219 (8.83)	Ref
Transhiatal	115/1261 (9.12)	1.03 (0.83-1.29)
3-holes	66/730 (9.04)	1.02 (0.78-1.34)
Intestinal conduit	21/169 (12.43)	1.41 (0.92-2.15)
Age group (%)
< 60	143/1562 (9.15)	Ref
60-69	126/1529 (8.24)	0.90 (0.72-1.13)
70-79	109/1082 (10.07)	1.10 (0.87-1.39)
≥ 80	20/206 (9.71)	1.06 (0.68-1.65)
Male (%)	325/3505 (9.27)	1.11 (0.87-1.41)
Race (%)
White	352/3763 (9.35)	Ref
Black	6/137 (4.38)	0.46 (0.21-1.00)
Other/unknown	40/479 (8.35)	0.89 (0.65-1.22)
ASA classification (%)
No disturb/mild disturb	88/930 (9.46)	Ref
Serious disturb	269/3104 (8.67)	0.92 (0.73-1.15)
Life threat/moribund	40/341 (11.73)	1.24 (0.87-1.76)
Body mass index (%)
18.5-24.9	100/1347 (7.42)	Ref
< 18.5	9/129 (6.98)	0.94 (0.49-1.81)
25-29.9	159/1561 (10.19)	1.37 (1.08-1.74)
≥ 30	130/1310 (9.92)	1.34 (1.04-1.72)
Diabetes (%)	75/692 (10.84)	1.24 (0.98-1.57)
Current smoker (%)	86/1111 (7.74)	0.81 (0.64-1.02)
Dyspnea (%)	48/436 (11.01)	1.24 (0.93-1.65)
History of COPD (%)	23/297 (7.74)	0.84 (0.56-1.26)
Weight loss (%)	73/812 (8.99)	0.99 (0.77-1.26)
Steroid use (%)	12/124 (9.68)	1.07 (0.62-1.84)
Emergency case	3/52 (5.77)	0.63 (0.21-1.90)
Esophageal/gastric cancer (%)	342/3707 (9.23)	1.11 (0.84-1.45)
Prolonged length of stay1 (%)	58/938 (6.18)	0.63 (0.48-0.82)
Prolonged operative time2 (%)	103/1087 (9.48)	1.06 (0.85-1.31)

¹Defined as length of stay > 75^th percentile;

²Defined as operative time > 75^th percentile. PDC: Post-discharge complication; RR: Risk ratio; ASA: American Society of Anesthesiology; COPD: Chronic obstructive pulmonary disease.