title: 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.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Observational study.
  
  
  METHODS
  Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
authors.forename: Ryan P
authors.initials: RP
authors.lastname: Merkow
authors.forename: Karl Y
authors.initials: KY
authors.lastname: Bilimoria
authors.forename: Martin D
authors.initials: MD
authors.lastname: McCarter
authors.forename: Joseph D
authors.initials: JD
authors.lastname: Phillips
authors.forename: Malcolm M
authors.initials: MM
authors.lastname: DeCamp
authors.forename: Karen L
authors.initials: KL
authors.lastname: Sherman
authors.forename: Clifford Y
authors.initials: CY
authors.lastname: Ko
authors.forename: David J
authors.initials: DJ
authors.lastname: Bentrem
mesh_terms: D000368:Aged; D000704:Analysis of Variance; D015331:Cohort Studies; D016001:Confidence Intervals; D016208:Databases, Factual; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D004943:Esophagogastric Junction / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends*; D006761:Hospitals / Q000592:standards / Q000639:trends; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016017:Odds Ratio; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality*; D011237:Predictive Value of Tests; D015397:Program Evaluation; D058996:Quality Improvement / Q000458:organization & administration*; D011787:Quality of Health Care; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D013908:Thoracotomy / Q000379:methods / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States