Cost burden following esophagectomy: A single centre observational study

Table 1 Baseline characteristics, surgical and oncological data, n (%)

Variable	n = 110
Demographics
Sex
Male	91 (82.7)
Female	19 (17.3)
Age (years)	64.47 ± 9.694
Body mass index (kg/m2)	27.0 ± 4.9
Smoking
Never	30 (27.3)
Active	12 (10.9)
Quit < 6 weeks prior to surgery	5 (4.5)
Quit 6 weeks to 90 days prior to surgery	4 (3.6)
Quit > 90 days prior to surgery	59 (53.6)
Pack year history	20 (0-40)
Alcohol consumption > 4 standard drinks	13 (11.8)
Risk classification
ASA
1	2 (1.8)
2	35 (31.8)
3	68 (61.8)
4	5 (4.5)
ECOG
0	78 (70.9)
1	28 (25.5)
2	3 (2.7)
ACCI (median)	4 (3-5)
Comorbidities
Coronary artery disease	3 (2.7)
Myocardial infarction	6 (5.5)
Congestive heart failure	1 (0.9)
Peripheral vascular disease	7 (6.4)
Cerebrovascular accident	5 (4.5)
Chronic pulmonary disease	11 (10)
Diabetes mellitus (uncomplicated)	13 (11.8)
Diabetes mellitus (end-organ damage)	2 (1.8)
Moderate to severe renal disease	1 (0.9)
Synchronous malignancy (solid tumor)	2 (1.8)
Past malignancy	16 (14.5)
Previous laparotomy	13 (11.8)
Previous thoracotomy	8 (7.3)
Previous hiatal operation	4 (3.6)
Laboratory tests
Hemoglobin (g/L)	132 (90, 176)
White cell ( 109/L)	6.6 (3, 13)
Platelet ( 109/L)	231.5 (110, 541)
Creatinine (mmol/L)	79.5 (44, 72)
eGFR (mL/minute/1.73 m2)	87 (33, 91)
Albumin (g/L)	38 (27, 44)
Principal diagnosis (indication for surgery)
Malignant	104 (94.5)
Benign	6 (5.5)
Surgical approach
Open	94 (85.4)
Minimally invasive (laparoscopy & thoracoscopy)	3 (2.7)
Hybrid (chest or abdomen)	13 (11.8)
Conversion to open	5 (4.5)
Anastomosis site
Chest	68 (61.8)
Neck	42 (38.2)
Esophageal conduit
Stomach	107 (97.3)
Colon	3 (2.7)
AJCC staging (8th edition)
I	36 (32.7)
II	14 (12.7)
IIIA	10 (9)
IIIB	27 (24.5)
IVA	13 (11.8)
IVB	3 (2.7)
Resection margin
R0: Negative	97 (88.1)
R1: Microscopic positive	10 (9)
R2: Macroscopic positive	1 (0.9)
Admission details
ICU length of stay (days) n = 108	2.7 (1.6-6.3)
HDU length of stay (days) n = 17	0.5 (0.4-0.7)
Length of hospital stay	18 (13-27)
Discharge destination
Home	84 (76.4)
Hospital at home	5 (4.5)
Rehabilitation facility/subacute care	19 (17.3)
Death	2 (1.8)
Readmission
30-day readmission	26 (23.6)
90-day readmission	47 (42.7)

Data are presented as count (proportion), mean ± SD, and median (interquartile range). ASA: American Society of Anesthesiology; ACCI: Age-related Charlson Comorbidity Index; ECOG: Eastern Cooperative Oncology Group; AJCC: American Joint Committee on Cancer; ICU: Intensive care unit; HDU: High dependency unit; eGFR: Estimate glomerular filtration rate.

Table 2 Complications summary, severity grade and number, n (%)

Clavien-Dindo highest grade	n = 110
None	2 (1.8)
I	4 (3.6)
II	58 (52.7)
IIIa	9 (8.2)
IIIb	13 (11.8)
IVa	19 (17.3)
IVb	3 (2.7)
V	2 (1.8)
Number of complications per patient
0-2	10 (9)
3-6	58 (52.7)
> 7	42 (38.1)
Complications per patient (mean SD)	6.0 ± 2.9

Data are presented as count (proportion) and mean ± SD.

Table 3 Esophagectomy key complications, n (%)

Complications	Grade	n = 110
Anastomotic leak: Full-thickness GI defect involving esophagus, anastomosis, staple line, or conduit irrespective of presentation or method of identification	Type I: Local defect requiring no change in therapy or treated medically or with dietary modification	11 (10.0)
	Type II: Localized defect requiring interventional but not surgical therapy	5 (4.5)
	Type III: Localized defect requiring surgical therapy	4 (3.64)
Subtotal		20 (18.2)
Conduit necrosis/failure: Postoperative identification of conduit necrosis	Type I: Focal conduit necrosis identified endoscopically requiring monitoring or non-surgical therapy	0 (0)
	Type II: Focal conduit necrosis focal identified endoscopically and not associated with free anastomotic or conduit leak, requiring surgical therapy without esophageal diversion	2 (1.8)
	Type III: Conduit necrosis extensive requiring with conduit resection with diversion	1 (0.9)
Subtotal		3 (2.7)
Chyle leak: Milky discharge upon initiation of enteric feeds and/or pleural fluid analysis demonstrating triglyceride level > 100 mg/dL and/or chylomicrons in pleural fluid	Type Ia: < 1 L output, Treatment-enteric dietary 3 modifications	3 (2.7)
	Type Ib: > 1 L output, treated with enteric dietary modifications	0 (0)
	Type IIa: < 1 L output, treated with total parenteral nutrition	1 (0.9)
	Type IIb: > 1 L output, treated with total parenteral nutrition	0 (0)
	Type IIIa: < 1 L output, treated with interventional or surgical therapy	2 (1.8)
	Type IIIb: > 1 L output, treated with interventional or surgical therapy	5 (4.5)
Subtotal		11 (10)
	Type Ia: Unilateral injury transient injury requiring no therapy (dietary modification aloud)	5 (4.5)
	Type Ib: Bilateral injury transient injury requiring no therapy (dietary modification aloud)	0 (0)
	Type IIa: Unilateral injury requiring elective surgical procedure, for example thyroplasty or medialization procedure	3 (2.7)
	Type IIb: Unilateral injury requiring elective surgical procedure for example thyroplasty or medialization procedure	0 (0)
	Type IIIa: Unilateral injury requiring acute surgical intervention (due to aspiration or respiratory issues), for example, thyroplasty or medialization procedure	2 (1.8)
	Type IIIb: Bilateral Injury requiring acute surgical intervention (due to aspiration or respiratory issues), for example, thyroplasty or medialization procedure	3 (2.7)
Subtotal		13 (11.8)
Total		47 (42.7)

Complications are defined and graded as per the Esophageal Complications Consensus Group[19]. GI: Gastrointestinal.

Table 4 Complications costs analysis - Clavien-Dindo severity grade, number of complications and esophagectomy key complications

	Median cost USD (IQR)
CD grade
No complication or CD I	37427.94 (34277.96-42283.38)
CD II	43174.77 (29114.99-49366.61)
CD III	54454.79 (43421.93-78679.18)a,b
CD IV & V	76 063.38 (61 579.73-114 664.51)a,b,c
Number of complications
0-3	29629.58 (25592.76-41683.1)
4-7	46666.14 (36410.33-58611.02)d
> 7	75516.55 (56456.86-136612.02)d,e
Esophagectomy key complication
No	42937.5 (29992.1-49629.0)
Yes	75516.6 (53544.1-101343.0)f

^aP < 0.05 vs no complications or Clavien-Dindo (CD) I.

^bP < 0.05 vs CD grade II.

^cP < 0.05 vs CD III.

^dP < 0.05 vs 0-3 complications.

^eP < 0.05 vs 4-7 complications.

^fP < 0.05 vs no key complications.

CD: Clavien-Dindo; USD: United States dollars.