Evaluating the Surgeon’s Experience as a Risk Factor for Post-Esophagectomy Chylothorax on a Four-Year Cohort

Abstract

Background: Chylothorax (CHT) is a known post-operative complication after esophageal surgery with vaguely defined risk factors. Methods: This is a retrospective chart review of 70 consecutive patients with operable cancer over a period of four years (January 2013 to December 2016). Ivor Lewis and McKeown interventions were performed. Thoracic duct is identified and ligated routinely. Factors related to the patient, the tumor, and the operating surgeon were analyzed. Results: Incidence of CHT was 10%. Surgeons with less than five years of esophageal surgery experience had the most CHT, 71% (p=0.001). No association was found between tumor location, type, body mass index (BMI), neoadjuvant therapy, response to neoadjuvant therapy or male sex, and CHT. The odds of developing CHT were 17 times higher in patients operated by a junior surgeon (odds ratio, OR=17.67, confidence interval, CI 2.68-116.34, p=0.003). Four patients (5.7%) had anastomotic leaks, none of them had CHT. Senior surgeons had less operative time and harvested more lymph nodes (p=0.0002 and p=0.1086 respectively). Conclusion: Surgeon’s experience might be considered a major risk factor to develop CHT. This finding needs to be confirmed by a larger multicentric series taking into consideration the human factor.

Incidence of chylothorax over nineteen years of transhiatal esophagectomy: A case series and review study

“…Another controversial issue is that the incidence of this complication has not been determined accurately and that there are major differences between various reports in this regard (8,12,13,15,16). There is considerable difference between studies regarding the reports of post-esophagectomy chylothorax, with low incidence in our patients but higher prevalence reported in other studies (2,17).…”

Association between underweight status and chylothorax after esophagectomy for esophageal cancer: A propensity score–matched analysis

“…Following propensity score matching, multivariable logistic regression models adjusted for covariates chosen a priori to control for patient morbidity and proposed risk factors of chylothorax following esophagectomy from prior studies. 6 , 7 , 8 In the matched cohort, the association of underweight status with chylothorax or other postoperative complications, after adjusting for Charlson Comorbidity Index, history of chemotherapy or radiation therapy, minimally invasive approach, and resection of thoracic lymphatics was assessed ( Table 2 ). Patients who were underweight were estimated to have 2.06 times the odds for chylothorax (95% CI, 1.07-4.25, P = .035) in the multivariable analysis.…”

“… 3 , 4 , 7 Previous studies have shown mixed associations between chylothorax and preoperative chemotherapy or chemoradiation therapy. 4 , 6 , 8 Therefore, our study controlled for preoperative chemotherapy and/or radiation therapy in the matched analysis and multivariable logistic regression models. In the multivariable analysis, underweight status remained a significant risk factor for development of chylothorax.…”

“…The chosen covariates were proposed risk factors for postoperative complications, including chylothorax, in previous studies. 6 , 7 , 8 Charlson Comorbidity Index was included as a covariate to represent patient morbidity which could confound the association between underweight status and postoperative outcomes. Balance of the covariates in the propensity score–matched groups was evaluated using absolute standardized mean differences.…”

“…Previous studies of relatively small sample size have proposed surgeon experience, history of chemotherapy, low BMI, radicality of dissection, and high intraoperative fluid balance as potential risk factors for chylothorax. 6 , 7 , 8 The goal of this study was to use a large nationwide all-payer database of hospitalizations to investigate underweight BMI as a risk factor for postoperative complications, such as chylothorax, after esophagectomy through a propensity score–matched analysis of patients who are underweight and not underweight.…”