A. Ninh1, A. Bui1, M. B. Yammine2, A. Kaufman2, I. Leitman1 1Icahn School of Medicine at Mount Sinai,Surgery,New York, NY, USA 2Icahn School of Medicine at Mount Sinai,Thoracic Surgery,New York, NY, USA
Introduction: Esophagectomy is a complicated surgical operative procedure, which has been associated with respiratory complications sometimes requiring unplanned reintubation. The purpose of this study is to identify risk factors and adverse postoperative outcomes associated with unplanned intubation following esophagectomy.
Methods: The American College of Surgery National Surgical Quality Improvement Program (ACS-NSQIP) participant user database was queried from 2012 to 2015. Patients who underwent total or partial esophagectomy were identified and demographic data, intraoperative variables, and postoperative outcomes were collected. The primary outcome was unplanned intubation following esophagectomy. Multivariate analyses (logistic and linear regression) were performed to assess for risk factors and adverse outcomes associated with unplanned intubation.
Results: Of the 4,938 patients that underwent esophagectomy, 614 patients (12.4%) required unplanned reintubation following surgery. Risk factors for unplanned reintubation following esophagectomy include age greater than 60 (OR=1.58, 95% CI=1.28-1.94), active smoking (OR=1.36, 95% CI=1.11-1.66), morbid obesity defined as BMI>40 or BMI≥35 with hypertension or diabetes (OR=1.58, 95% CI=1.20-2.07), history of chronic obstructive pulmonary disease (OR=2.40, 95% CI=1.86-3.09), history of congestive heart failure (OR=5.15, 95% CI=1.78-14.85), and history of bleeding disorders (OR=1.90, 95% CI=1.30-2.79).Total esophagectomy increases the risk of unplanned reintubation (OR=1.30, 95% CI=1.09-1.54) when compared to partial esophagectomy. Additionally, patients requiring unplanned reintubation experienced longer operations, averaging 21.65 extra minutes (95% CI=10.05-33.26). Patients requiring unplanned reintubation were associated with an increased risk of pneumonia (OR=13.62, 95% CI=11.16-16.61), cerebral vascular accidents (OR=6.61, 95% CI=2.73-16.01), cardiac arrest (OR=11.42, 95% CI=11.30-11.55), and myocardial infarction (OR=6.29, 95% CI=3.58-11.05) when compared to patients that did not require unplanned reintubation. Of those that underwent reintubation following esophagectomy, 72 (13.4%) expired within 30 days, compared to 59 (1.38%) who did not undergo unplanned reintubation (p<0.001). Unplanned intubation following esophagectomy is associated with increased risk of 30-day mortality (OR=9.33, 95% CI=6.44-13.51) and return to operating room (OR=5.76, 95% CI= 4.75-6.98). Hospital length of stay is increased by an average of 11.50 days (95% CI=10.46-12.54).
Conclusion: Patients requiring unplanned reintubation following esophagectomy are at significant risk for adverse postoperative morbidity and mortality. The findings of this study can help to identify patients at increased risk for unplanned reintubation, and serve to guide physician-patient discussion about the risk of significant postoperative complications in at-risk patients following esophagectomy.