Paraesophageal hernia has a significant effect on respiratory function, which is largely underappreciated. This study demonstrates that these repairs can be done safely and supports routine consideration for elective repair; older patients with borderline respiratory function may achieve substantial improvements in their respiratory status and quality of life.

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IMPORTANCENinety-day mortality rates after esophagectomy are an indicator of the quality of surgical oncologic management. Accurate risk prediction based on large data sets may aid patients and surgeons in making informed decisions.OBJECTIVE To develop and validate a risk prediction model of death within 90 days after esophagectomy for cancer using the International Esodata Study Group (IESG) database, the largest existing prospective, multicenter cohort reporting standardized postoperative outcomes. DESIGN, SETTING, AND PARTICIPANTSIn this diagnostic/prognostic study, we performed a retrospective analysis of patients from 39 institutions in 19 countries between January 1, 2015, and December 31, 2019. Patients with esophageal cancer were randomly assigned to development and validation cohorts. A scoring system that predicted death within 90 days based on logistic regression β coefficients was conducted. A final prognostic score was determined and categorized into homogeneous risk groups that predicted death within 90 days. Calibration and discrimination tests were assessed between cohorts.EXPOSURES Esophageal resection for cancer of the esophagus and gastroesophageal junction. MAIN OUTCOMES AND MEASURES All-cause postoperative 90-day mortality.RESULTS A total of 8403 patients (mean [SD] age, 63.6 [9.0] years; 6641 [79.0%] male) were included. The 30-day mortality rate was 2.0% (n = 164), and the 90-day mortality rate was 4.2% (n = 353). Development (n = 4172) and validation (n = 4231) cohorts were randomly assigned. The multiple logistic regression model identified 10 weighted point variables factored into the prognostic score: age, sex, body mass index, performance status, myocardial infarction, connective tissue disease, peripheral vascular disease, liver disease, neoadjuvant treatment, and hospital volume. The prognostic scores were categorized into 5 risk groups: very low risk (score, Ն1; 90-day mortality, 1.8%), low risk (score, 0; 90-day mortality, 3.0%), medium risk (score, -1 to -2; 90-day mortality, 5.8%), high risk (score, −3 to −4: 90-day mortality, 8.9%), and very high risk (score, Յ−5; 90-day mortality, 18.2%). The model was supported by nonsignificance in the Hosmer-Lemeshow test. The discrimination (area under the receiver operating characteristic curve) was 0.68 (95% CI, 0.64-0.72) in the development cohort and 0.64 (95% CI, 0.60-0.69) in the validation cohort. CONCLUSIONS AND RELEVANCEIn this study, on the basis of preoperative variables, the IESG risk prediction model allowed stratification of an individual patient's risk of death within 90 days after esophagectomy. These data suggest that this model can help in the decision-making process when esophageal cancer surgery is being considered and in informed consent.

Costs vary significantly among treatment approaches: surgery alone costs 80% of chemotherapy and surgery, 71% of chemoradiotherapy and surgery, and 72% of chemoradiotherapy alone. Costs of tri-modality therapy and definitive chemoradiotherapy are similar. Especially in the absence of definitive evidence-based data, these costs should be a factor in the production of future national treatment guidelines. Decreasing costs requires future quality initiatives in esophageal cancer treatment that focus on minimizing complications related to treatment.

Summary Esophageal surgery is historically associated with adverse postoperative outcomes. Selected high-volume centers have previously reported the effect on clinical outcomes following the adoption of a standardized clinical pathway (SCP). This meta-analysis aims to evaluate the current literature to document the effect of SCP and enhanced recovery after surgery (ERAS) on esophagectomy outcomes. A literature search was conducted through the main search engines (PubMed, Embase, Medline, and Cochrane database) in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. All eligible comparative studies (randomized control trial, prospective, retrospective, and combined) were identified and assessed based on Methodological Index for Non-Randomized Studies and Jadad quality criteria. Data concerning overall morbidity, early mortality, and length of stay (LOS) were primarily collected and compared. Secondary outcomes included anastomotic leaks, pulmonary complications, and readmission rate. Twenty-six articles (including five randomized controlled trials and six prospective trials) were included in the analysis. Overall study quality was moderate and the included studies utilized a variable approach to SCP. No statistically significant differences were found between groups in terms of overall morbidity, postoperative mortality, anastomotic leak, and readmission rates. Significant improvements included pulmonary complications (odds ratios [OR] 0.66, 95% confidence interval [CI] 0.49–0.94) and hospital LOS (OR −3.68, 95% CI −4.49 to −2.87). Previous reports of SCP within esophagectomy programs have demonstrated clinical improvements in postoperative pulmonary complications and LOS. Given the high heterogeneity historically demonstrated within SCPs, further improvement in outcomes should be expected following the adoption of standardized ERAS guidelines.