Comparing Robotic, Thoracoscopic, and Open Segmentectomy: A National Cancer Database Analysis.

INTRODUCTION: Minimally invasive approaches to lung resection have become widely acceptable and more recently, segmentectomy has demonstrated equivalent oncologic outcomes when compared to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, studies comparing outcomes following segmentectomy by different surgical approaches are lacking. Our objective was to investigate the outcomes of patients undergoing robotic, video-assisted thoracoscopic surgery (VATS), or open segmentectomy for NSCLC using the National Cancer Database. METHODS: NSCLC patients with clinical stage I who underwent segmentectomy from 2010 to 2016 were identified. After propensity-score matching (1:4:1), multivariate logistic regression analyses were performed to determine predictors of 30-d readmissions, 90-d mortality, and overall survival. RESULTS: 22,792 patients met study inclusion. After matching, approaches included robotic (n = 2493; 17%), VATS (n = 9972; 66%), and open (n = 2493; 17%). An open approach was associated with higher 30-d readmissions (7% open versus 5.5% VATS versus 5.6% robot, P = 0.033) and 90-d mortality (4.4% open versus 2.2% VATS versus 2.5% robot, P < 0.001). A robotic approach was associated with improved 5-y survival (50% open versus 58% VATS versus 63% robot, P < 0.001). CONCLUSIONS: For patients with clinical stage I NSCLC undergoing segmentectomy, compared to the open approach, a VATS approach was associated with lower 30-d readmission and 90-d mortality. A robotic approach was associated with improved 5-y survival compared to open and VATS approaches when matched. Additional studies are necessary to determine if unrecognized covariates contribute to these differences.

Surgical and endoscopic management options for patients with GERD based on proton pump inhibitor symptom response: recommendations from an expert U.S. panel.

BACKGROUND AND AIMS: The objective of this study was to examine expert opinion and agreement on the treatment of distinct GERD profiles from surgical and therapeutic endoscopy perspectives. METHODS: We used the RAND/University of California, Los Angeles Appropriateness Method over 6 months (July 2018 to January 2019) to assess the appropriateness of antireflux interventions among foregut surgeons and therapeutic gastroenterologists. Patients with primary atypical or extraesophageal symptoms were not considered. Patient scenarios were grouped according to their symptom response to proton pump inhibitor (PPI) therapy. The primary outcome was appropriateness of an intervention. RESULTS: Antireflux surgery with laparoscopic fundoplication (LF) and magnetic sphincter augmentation (MSA) were ranked as appropriate for all complete and partial PPI responder scenarios. Transoral incisionless fundoplication was ranked as appropriate in complete and partial PPI responders without a hiatal hernia. Radiofrequency energy was not ranked as appropriate for complete or partial responders. There was lack of agreement between surgery and interventional gastroenterology groups on the appropriateness of LF and MSA for PPI nonresponders. Rankings for PPI nonresponders were similar when results from impedance-pH testing on PPI therapy were available, except that LF and MSA were not ranked as appropriate for PPI nonresponders if the impedance-pH study was negative. CONCLUSIONS: This work highlights areas of agreement for invasive therapeutic approaches for GERD and provides impetus for further interdisciplinary collaboration and trials to compare and generate novel and effective treatment approaches and care pathways, including the role of impedance-pH testing in PPI nonresponders.

Esophageal Cancer: Associations With (pN+) Lymph Node Metastases.

OBJECTIVES: To identify the associations of lymph node metastases (pN+), number of positive nodes, and pN subclassification with cancer, treatment, patient, geographic, and institutional variables, and to recommend extent of lymphadenectomy needed to accurately detect pN+ for esophageal cancer. SUMMARY BACKGROUND DATA: Limited data and traditional analytic techniques have precluded identifying intricate associations of pN+ with other cancer, treatment, and patient characteristics. METHODS: Data on 5806 esophagectomy patients from the Worldwide Esophageal Cancer Collaboration were analyzed by Random Forest machine learning techniques. RESULTS: pN+, number of positive nodes, and pN subclassification were associated with increasing depth of cancer invasion (pT), increasing cancer length, decreasing cancer differentiation (G), and more regional lymph nodes resected. Lymphadenectomy necessary to accurately detect pN+ is 60 for shorter, well-differentiated cancers (<2.5 cm) and 20 for longer, poorly differentiated ones. CONCLUSIONS: In esophageal cancer, pN+, increasing number of positive nodes, and increasing pN classification are associated with deeper invading, longer, and poorly differentiated cancers. Consequently, if the goal of lymphadenectomy is to accurately define pN+ status of such cancers, few nodes need to be removed. Conversely, superficial, shorter, and well-differentiated cancers require a more extensive lymphadenectomy to accurately define pN+ status.

Long-term Outcomes of Patients Receiving a Magnetic Sphincter Augmentation Device for Gastroesophageal Reflux.

BACKGROUND & AIMS: Based on results from year 2 of a 5-year trial, in 2012 the US Food and Drug Administration approved the use of a magnetic device to augment lower esophageal sphincter function in patients with gastroesophageal reflux disease (GERD). We report the final results of 5 years of follow-up evaluation of patients who received this device. METHODS: We performed a prospective study of the safety and efficacy of a magnetic device in 100 adults with GERD for 6 months or more, who were partially responsive to daily proton pump inhibitors (PPIs) and had evidence of pathologic esophageal acid exposure, at 14 centers in the United States and The Netherlands. The magnetic device was placed using standard laparoscopic tools and techniques. Eighty-five subjects were followed up for 5 years to evaluate quality of life, reflux control, use of PPIs, and side effects. The GERD-health-related quality of life (GERD-HRQL) questionnaire was administered at baseline to patients on and off PPIs, and after placement of the device; patients served as their own controls. A partial response to PPIs was defined as a GERD-HRQL score of 10 or less on PPIs and a score of 15 or higher off PPIs, or a 6-point or more improvement when scores on vs off PPI were compared. RESULTS: Over the follow-up period, no device erosions, migrations, or malfunctions occurred. At baseline, the median GERD-HRQL scores were 27 in patients not taking PPIs and 11 in patients on PPIs; 5 years after device placement this score decreased to 4. All patients used PPIs at baseline; this value decreased to 15.3% at 5 years. Moderate or severe regurgitation occurred in 57% of subjects at baseline, but only 1.2% at 5 years. All patients reported the ability to belch and vomit if needed. Bothersome dysphagia was present in 5% at baseline and in 6% at 5 years. Bothersome gas-bloat was present in 52% at baseline and decreased to 8.3% at 5 years. CONCLUSIONS: Augmentation of the lower esophageal sphincter with a magnetic device provides significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a 5-year follow-up period. These findings validate the long-term safety and efficacy of the magnetic sphincter augmentation device for patients with GERD. ClinicalTrials.gov no: NCT00776997.

24-h multichannel intraluminal impedance-pH monitoring may be an inadequate test for detecting gastroesophageal reflux in patients with mixed typical and atypical symptoms.

BACKGROUND: The detection of gastroesophageal reflux (GERD) via pH testing is the key component of the evaluation of patients considered for antireflux surgery. Two common pH testing systems exist, a multichannel, intraluminal impedance-pH monitoring (MII-pH) catheter, and wireless (Bravo(®)) capsule; however, discrepancies between the two systems exist. In patients with atypical symptoms, MII-pH catheter is often used preferentially. We aimed to elucidate the magnitude of this discrepancy and to assess the diagnostic value of MII-pH and the Bravo wireless capsule in a population of patients with mixed respiratory and typical symptoms. METHODS: The study population consisted of 66 patients tested with MII-pH and Bravo pH testing within 90 days between July 2009 and 2013. All patients presented with laryngo-pharyngo-respiratory (LPR) symptoms. Patient demographics, symptomatology, manometric and endoscopic findings, and pH monitoring parameters were analyzed. Patients were divided into four comparison groups: both pH tests positive, MII-pH negative/Bravo positive, MII-pH positive/Bravo negative, and both pH tests negative. RESULTS: Nearly half of the patients (44%) had discordant pH test results. Of these, 90% (26/29) had a negative MII-pH but positive Bravo study. In this group, the difference in the DeMeester score was large, a median of 29.3. These patients had a higher BMI (28.5 vs. 26.1, p = 0.0357), were more likely to complain of heartburn (50 vs. 23%, p = 0.0110), to have a hiatal hernia, (85 vs. 53%, p = 0.0075) and a structurally defective lower esophageal sphincter (LES, 85 vs. 58%, p = 0.0208). CONCLUSIONS: In patients with LPR symptoms, we found a high prevalence of discordant esophageal pH results, most commonly a negative MII-pH catheter and positive Bravo. As these patients exhibited characteristics consistent with GERD (heartburn, defective LES, hiatal hernia), the Bravo results are likely true. A 24-h MII-pH catheter study may be inadequate to diagnose GERD in this patient population.

Esophagectomy for end-stage achalasia.

Achalasia is a disease for which treatments are palliative in nature. Success of therapy is judged by a number of metrics, the most important being relief of symptoms, such as dysphagia and regurgitation. Patients often compensate for symptoms though a variety of dietary and lifestyle modifications, making symptomatic assessment of therapeutic outcome unreliable. Given this fact, and the progressive nature of the condition if left inadequately treated, patients not infrequently present with the disabling manifestations of end-stage disease for which esophagectomy is the best option. In appropriately selected patients, and when performed in experienced centers, esophagectomy with foregut reconstruction can be undertaken successfully with acceptable rates of morbidity and mortality, as well as a good long-term symptomatic outcome, in cases of end-stage achalasia.

The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction.

Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.

The Society of Thoracic Surgeons/American Society for Radiation Oncology Updated Clinical Practice Guidelines on Multimodality Therapy for Locally Advanced Cancer of the Esophagus or Gastroesophageal Junction.

Outcomes for patients with esophageal cancer have improved over the last decade with the implementation of multimodality therapy. There are currently no comprehensive guidelines addressing multidisciplinary management of esophageal cancer that have incorporated the input of surgeons, radiation oncologists, and medical oncologists. To address the need for multidisciplinary input in the management of esophageal cancer and to meet current best practices for clinical practice guidelines, the current guidelines were created as a collaboration between The Society of Thoracic Surgeons (STS), American Society for Radiation Oncology (ASTRO), and the American Society of Clinical Oncology (ASCO). Physician representatives chose 8 key clinical questions pertinent to the care of patients with locally advanced, resectable thoracic esophageal cancer (excluding cervical location). A comprehensive literature review was performed identifying 227 articles that met the inclusion criteria covering the use of induction chemotherapy, chemotherapy vs chemoradiotherapy before surgery, optimal radiation dose, the value of esophagectomy, timing of esophagectomy, the approach and extent of lymphadenectomy, the use of minimally invasive esophagectomy, and the value of adjuvant therapy after resection. The relevant data were reviewed and voted on by the panel with 80% of the authors, with 75% agreement on class and level of evidence. These data were then complied into the guidelines document.

Benchmarking for perturbative triple-excitations in EE-EOM-CC methods.

Perturbative triples corrections ((T) and (T̃)) to the equation of motion coupled cluster singles and doubles (EOM-CCSD) are rederived and implemented in a pilot parallel code. The vertical excitation energies of molecules in the test set of Sauer et al. [J. Chem. Theor. Comput. 2009, 5, 555] are reported and compared to the iterative EOM-CCSDT-3 method. The average absolute deviations of EOM-CCSD(T) and EOM-CCSD(T̃) from EOM-CCSDT-3 over this wide test set are 0.06 and 0.18 eV, respectively. The poor performance of the latter suggests misbalanced handling of the (T̃) terms. Scaling curves for EOM-CCSD(T) are also presented to demonstrate the performance across multiple compute nodes, thus enabling the routine and accurate study of excited states for ever larger molecular systems.

The Etiology, Diagnosis, and Management of Esophageal Perforation.

BACKGROUND: Esophageal perforation is a serious and potentially life-threatening medical emergency. Given multiple etiologies and varying clinical presentations of the perforated esophagus, the diagnosis is commonly delayed, complicating expeditious and optimal intervention. METHODS: We thoroughly reviewed the latest literature on the subject and herein describe the various treatment strategies in varying settings. RESULTS: Treatment depends on multiple factors including the cause and location of the perforation, the time interval between the inciting event and presentation to the managing clinician, the overall medical stability of the patient, comorbidities including pre-existent esophageal pathology or prior foregut operations, and both the location and extent of extra-esophageal fluid collections. Because of these various considerations, determining the best diagnostic and therapeutic approach requires considerable clinical experience and judgment on the part of the physician. Management principles include (1) adequate fluid resuscitation; (2) expeditious administration of appropriate broad-spectrum antibiotics; (3) repair, occlusion, exclusion, diversion, or exteriorization of the perforation site; (4) drainage of extraluminal fluid collections; (5) relief of distal obstruction; and (6) nutritional support. CONCLUSIONS: For decades, operative intervention has been the mainstay of therapy for esophageal perforation. More recently, endoscopic therapies, including stenting, clipping, suturing, or endoscopic vacuum therapy, have been introduced, expanding the clinician's therapeutic armamentarium while supplanting surgical approaches in many cases. With further experience and introduction of novel therapies, the management of esophageal perforation undoubtedly will continue to evolve.

Can Clinical Response Predict Pathologic Response Following Neoadjuvant Chemoradiation for Esophageal Cancer?

OBJECTIVES: Approximately 20-40% of patients with locally advanced esophageal cancer will achieve a pathologic complete response (ypCR) following neoadjuvant chemoradiotherapy (nCRT). Predicting ypCR based on a clinical complete response (ycCR) has been a challenge. This study assessed the correlation between ycCR and ypCR, as determined from esophagectomy specimens. METHODS: Patients undergoing esophagectomy following nCRT at three major institutions between 2005 and 2018 were reviewed. Restaging, including PET/CT, endoscopy with biopsy, and esophageal ultrasound (EUS), was performed to determine ycCR. RESULTS: Six hundred sixty patients were included, with 93.3% with esophageal adenocarcinoma histology. Six hundred fifty-eight of these patients underwent PET, 304 EUS, and 584 underwent a biopsy. Following nCRT, 148 (22.4%) were found to have a ypCR. Only 12/32 (37.5%) determined to have a ycCR were found to have a ypCR, while 136/628 (21.6%) with a non-ycCR were found to have a ypCR (p 0.075). Individual modality PPV was 28% for PET, 54% for EUS, and 26% for biopsy. When PET was combined with EUS, 168 reports were concordant and the PPV of ypCR was 50%, though the number of patients was low (1/2). With all 3 re-staging modalities combined, the PPV and NPV both rose to 100%. CONCLUSIONS: Current restaging tools cannot reliably predict ypCR after nCRT. While multimodal restaging appears to be a more accurate predictor of ypCR than any testing modality alone, patients cannot reliably be advised to avoid an esophagectomy on the assumption that ycCR predicts ypCR at this time.

Antireflux and Endoscopic Therapies for Barrett Esophagus and Superficial Esophageal Neoplasia.

Barrett esophagus (BE), defined as intestinal metaplasia of the distal esophageal mucosa, typically results from chronic gastroesophageal reflux disease and is the only known precursor of esophageal adenocarcinoma. The standard of care for the management of early esophageal neoplasia in the setting of BE has changed drastically over the past 15 years. Further investigation into diagnostic and therapeutic adjuncts will continue to improve our ability to control or cure BE before its advancement to a life-threatening malignancy.

Surgical Management of Barrett's-Related Neoplasia.

The management of Barrett's-related neoplasia has benefited from advances in endoscopic assessment, resection, and ablation, along with improved pathologic and radiographic staging. The development of specialized, high-volume esophageal multidisciplinary teams, with improvements in patient selection, preparation, perioperative care, minimally invasive operative approaches, and enhanced recovery after surgery programs, has contributed to improved outcomes for patients undergoing esophagectomy for Barrett's-related neoplasia.

A clinical nomogram predicting pathologic lymph node involvement in esophageal cancer patients.

BACKGROUND: Esophageal cancer patients with pathologic lymph-node involvement (pN1) generally have a poor prognosis with surgery alone. We, therefore, constructed a nomogram to predict the risk of pN1 prior to surgical resection and externally validated the clinical utility of the model. METHODS: A total of 273 esophageal adenocarcinoma patients treated with surgery alone were reviewed from 2 different institutions (University of Texas M. D. Anderson Cancer Center = 164, training set; University of Rochester School of Medicine and Dentistry = 109, validation set). Pretreatment clinical parameters were used to construct a nomogram for predicting the risk of pN1. Internal and external validation of the nomogram was performed to assess clinical utility. RESULTS: Of the 164 patients in the training set, 56 patients (34%) had lymph-node involvement (pN1). Significant factors associated with pN1 on univariable logistic regression analysis (using a P < 0.05) included endoscopically determined clinical tumor depth (cT), clinical nodal (cN) status, and clinical tumor length (cL). Multivariable analysis suggested the significant independent factors were cT (odds ratio, 5.6; 95% confidence interval, 1.7-18.6; P < 0.01) and cL >2 cm (odds ratio, 7.0; 95% confidence interval, 2.7-18.1; P < 0.001). Regression tree analysis was used to determine the best cutoff for cL. A nomogram was created for pN1 using these clinical parameters and was internally validated by bootstrapping with a predicted accuracy of 85.1%. External validation performed on the validation set demonstrated an original C-index of 0.777 suggesting good clinical utility. CONCLUSIONS: Our analyses demonstrate that the risk of pathologic nodal involvement in esophageal adenocarcinoma patients can be estimated by this clinical nomogram, which will allow the identification of patients at high-risk of harboring positive lymph-nodes, who may be candidates for en bloc resection and/or neoadjuvant treatment.

Optimum lymphadenectomy for esophageal cancer.

OBJECTIVE: Using Worldwide Esophageal Cancer Collaboration data, we sought to (1) characterize the relationship between survival and extent of lymphadenectomy, and (2) from this, define optimum lymphadenectomy. SUMMARY BACKGROUND DATA: What constitutes optimum lymphadenectomy to maximize survival is controversial because of variable goals, analytic methodology, and generalizability of the underpinning data. METHODS: A total of 4627 patients who had esophagectomy alone for esophageal cancer were identified from the Worldwide Esophageal Cancer Collaboration database. Patient-specific risk-adjusted survival was estimated using random survival forests. Risk-adjusted 5-year survival was averaged for each number of lymph nodes resected and its relation to cancer characteristics explored. Optimum number of nodes that should be resected to maximize 5-year survival was determined by random forest multivariable regression. RESULTS: For pN0M0 moderately and poorly differentiated cancers, and all node-positive (pN+) cancers, 5-year survival improved with increasing extent of lymphadenectomy. In pN0M0 cancers, no optimum lymphadenectomy was defined for pTis; optimum lymphadenectomy was 10 to 12 nodes for pT1, 15 to 22 for pT2, and 31 to 42 for pT3/T4, depending on histopathologic cell type. In pN+M0 cancers and 1 to 6 nodes positive, optimum lymphadenectomy was 10 for pT1, 15 for pT2, and 29 to 50 for pT3/T4. CONCLUSIONS: Greater extent of lymphadenectomy was associated with increased survival for all patients with esophageal cancer except at the extremes (TisN0M0 and >or=7 regional lymph nodes positive for cancer) and well-differentiated pN0M0 cancer. Maximum 5-year survival is modulated by T classification: resecting 10 nodes for pT1, 20 for pT2, and >or=30 for pT3/T4 is recommended.

A population-based analysis of emergent vs. elective hospital admissions for an intrathoracic stomach.

BACKGROUND: Large-scale, population-based analyses of the demographics, management, and healthcare resource utilization of patients with an intrathoracic stomach are largely unknown, an issue which has become more important with the aging of the population. Our objective was to understand the magnitude of the problem and to assess clinical outcomes and hospital costs in elective and emergent admissions of patients with an intrathoracic stomach in a large population-based study. METHODS: The New York Statewide Planning and Research Cooperative System (SPARCS) administrative database was queried for primary ICD-9-CM codes 553.3 and 552.3 in patients 18 years or older; 4858 hospital admissions were identified over a 5-year period (2002-2006). Database variables included age, gender, race, type of admission, operative intervention, in-hospital mortality, length of stay, and cost. RESULTS: Approximately 1000 patients are admitted to the hospital each year with primary diagnosis of intrathoracic stomach, an estimated 52 per 1 million of the population in New York State. Over half of those (53%) were emergent admissions. Interestingly, the majority of emergent admissions (66%) were discharged before any surgical intervention. Patients admitted emergently were older (68.0 vs. 62.1 years, p < 0.0001) and more likely African-American (12% vs. 6%, p < 0.0001). Compared to elective admissions, emergent admissions had higher mortality (2.7% vs. 1.2%, p < 0.001), longer length of stay (LOS) (7.3 vs. 4.9 days, p < 0.0001), and higher cost ($28,484 vs. $24,069, p < 0.001). Among patients who underwent surgery, emergent admissions had higher mortality (5.1% vs. 1.1%, p < 0.0001), greater LOS (13.1 vs. 4.9 days, p < 0.0001), and higher costs ($55,460 vs. $24,760, p < 0.0001). Multivariate regression analysis demonstrated age, emergent presentation, and operative admission as independent predictors for hospital mortality, LOS, and cost (p < 0.0001). CONCLUSIONS: Strikingly, more than half of admissions for intrathoracic stomach were emergent. Emergent admissions had higher mortality, longer LOS, and higher cost than elective admissions. These data support consideration of early elective repair.

Management of anastomotic leaks after esophagectomy and gastric pull-up.

Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient's clinical status and the surgeon's preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.

Mortality After Esophagectomy: Analysis of Individual Complications and Their Association with Mortality.

BACKGROUND: The relationship between individual complications and esophagectomy mortality is unclear. The influence of comorbidities on the impact of complications on operative mortality is also unknown. We sought to assess the impact of individual complications and the effect of coexisting comorbidities on operative mortality following esophagectomy. METHODS: All gastric conduit esophagectomies performed for cancer from 2008 to 2017 in the Society of Thoracic Surgery database were identified. Chi square was utilized to identify postoperative events associated with operative mortality. Multivariable logistic regression analysis was performed, utilizing postoperative events, to determine the risk-adjusted effect on operative mortality for each postoperative event. To assess the effect of preoperative comorbidities, a second logistic regression analysis was performed, incorporating preoperative characteristics. RESULTS: Of 11,943 esophagectomy patients, 63.9% had a postoperative event and 3.3% died, which did not change over the study period. The postoperative events with the highest impact on operative mortality were respiratory distress syndrome (OR 7.48 (95% CI 5.23-10.7)), reintubation (OR 6.55 (4.61-9.30)), and renal failure (OR 5.97 (4.08-8.75)). Anastomotic leak requiring reoperation was associated with increased operative mortality (OR 1.48 (1.03-2.14)), but medically managed leak was not. Incorporating preoperative characteristics into the operative mortality model had little effect on odds ratio for death for individual postoperative events. CONCLUSIONS: In the Society of Thoracic Surgery database, 64% of patients suffer postoperative events and 3.3% die following esophagectomy. The independent association of certain postoperative events with mortality is an objective method of terming a complication "major" and may aid efforts to reduce mortality.

Utility of erector spinae plane block in thoracic surgery.

BACKGROUND: Thoracic surgeons have been incorporating enhanced recovery after surgery (ERAS) protocols into their practices, not only to reduce narcotic usage but also to improve complication rates and decrease lengths of stay. Here, we describe the utility of a regional block technique that can be used for patients undergoing urgent or elective thoracic surgical procedures or suffering from rib fractures. METHODS: We report our initial one-year experience with these erector spinae plane (ESP) blocks. RESULTS: ESP blocks were placed in 42 patients. The procedure was performed by a trained team of anesthesiologists and certified nurse practitioners. It included placement of a catheter on the ipsilateral chest, followed by a 20 ml of 0.2% ropivacaine bolus and continuous infusion. Patients were then followed by the regional team, as long as the catheter was in place. While it had some technical challenges, the block was effective in 83.3% of patients with no reported mortality or major complications. However, given the confounding factors of the study (such as simultaneous implementation of ERAS protocol) and heterogeneity of the patient population, a control group was difficult to ascertain and meaningful opioid consumption analysis was difficult to perform. CONCLUSIONS: Regional blocks, such as the ESP block, complement fundamental ERAS principles and serve as an adjunct to the available armamentarium for non-narcotic ways to control pain in thoracic surgical and chest trauma patients. Continued collaboration between the thoracic surgeons and anesthesiologists is needed for its success.