Fast-Track Esophagectomy Protocol for Esophageal Cancer
The characteristics of 322 patients in group A and 386 patients in group B are summarized in Table 1. The 2 groups were similar in terms of sex and age as well as history of chronic obstructive pulmonary disease (COPD), coronary artery disease, and diabetes. Although tumor histology, location, grade, and pathological stage did not differ between the 2 groups, the mean tumor size of group A (1.9 cm) was significantly smaller than that of group B (2.5 cm; P = 0.025) (Table 2). There was also difference in the distribution of clinical staging of tumor between the 2 groups. Compared with group B, group A had lower proportions of patients with stage II cancer (39% vs 32%) and stage III cancer (46% vs 42%) and higher proportions of patients with stage I cancer (12% vs 19%) and stage IV cancer (3% vs 6%; P < 0.008) (Table 2). The types of preoperative treatment the 2 groups received also differed, with a greater proportion of patients in group B (85%) than in group A (73%) receiving chemotherapy plus radiation therapy (P < 0.001). The type of surgery also differed between the 2 groups; minimally invasive esophagectomy (MIE) was performed more frequently in group B (22%) than in group A (12%; P < 0.001) (Table 4).
The 2 groups' short-term postoperative outcomes are summarized in Table 5. The median LOS of group A (12 days) was significantly longer than that of group B (8 days; P < 0.001) (see also Fig. 1). The mean numbers of total ICU days and telemetry days of group A (4.5 and 12.7, respectively) were also significantly higher than those of group B (1.2 and 9.7, respectively; P < 0.001 for both). In addition, group A had higher mean numbers of postoperative ventilator days (1.3) and total ventilator days (2.5) than did group B (0.3 and 0.8, respectively; P < 0.001 for both). The direct ICU admission rate of group A (71%) was significantly higher than that of group B (7%; P < 0.001). In terms of postoperative complications, the incidences of aspiration, pneumonia, discharge on home oxygen, atelectasis requiring bronchoscopy, anastomotic leak, ICU readmission, and reoperation did not differ significantly between the 2 groups. However, compared with group A, group B had significantly lower incidences of ARDS (6% vs 0.5%; P < 0.001), reintubation (9% vs 4%; P = 0.005), atrial arrhythmia requiring treatment (27% vs 19%; P = 0.015), and overall pulmonary complications (27% vs 20%, with aspiration, ARDS, pneumonia, discharge on home oxygen, and atelectasis grouped together; P = 0.022). The 2 groups' rates of 30-day mortality (3% in group A vs 2% in group B; P = 0.386), 90-day mortality (5% vs 4%; P = 0.377), and 90-day readmission (12% vs 15%; P = 0.134) did not differ significantly. The reasons for readmission within 90 days are summarized in Table 7. Pulmonary complication (38%), gastrointestinal symptoms (16%) like nausea, vomiting and diarrhea, and dysphagia (11%) were the major reasons for readmission. The 2 groups' rates of direct admission to the ICU, total LOS, total ICU days, total ventilator days, and immediate postoperative ventilator days for each year of the study period are summarized in Table 6 and Figure 2. Multivariable analysis revealed that the institution of the FTEP was associated with shorter LOS [β = -6.415; 95% confidence interval (CI) = 8.294 to -4.536; P < 0.001] even after adjustment for factors such as tumor location and histology (Table 8). Multivariable analysis also revealed that the institution of the FTEP was associated with fewer pulmonary complications (odds ratio = 0.655; 95% CI = 0.456–0942; P = 0.022) even after adjustment for other independent predictors such as sex, COPD, and type of esophagectomy (Table 9).
(Enlarge Image)
Figure 1.
Box and whisker plot for LOS. The box (interquartile range) has 50% of all data, whereas the whiskers extend to the 5th and 95th percentile. Dotes indicate data beyond 5th and 95th percentile. On Y Axis, the unit of measurement for LOS is "number of days." *75th percentile; †50th percentile (median); ‡25th percentile.
(Enlarge Image)
Figure 2.
ICU direct admission rate and mean length of hospital stay by year.
The median technical hospital charge associated with primary admission after surgery for group B ($63,406) was significantly lower than that for group A ($76,685; P < 0.001) (Table 10). Multivariable analysis revealed that the institution of the FTEP decreased hospital charges (β = -41714.3; 95% CI = -63706.3 to -19722.3; P < 0.001) even after adjustment for predictors such as tumor histology and location (Table 11). Also, there was no significant difference in median hospital charges associated with readmission within 90 days between the 2 groups ($13,336 in group A vs $22,373 in group B, P = 0.275). However, when we compared combined technical hospital charges associated with both primary admission after surgery and readmissions within 90 days of discharge, group B ($65,649) still had significantly lower charges than those for group A ($79,117; P < 0.001) (Table 10).
Results
Patient Characteristics
The characteristics of 322 patients in group A and 386 patients in group B are summarized in Table 1. The 2 groups were similar in terms of sex and age as well as history of chronic obstructive pulmonary disease (COPD), coronary artery disease, and diabetes. Although tumor histology, location, grade, and pathological stage did not differ between the 2 groups, the mean tumor size of group A (1.9 cm) was significantly smaller than that of group B (2.5 cm; P = 0.025) (Table 2). There was also difference in the distribution of clinical staging of tumor between the 2 groups. Compared with group B, group A had lower proportions of patients with stage II cancer (39% vs 32%) and stage III cancer (46% vs 42%) and higher proportions of patients with stage I cancer (12% vs 19%) and stage IV cancer (3% vs 6%; P < 0.008) (Table 2). The types of preoperative treatment the 2 groups received also differed, with a greater proportion of patients in group B (85%) than in group A (73%) receiving chemotherapy plus radiation therapy (P < 0.001). The type of surgery also differed between the 2 groups; minimally invasive esophagectomy (MIE) was performed more frequently in group B (22%) than in group A (12%; P < 0.001) (Table 4).
Short-term Postoperative Outcomes
The 2 groups' short-term postoperative outcomes are summarized in Table 5. The median LOS of group A (12 days) was significantly longer than that of group B (8 days; P < 0.001) (see also Fig. 1). The mean numbers of total ICU days and telemetry days of group A (4.5 and 12.7, respectively) were also significantly higher than those of group B (1.2 and 9.7, respectively; P < 0.001 for both). In addition, group A had higher mean numbers of postoperative ventilator days (1.3) and total ventilator days (2.5) than did group B (0.3 and 0.8, respectively; P < 0.001 for both). The direct ICU admission rate of group A (71%) was significantly higher than that of group B (7%; P < 0.001). In terms of postoperative complications, the incidences of aspiration, pneumonia, discharge on home oxygen, atelectasis requiring bronchoscopy, anastomotic leak, ICU readmission, and reoperation did not differ significantly between the 2 groups. However, compared with group A, group B had significantly lower incidences of ARDS (6% vs 0.5%; P < 0.001), reintubation (9% vs 4%; P = 0.005), atrial arrhythmia requiring treatment (27% vs 19%; P = 0.015), and overall pulmonary complications (27% vs 20%, with aspiration, ARDS, pneumonia, discharge on home oxygen, and atelectasis grouped together; P = 0.022). The 2 groups' rates of 30-day mortality (3% in group A vs 2% in group B; P = 0.386), 90-day mortality (5% vs 4%; P = 0.377), and 90-day readmission (12% vs 15%; P = 0.134) did not differ significantly. The reasons for readmission within 90 days are summarized in Table 7. Pulmonary complication (38%), gastrointestinal symptoms (16%) like nausea, vomiting and diarrhea, and dysphagia (11%) were the major reasons for readmission. The 2 groups' rates of direct admission to the ICU, total LOS, total ICU days, total ventilator days, and immediate postoperative ventilator days for each year of the study period are summarized in Table 6 and Figure 2. Multivariable analysis revealed that the institution of the FTEP was associated with shorter LOS [β = -6.415; 95% confidence interval (CI) = 8.294 to -4.536; P < 0.001] even after adjustment for factors such as tumor location and histology (Table 8). Multivariable analysis also revealed that the institution of the FTEP was associated with fewer pulmonary complications (odds ratio = 0.655; 95% CI = 0.456–0942; P = 0.022) even after adjustment for other independent predictors such as sex, COPD, and type of esophagectomy (Table 9).
(Enlarge Image)
Figure 1.
Box and whisker plot for LOS. The box (interquartile range) has 50% of all data, whereas the whiskers extend to the 5th and 95th percentile. Dotes indicate data beyond 5th and 95th percentile. On Y Axis, the unit of measurement for LOS is "number of days." *75th percentile; †50th percentile (median); ‡25th percentile.
(Enlarge Image)
Figure 2.
ICU direct admission rate and mean length of hospital stay by year.
Technical Hospital Charges
The median technical hospital charge associated with primary admission after surgery for group B ($63,406) was significantly lower than that for group A ($76,685; P < 0.001) (Table 10). Multivariable analysis revealed that the institution of the FTEP decreased hospital charges (β = -41714.3; 95% CI = -63706.3 to -19722.3; P < 0.001) even after adjustment for predictors such as tumor histology and location (Table 11). Also, there was no significant difference in median hospital charges associated with readmission within 90 days between the 2 groups ($13,336 in group A vs $22,373 in group B, P = 0.275). However, when we compared combined technical hospital charges associated with both primary admission after surgery and readmissions within 90 days of discharge, group B ($65,649) still had significantly lower charges than those for group A ($79,117; P < 0.001) (Table 10).
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