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PREDICTING RISK FACTORS FOR UNPLANNED REINTUBATION FOLLOWING ESOPHAGECTOMY FOR MALIGNANT INDICATIONS: A NSQIP ANALYSIS
Jahnavi Kakuturu^*1, Cameron Stock², Karl Fabian Uy², Geoffrey Graeber², Giles F. Whalen¹, Jennifer LaFemina^1
1Surgery, University of Massachusetts Medical School , Worcester, MA; ²Thoracic Surgery, University of Massachusetts Medical School, Worcester, MA

BACKGROUND: Pulmonary complications occur frequently after esophageal surgery and are associated with significant morbidity and mortality. The aim of this study was to identify risk factors associated with unplanned reintubation following esophagectomy performed for malignant indications using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.
METHODS: All patients undergoing esophagectomy (total or partial) for a diagnosis of malignancy, from 2007-2014 were identified using the NSQIP database. Univariate and multivariate analyses were performed to assess risk factors associated with the occurrence of postoperative unplanned reintubation.
RESULTS: 5358 esophagectomies were performed during this period. Postoperative unplanned reintubation occurred in 13% (705). Mean age and operative time were higher in the reintubated group when compared to those who were not reintubated (66 vs 64 years and 368 vs 350 minutes, respectively). On univariate analysis, patients who were reintubated had a longer length of hospital stay (27 vs 13 days, p<0.001) and a higher mortality rate (16% vs 2%, p<0.001). Nine preoperative variables and 14 postoperative outcomes were found to be associated with unplanned reintubation. Multivariate analysis was used to adjust for age, body mass index (BMI), operative time, postoperative pneumonia, pulmonary embolism, stroke with neurological deficits, cardiac arrest, myocardial infarction, sepsis and septic shock, as these outcomes may impact respiratory function. After adjusting for these confounding factors, unplanned reintubation was independently associated with smoking (OR 1.5), chronic obstructive pulmonary disease (OR 1.7), postoperative blood transfusions (OR 1.4) and deep vein thrombosis (OR 2.0).
CONCLUSIONS: Unplanned reintubation in patients undergoing esophagectomy for malignant indications is associated with increased mortality and increased length of hospital stay. Recognition of the contributing factors can help in perioperative management and minimizing complications.

Univariate analysis of perioperative variables associated with unplanned reintubation*

Variable	Unplanned Reintubation N=705	No Reintubation N=4653	P value
Preoperative Variables
Chronic obstructive pulmonary disease (%)	16	7	p<0.001
Congestive heart failure (%)	0.7	0.1	p<0.01
Dependent functional status (%)	3	1	p<0.001
Diabetes (%)	25	17	p<0.001
Dyspnea (%)	15	9	p<0.001
Hypertension (%)	61	51	p<0.001
Previous cardiac surgery (%)	11	6	p<0.01
Steroid use (%)	4	3	p<0.05
Smoking (%)	32	25	p<0.001
Postoperative Variables
Acute renal failure (%)	7	1	p<0.001
Cardiac arrest (%)	11	0.5	p<0.001
Deep incisional SSI (%)	4	2	p<0.01
Deep vein thrombosis (%)	10	3	p<0.001
Myocardial infarction (%)	4	0.5	p<0.001
Organ space infection (%)	17	6	p<0.001
Postoperative pneumonia (%)	57	9	p<0.001
Postoperative stroke (%)	2	0.2	p<0.001
Postoperative transfusion (%)	23	14	p<0.001
Pulmonary embolism (%)	4	2	p<0.001
Renal insufficiency (%)	2	0.5	p<0.001
Sepsis (%)	16	7	p<0.001
Septic shock (%)	37	21	p<0.001
Urinary tract infection (%)	5	2	p<0.001

* Variables not reaching statistical significance excluded from the table
Multivariate analysis of perioperative variables associated with unplanned reintubation*

Variable	Odds Ratio	95% Confidence Interval	p Value
Smoking (%)	1.5	1.2 - 1.9	p<0.001
Chronic obstructive pulmonary disease (%)	1.7	1.2 - 2.3	p<0.01
Postoperative transfusion (%)	1.4	1.1 - 1.8	p<0.05
Deep vein thrombosis (%)	2.0	1.3 - 3.0	p<0.01

*Variables not reaching statistical significance excluded from the table

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