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Original Investigation |

Esophagectomies With Thoracic Incisions Carry Increased Pulmonary Morbidity

Neil H. Bhayani, MD, MHS1; Aditya Gupta, MD2; Christy M. Dunst, MD3; Ashwin A. Kurian, MD1; Kevin M. Reavis, MD2; Lee L. Swanström, MD3
[+] Author Affiliations
1Providence Cancer Center, Portland, Oregon
2Legacy Weight Management Institute, Portland, Oregon
3The Oregon Clinic, Portland
JAMA Surg. 2013;148(8):733-738. doi:10.1001/jamasurg.2013.2356.
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Published online

Importance  Thoracic incisions are not required for all esophagectomies and may increase pulmonary morbidity.

Objective  To compare the pulmonary and overall morbidity of esophagectomies with and without thoracic incisions.

Design  Observational study.

Setting  Hospitals participating in the National Surgical Quality Improvement Project.

Participants  Patients without metastatic cancer undergoing nonemergency total esophagectomies with reconstruction from 2005 through 2010. Patients who underwent transhiatal esophagectomy (THE) were compared with a THORACIC group (Ivor Lewis and McKeown techniques).

Main Outcomes and Measures  Pulmonary and overall morbidity, infection, and thromboembolic complications.

Results  Of 1568 patients, 717 (45.7%) underwent THE, and 851 (54.3%) were in the THORACIC group (Ivor Lewis technique in 487 [31.1%] and McKeown technique in 364 [23.2%]). The population was 80.5% male, with a mean age of 62.9 years. Patients undergoing THE were older (P = .02). Diabetes mellitus was less common in the THORACIC group (11.2% vs 15.9% for THE; P = .02), and cancer was more common (91.0% vs 87.0%; P = .01). Morbidity was 49.2% and mortality was 3.3%, without differences between groups. The mean length of stay was 1.6 days shorter (P = .009) in the THE group. Multivariable analysis showed that thoracic incisions increased rates of pneumonia (odds ratio [OR], 1.47; P = .007), ventilator dependence (OR, 1.35; P = .04), and septic shock (OR, 1.86; P = .001) but not mortality. Compared with the Ivor Lewis technique, the McKeown technique worsened the odds of superficial wound infections (OR, 1.71; P = .02) but not septic shock (OR, 0.84; P = .47).

Conclusions and Relevance  Esophagectomies have an acceptable mortality rate but a significant morbidity rate. We demonstrated that rates of pneumonia, ventilator dependence, and septic shock are increased with the use of thoracic incision. Avoiding thoracic incisions may therefore decrease the risk of pulmonary morbidity and septic shock.

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