RT Journal
A1 Merkow RP, Bilimoria KY,  McCarter MD, et al
T1 Short-term outcomes after esophagectomy at 164 american college of surgeons national surgical quality improvement program hospitals: Effect of operative approach and hospital-level variation
JF Archives of Surgery
JO Archives of Surgery
YR 2012
FD November 1
VO 147
IS 11
SP 1009
OP 1016
DO 10.1001/2013.jamasurg.96
UL http://dx.doi.org/10.1001/2013.jamasurg.96
AB Hypothesis 
                  When assessing the effect of operative approach on outcomes, it may be less relevant whether a transhiatal or an Ivor Lewis esophagectomy was performed and may be more important to focus on patient selection and the quality of the hospital performing the operation.Design 
                  Observational study.Setting 
                  Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.Patients 
                  Individuals undergoing esophagectomy were identified from January 1, 2005, to December 31, 2010. The following 4 groups were created based on operative approach: transhiatal, Ivor Lewis, 3-field, and any approach with an intestinal conduit.Main Outcome Measures 
                  Risk-adjusted 30-day outcomes and hospital-level variation in performance.Results 
                  At 164 hospitals, 1738 patients underwent an esophageal resection: 710 (40.9%) were transhiatal, 497 (28.6%) were Ivor Lewis, 361 (20.8%) were 3-field, and 170 (9.8%) were intestinal conduits. Compared with the transhiatal approach, Ivor Lewis esophagectomy was not associated with increased risk for postoperative complications; however, 3-field esophagectomy was associated with increased likelihood of postoperative pneumonia (odds ratio [OR], 1.88; 95% CI, 1.28-2.77) and prolonged ventilation exceeding 48 hours (OR, 1.68; 95% CI, 1.16-2.42). Intestinal conduit use was associated with increased 30-day mortality (OR, 2.65; 95% CI, 1.08-6.47), prolonged ventilation exceeding 48 hours (OR, 1.61; 95% CI, 1.01-2.54), and return to the operating room for any indication (OR, 1.85; 95% CI, 1.16-2.96). Patient characteristics were the strongest predictive factors for 30-day mortality and serious morbidity. After case-mix adjustment, hospital performance varied by 161% for 30-day mortality and by 84% for serious morbidity.Conclusions 
                  Compared with transhiatal dissection, Ivor Lewis esophagectomy did not result in worse postoperative complications. After controlling for case-mix, hospital performance varied widely for all outcomes assessed, indicating that reductions in short-term outcomes will likely result from expanding other aspects of hospital quality beyond a focus on specific technical maneuvers.