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J Thorac Cardiovasc Surg 2009;137:587-596
© 2009 The American Association for Thoracic Surgery

Predictors of major morbidity and mortality after esophagectomy for esophageal cancer: A Society of Thoracic Surgeons General Thoracic Surgery Database risk adjustment model

Cameron D. Wright, MDa,*, John C. Kucharczuk, MDb, Sean M. O'Brien, PhDc, Joshua D. Grab, MSc, Mark S. Allen, MDd

a Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
b Division of Thoracic Surgery, University of Pennsylvania, Philadelphia, Pa
c Duke Clinical Research Institute, Duke University, Durham, NC
d Division of General Thoracic Surgery, Mayo Clinic School of Medicine, Rochester, Minn

Received for publication May 7, 2008; revisions received September 30, 2008; accepted for publication November 16, 2008.

* Address for reprints: Dr. Cameron D. Wright, Massachusetts General Hospital, Thoracic Surgery, Blake 1570, 55 Fruit Street, Boston, MA02114. (Email: wright.cameron{at}mgh.harvard.edu).

Objective: To create a model for perioperative risk of esophagectomy for cancer using the Society of Thoracic Surgeons General Thoracic Database.

Methods: The Society of Thoracic Surgeons General Thoracic Database was queried for all patients treated with esophagectomy for esophageal cancer between January 2002 and December 2007. A multivariable risk model for mortality and major morbidity was constructed.

Results: There were 2315 esophagectomies performed by 73 participating centers. Hospital mortality was 63/2315 (2.7%). Major morbidity (defined as reoperation for bleeding [n = 12], anastomotic leak [n = 261], pneumonia [n = 188], reintubation [n = 227], ventilation beyond 48 hours [n = 71], or death [n = 63]) occurred in 553 patients (24%). Preoperative spirometry was obtained in 923/2315 (40%) of patients. A forced expiratory volume in 1 second < 60% of predicted was associated with major morbidity (P = .0044). Important predictors of major morbidity are: age 75 versus 55 (P = .005), black race (P = .08), congestive heart failure (P = .015), coronary artery disease (P = .017), peripheral vascular disease (P = .009), hypertension (P = .029), insulin-dependent diabetes (P = .009), American Society of Anesthesiology rating (P = .001), smoking status (P = .022), and steroid use (P = .026). A strong volume performance relationship was not observed for the composite measure of morbidity and mortality in this patient cohort.

Conclusions: Thoracic surgeons participating in the Society of Thoracic Surgeons General Thoracic Database perform esophagectomy with a low mortality. We identified important predictors of major morbidity and mortality after esophagectomy for esophageal cancer. Volume alone is an inadequate proxy for quality assessment after esophagectomy.

Abbreviations and Acronyms ASA = American Society of Anesthesiology; CAD = coronary artery disease; CHF = congestive heart failure; COPD = chronic obstructive pulmonary disease; FEV1 = forced expiratory volume in 1 second; GTDB = General Thoracic Database; NIS = Nationwide Inpatient Sample; PVD = peripheral vascular disease; RAR = risk-adjusted rate; SEER = Surveillance, Epidemiology, and End Results; STS = Society of Thoracic Surgeons; VA NSQIP = Department of Veterans Affairs National Surgical Quality Improvement Program; BMI = body mass index




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