title: Transthoracic approach is associated with increased incidence of atrial fibrillation after esophageal resection.
abstract: OBJECTIVE
  Atrial fibrillation (AF) has been associated with higher morbidity after esophagectomy. The objective of this study is to identify the surgical risk factors associated with new-onset atrial fibrillation after esophagectomy.
  
  
  METHODS
  After Institutional Review Board approval, a prospectively maintained database was retrospectively queried to identify patients who underwent esophagectomy between 2003 and 2013. Data variables collected include pre-operative, intra-operative, and post-operative factors. Appropriate statistical analysis is performed utilizing Sigmaplot(®) version 12.3.
  
  
  RESULTS
  From 2003 to 2013, 245 esophagectomies were performed at our institution, of these, 192 (147 males, mean age of 62 ± 11.12 years) were included in the final analysis and 53 were excluded [25 Roux-en-Y reconstruction (including three Merendino procedures), 20 had AF before surgery, and eight with staged esophagectomy]. Of 192 esophagectomies, 160 had malignancy (138 adenocarcinoma and 22 squamous cell carcinoma) and 106 (66.25%) received neo-adjuvant therapy. Esophagectomies were performed with Ivor Lewis Mckeown approach in 78 patients [34 Minimally Invasive (MIE), 37 open, and 7 Hybrid], Ivor Lewis approach in 56 patients (31 MIE, 10 Open, 15 Hybrid) and Transhiatal approach in 58 patients (16 MIE and 42 Open). Gastric conduit was used in 185 patients and colonic conduit in seven patients. Overall 30-day or in-hospital mortality was 3.6% (7/192). Forty-five (23.4%) patients with esophagectomy developed new-onset AF. Median onset of AF was post-op day 3 (0-32). They were older (65.7 vs. 61.3, p = 0.021), with medical comorbidities (thyroid disorder, hyperlipidemia, and coronary artery disease; p < 0.05) and lower diffusion capacity on Pulmonary function test (80.16 vs. 87.74%, p = 0.02) and stayed longer in hospital (19 vs. 14 days, p < 0.001) with severe post-operative complications (Clavien score ≥ III) (69 vs. 35.3%, p < 0.001). Multiple logistic regression analysis showed transthoracic approach (OR = 3.71, CI = 1.23-11.17, p = 0.02) and thyroid disorder (OR = 6.29, CI = 1.54-25.65, p = 0.01), and severe post-op complications (OR = 3.34, CI = 1.20-9.28, p = 0.02) were significantly associated with the development of new-onset AF.
  
  
  CONCLUSIONS
  Transthoracic approach is an independent risk factor for the development of new-onset AF after esophagectomy. New-onset AF is associated with severe post-operative complications and longer hospital stay. Minimally invasive approach does not decrease the incidence of new-onset AF.
authors.affiliation: Department of Surgery, Creighton University School of Medicine, Omaha, NE, 68131, USA.
authors.forename: Kush R
authors.initials: KR
authors.lastname: Lohani
authors.forename: Kalyana C
authors.initials: KC
authors.lastname: Nandipati
authors.forename: Sarah E
authors.initials: SE
authors.lastname: Rollins
authors.forename: Katharina
authors.initials: K
authors.lastname: Fetten
authors.forename: Tommy H
authors.initials: TH
authors.lastname: Lee
authors.forename: Pradeep K
authors.initials: PK
authors.lastname: Pallati
authors.forename: Se Ryung
authors.initials: SR
authors.lastname: Yamamoto
authors.forename: Sumeet K
authors.initials: SK
authors.lastname: Mittal
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000367:Age Factors; D000368:Aged; D001281:Atrial Fibrillation / Q000453:epidemiology*; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D015897:Comorbidity; D003324:Coronary Artery Disease / Q000453:epidemiology; D016208:Databases, Factual; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006949:Hyperlipidemias / Q000453:epidemiology; D015994:Incidence; D010535:Laparoscopy / Q000379:methods; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology*; D011653:Pulmonary Diffusing Capacity; D012189:Retrospective Studies; D012307:Risk Factors; D013959:Thyroid Diseases / Q000453:epidemiology