Accepted Manuscript. Going home after Esophagectomy: The Story is not over Yet. Yaron Shargall, MD, FRCSC

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1 Accepted Manuscript Going home after Esophagectomy: The Story is not over Yet Yaron Shargall, MD, FRCSC PII: S (18) DOI: /j.jtcvs Reference: YMTC To appear in: The Journal of Thoracic and Cardiovascular Surgery Received Date: 23 September 2018 Accepted Date: 24 September 2018 Please cite this article as: Shargall Y, Going home after Esophagectomy: The Story is not over Yet, The Journal of Thoracic and Cardiovascular Surgery (2018), doi: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

2 GOING HOME AFTER ESOPHAGECTOMY: THE STORY IS NOT OVER YET Yaron Shargall, MD, FRCSC 1 1 McMaster University Faculty of Health Sciences Department of Surgery, Division of Thoracic Surgery St. Joseph s Healthcare Hamilton T Charlton Ave East Hamilton, ON L8N 4A6 Central message: Post-discharge emergency room visits are a common event after esophagectomy and continue beyond days after discharge. It is therefore judicious that longitudinal, post-discharge care pathways for these patients be developed. Word Count: 1020 Conflict of interest: none Corresponding author: Yaron Shargall, MD, FRCSC St. Joseph s Healthcare Hamilton T Charlton Ave East Hamilton, ON L8N 4A6 Phone: (905) , ext Fax: (905) shargal@mcmaster.ca

3 Post-discharge readmissions and emergency room visits are considered an important measure of quality care. While there is a general agreement that most preventable readmissions and emergency room visits occur within one month of discharge, some patients populations will continue to be at risk for a longer period of time. Patients who undergo esophagectomy are one of the most challenging populations in thoracic surgery, as they would typically present to surgery following neoadjuvant chemotherapy and radiation and the impact of the surgical intervention itself is substantial. As such, it is not surprizing that morbidity and mortality in this group of patients remain substantial. In the era of ERAS, many centers have been looking at pathways for an early discharge following esophagectomy with some encouraging outcomes 1. However, those reports are mostly retrospective and typically assess early (up to 30 days postoperatively) outcomes. In this issue of the journal, Kidane and colleagues have conducted a single-center, retrospective, observational cohort study, where they assessed reasons for emergency department visits in patients discharged home after esophagectomy. They demonstrated that, when followed for one year, more than 30% of the patients presented at least once to ED, mostly due to feeding tube problems (almost 40%), followed by dysphagia/stricture and dyspnea (around 10% of the admissions each). They also found that higher income and MIS techniques were associated with more ED visits, and that living far away from hospital and having surgery in the later years of the observed study period where associated with a lower risk of ED visits. Intriguingly (for this specific population), feeding tube issues continued to be a dominant cause for repeated ED visits beyond the first encounter. This is an important study, but not without limitations. First, the authors checked only ED visits rather than readmissions. It is very possible that a fraction of patients (perhaps a significant one) 1

4 got admitted to the hospital directly via post-op follow up clinics or were transferred directly from a different hospital to the original operating hospital. This might account for a significant proportion of patients not covered by the current analysis. Secondly, the current manuscript provides only data only about those patients admitted to authors center, potentially missing a significant proportion of patients admitted to a different, local hospital. Indeed, it has been shown that readmissions/ed admissions to a hospital different than the original index hospital are associated with worst prognosis 2,3. Moreover, the finding that patients living far away from the operating hospital had lower risk of ED visits might be a reflection of the fact that some ED visits (to a different, non local, hospitals) were simply not captured. Those other, presumably uncaptured visits might have been for a different etiology and as such would have changed the analysis in a meaningful way. Finally, it is surprising that feeding tube related problems were the leading cause for ED visits in the current study. Previous analyses have shown that leading readmissions and ER visits aetiologies for those patients are typically related to respiratory complications, anastomotic leakages and infections. Indeed, in a contemporary report by Bhagat et al 4, analyzing the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database for postoperative unplanned readmissions after esophagectomy, the main reasons for readmissions were equally divided between Pulmonary, Infectious and Gastrointestinal ( 25% each) and more that 5% were venous thromboembolic events ( VTE) related. Gastrostomy/jejunostomy related problems accounted for less than 1% of readmissions. As such, it is plausible to assume that patients seen in ED after esophagectomy in the current study might represent a somewhat different population, at least partially not including those patients who get readmitted via different routes. 2

5 Nevertheless, Kidane et al do provide us with a novel and important information, related to longterm ED utilization. They followed their patients for over a year post surgery, and clearly demonstrated that those patients continue to consume healthcare resources long after their index surgery, and that, for those patients, the story is far from being over following a successful resection and even a flawless hospital stay. Moreover, the fact that their report is an institutional one allows for a significantly higher granularity of data collection and interpretation, a common problem in retrospective based, regional or national databases. As such, the longitudinal outcomes information provided in this article are practical and beneficial for all of us who operate on those patients. Ultimately, their work, as well as previous reports, all point to the same conclusions; 1. Esophagectomy patients require significant amount of attention and care even after a successful operation, uneventful hospital stay and a seamless discharge from hospital. Additionally, they continue to require healthcare resources far beyond the days window, typically used for analysis. 2. Using hospital stay parameters, and even 90 days post discharge as the only surrogate for quality of care is simply not enough, as clearly demonstrated by Kidane et al; And 3. It is for us, their surgeons, to be responsible to introduce longitudinal, post-discharge care pathways for those patients 5, as their journey continues long after a successful home-discharge post-operatively. 3

6 References 1. Findlay JM, Gillies RS, Millo J, Sgromo B, Marshall RE, Maynard ND. Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg Mar;259(3): Staples JA, Thiruchelvam D, Redelmeier DA. Site of hospital readmission and mortality: a population-based retrospective cohort study.. CMAJ Open May 1;2(2):E doi: /cmajo ecollection 2014 Apr. 3. Zafar SN, Shah AA, Channa H, Raoof M, Wilson L, Wasif N. Comparison of Rates and Outcomes of Readmission to Index vs Nonindex Hospitals After Major Cancer Surgery. JAMA Surg Apr 11. doi: /jamasurg [Epub ahead of print] 4. Bhagat R, Bronsert MR, Juarez-Colunga E, Weyant MJ, MD, Mitchell JD, Glebova, WG Henderson, Fullerton D, MD, Meguid RA. Postoperative Complications Drive Unplanned Readmissions After Esophagectomy for Cancer. Ann Thorac Surg 2018;105: Shargall Y, Hanna WC, Schneider L, Schieman C, Finley CJ, Tran A, Demay S, Gosse C, Bowen JM, Blackhouse G, Smith K. The Integrated Comprehensive Care Program: A Novel Home Care Initiative After Major Thoracic Surgery. Semin Thorac Cardiovasc Surg Summer;28(2): doi: /j.semtcvs Epub 2015 Dec 11. 4

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