A 10-year ACS-NSQIP Analysis of Trends in Esophagectomy Practices.

BACKGROUND: Esophagectomy practices have evolved over time in response to new technologies and refinements in technique. Using the National Safety and Quality Improvement Program (NSQIP) database, we aimed to describe trends for esophagectomy in terms of approach, surgeon specialty, and associated outcomes. MATERIALS AND METHODS: Adult patients undergoing esophagectomy were identified within the 2007-2017 NSQIP database. The proportion of cases performed using different approaches was trended over time. Outcomes were compared with chi-squared and t-tests. Multivariate logistic regression was used to identify factors associated with outcomes and provide risk-adjusted measures. RESULTS: A total of 10,383 esophagectomies were included; 6347 (61.1%) were performed for cancer. The proportion of esophagectomies performed via the Ivor Lewis approach (ILE) increased between 2007 (37.0%) and 2017 (62.4%). Simultaneously, transhiatal esophagectomies (THEs) decreased from 41.1% to 21.5% (P < 0.001). THE was more frequently performed in patients with higher baseline probability of mortality (2.3% versus 2.0%, P < 0.001) and morbidity (32.2% versus. 28.7%, P < 0.001). The percentage performed with cardiothoracic surgeons increased from 0.8% in 2007 to 50.3% in 2017 (P < 0.001). The risk-adjusted complication rate was 45% for THE, 40% for ILE, and 50% for McKeown (MCK) esophagectomy (P < 0.001). The risk-adjusted rate of surgical site infection was 17.3% for THE, 13.1% for ILE, and 19% for MCK (P = 0.001). Within risk-adjusted analysis, surgical approach was not associated with complications. CONCLUSIONS: ILE has emerged as the predominant approach for esophagectomy nationwide among NSQIP-participating institutions and may be associated with lower complication rates than THE. The use of MCK esophagectomy has remained stable but is associated with increased complications.

Outcomes in Lung Cancer Surgery: Capturing Reliable Metrics.

BACKGROUND: Measuring variation in perioperative outcomes to accurately discriminate performance between surgical providers may be limited by reliability. We aimed to evaluate reliability estimates of metrics associated with lung cancer resection. METHODS: We performed a retrospective cohort study utilizing the 2015 National Cancer Database to identify patients undergoing lung cancer resection. Primary outcomes were reliability estimates for perioperative outcomes and for measures of adherence to clinical benchmarks, generated through hierarchical multilevel modeling techniques. RESULTS: We identified 27,300 patients undergoing resection. Overall risk-adjusted and reliability-adjusted 30-day and 90-day mortality rates were 1.7% and 3.3%, respectively; 61.0% and 41.1% of eligible patients received stage-appropriate adjuvant and neoadjuvant therapy. Video-assisted thoracoscopic surgery was performed in 59.6% of cases with clinical stage I disease. The mean reliability of 30-day and 90-day mortality was 0.11 ± 0.09 and 0.22 ± 0.15, respectively; for performing video-assisted thoracoscopic surgery for stage I disease, reliability was 0.97 ± 0.04. When stratified by hospital volume quartile, the mean reliability of 30-day mortality was 0.04 ± 0.03 in the lowest quartile and 0.20 ± 0.10 in the highest quartile. Only 14% of hospitals met an established 0.7 reliability benchmark for 30-day and 90-day mortality, but over 97% of hospitals exceeded these benchmarks for providing stage-appropriate systemic therapy and performing VATS for stage I disease. CONCLUSIONS: Metrics used to compare lung cancer surgical performance between providers have varying levels of reliability. Reliability should be considered when profiling providers, which will become particularly important as lung cancer treatment under screening programs continues to expand.