Scoring system identifies mortality risks in esophagectomy patients

Key clinical point: Certain predictive indicators can help stratify esophagectomy patients based on preoperative variables and risk factors so that morbidity rates are mitigated.

Major finding: Of 343 patients studied, morbidity occurred in 159 (45.8%); the combined 30-day and in-hospital mortality in subjects was 12 (3.5%); the most reliable predictors were prior cardiothoracic surgery, Zubrod score ≥ 2, diabetes mellitus requiring insulin therapy, current smoking, hypertension, female gender, and an FEV1 score less than 60% of predicted.

Data source: A retrospective analysis of 343 patients with esophageal cancer who underwent esophagectomy from August 2009 to December 2012.

Disclosures: Dr. Reinersman reported no relevant financial conflicts.




SAN DIEGO – Predictive factors such as Zubrod score, previous cardiothoracic surgery, history of smoking, and hypertension can give health care providers a powerful tool for predicting the likelihood of patient morbidity resulting from esophagectomy, thus allowing accurate stratification of such patients and thereby mitigating morbidity rates, a study showed.

Patients who had previously undergone cardiothoracic surgery, had Zubrod scores of at least 2, had diabetes mellitus requiring insulin therapy, were currently smoking, had hypertension, were female, and had a forced expiratory volume in 1 second (FEV1) score of less than 60% were the most highly predisposed to mortality after undergoing esophagectomy, said Dr. J. Matthew Reinersman of the Mayo Clinic in Rochester, Minn., who presented the findings at the annual meeting of the Society of Thoracic Surgeons.

Dr. Reinersman led a team of investigators in a retrospective analysis of 343 consecutive patients in the STS General Thoracic Surgery Database who underwent esophagectomies for malignancies between August 2009 and December 2012. “Our primary outcome variables were operative mortality, both in-hospital and 30-day mortality, as well as major morbidity, which we defined as anastomotic leak, myocardial infarction, pulmonary embolism, pneumonia, reintubation for respiratory failure, empyema, chylothorax, and any reoperation,” he explained.

Univariate and multivariate analyses, using a chi-square test or Fisher’s exact analyses, were performed to look for predictors within the data set, and were subsequently used to craft the risk-based model that assigned each patient a score for how likely he or she would be to experience morbidity or mortality after undergoing an esophagectomy. Each patient was then assigned to one of four groups based on this score – group A (86 subjects), group B (138 subjects), group C (81 subjects), or group D (38 subjects) – in ascending order of score.

Dr. Reinersman and his coauthors found that 17 subjects (19.8%) in group A had either morbidity or mortality, as did 45 subjects (32.6%) in group B, 61 subjects (75.3%) in group C, and 36 (94.7%) in group D, indicating that the model and scoring system developed by the investigators was successful in predicting likely morbidity and mortality outcomes based on patients’ medical histories.

The mean patient age was 63.2 years, and the majority of subjects were male. Smokers were prevalent in the study population: Roughly 56% were former smokers, and 12% were current smokers. Endocarcinoma was the predominant tissue type observed by the authors, and the most common tumor location was the gastroesophageal junction or lower third of the esophagus. Approximately, 75% of patients received neoadjuvant therapy as well.

“This risk-assessment tool, which uses only seven factors and an easy-to-remember scoring system dividing patients into four risk categories, can be easily integrated into everyday clinical practice,” said Dr. Reinersman. “It can help inform patient selection and education, [and] also identifies smoking as an important but modifiable preoperative risk factor.”

Dr. Reinersman reported no relevant financial conflicts.

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