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Prevalence, Significance and Risk Factors for Post-Discharge Complications After Esophagectomy in the United States
Daniela Molena*, Benedetto Mungo, Miloslawa Stem, Anne O. Lidor
Johns Hopkins Medicine, Baltimore, MD
Purpose: Although outcomes during hospitalization for patients undergoing esophagectomy are well known, little is reported about post-discharge complications (PDC) and their implications in this population. We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset in order to study the rate of PDC and their influence on the early outcomes after esophagectomy. Moreover, we sought to identify risk factors for developing PDC.
Methods: This was a retrospective analysis from 2005 to 2013. Patients ≥18 years of age who underwent an esophagectomy were grouped into three categories: no complications, pre-discharge complications only (PrDC), and PDC. Early surgical outcomes (30-day mortality, overall and serious morbidity, length of hospital stay, and operative time) were compared between patients experiencing complications before or after discharge. Readmission rates were studied during 2011-2013 and risk ratios for developing PDC were calculated.
Results: 4,871 patients were identified and PDC were observed in 364 (7.47%). About 30% of patients experiencing PDC also had a PrDC. The types of complications which occur before and after discharge were different, with higher number of respiratory problems and sepsis during hospitalization and higher wound infection,thromboembolism and organ space SSI after discharge. 65% of patients with PDC were re-admitted to the hospital (Table). Prolonged length of stay (PLOS) and experiencing a PrDC were found to be associated with a decreased risk of PDC (RR 0.67, 95% CI 0.50-0.90 , p=0.007 and 0.79, 0.64-0.98 , p=0.030, respectively), whereas diabetes was associated with increased risk of PDC (1.31, 1.03-1.68, p=0.029).
Conclusion: PDC occur in a small number of patients but account for a significant number of readmissions. The most common PDC are wound infection and thromboembolism which occur in patients who are discharged sooner from the hospital. Preventive measures (i.e. DVT prophylaxis and wound care) should be considered in these patients to decrease readmissions.
TABLE. Observed unadjusted rates of pre and post-discharge outcomes after undergoing esophagectomy, NSQIP 2005-2013
| Outcome | Total
N=2,289 | Pre-discharge complication
n=1,925 (84.10%) | Post-discharge complication
n=364 (15.90%) | p | | 30-day mortality (%) | 140 (6.12) | 104 (5.40) | 36 (9.89) | <0.001 | | Overall morbidity (%) | | | Wound infection | 544 (23.77) | 382 (19.84) | 162 (44.51) | <0.001 | | Pneumonia | 747 (32.63) | 660 (34.29) | 87 (23.90) | <0.001 | | Urinary tract infection | 141 (6.16) | 121 (6.29) | 20 (5.49) | 0.565 | | Venous thromboembolism | 272 (11.88) | 207 (10.75) | 65 (17.86) | <0.001 | | Cardiac complication | 132 (5.77) | 116 (6.03) | 16 (4.40) | 0.221 | | Shock/sepsis | 748 (32.68) | 653 (33.92) | 95 (26.10) | 0.004 | | Unplanned intubation | 600 (26.21) | 551 (28.62) | 49 (13.46) | <0.001 | | Bleeding transfusion | 668 (29.18) | 617 (32.05) | 51 (14.01) | <0.001 | | Renal complication | 107 (4.67) | 98 (5.09) | 9 (2.47) | 0.030 | | On ventilator >48 hours | 697 (30.45) | 655 (34.03) | 42 (11.54) | <0.001 | | Organ space SSI | 333 (14.55) | 266 (13.82) | 67 (18.41) | 0.023 | | Serious Morbidity 1 | 1,330 (58.10) | 1,169 (60.73) | 161 (44.23) | <0.001 | Length of stay,
days (median) | 19.7±16.5 (14) | 21.5±17.4 (16) | 10.4±4.4 (9) | <0.001 | | Prolonged length of stay2 (%) | 934 (40.80) | 896 (46.55) | 38 (10.44) | <0.001 | Operative time,
min (median) | 362.8±146.2 (346) | 365.6±148.5 (350) | 348.1±132.5 (332.5) | 0.036 | | Prolonged operative time3 (%) | 569 (24.86) | 492 (25.56) | 77 (21.15) | 0.075 | | Readmission 2011-2013 | 207/1,308 (15.83) | 70/1,097 (6.38) | 137/211 (64.93) | <0.001 |
Abbreviation: SSI, surgical site infection. 1Serious morbidity: cardiac complication, shock/sepsis, unplanned intubation, on ventilator >48 hours, and organ space SSI. 2Defined as length of stay greater than or equal to the 75th percentile. 3Defined as operative time greater than or equal to the 75th percentile.
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