Transthoracic Approach Is Associated with Increased Risk of New Onset Atrial Fibrillation After Esophagectomy.

Kush R Lohani, Kalyana C Nandipati, Sarah E Rollins, Tommy H Lee, Pradeep K Pallati, Se Ryung Yamamoto, Sumeet K Mittal. Department of Surgery, Creighton University School of Medicine, Omaha, Nebraska..

Aim: Atrial fibrillation (AF) has been associated with higher morbidity after esophagectomy. The objective of this study is to identify the surgical risk factors associated with new onset atrial fibrillation after esophagectomy.

Methods: After Institutional Review Board approval, a prospectively maintained database was retrospectively queried to identify patients who underwent esophageal resection between 2003 and 2013. Data variables collected include preoperative (demographics, esophageal pathology, comorbidities, neo-adjuvant treatment), intra-operative (type of approach, operative time, anastomotic site, conduits used, blood loss, intraoperative fluids, urine output) and postoperative factors [length of hospital stay and immediate post-operative complications (using Clavien grading system)]. Appropriate statistical analysis is performed utilizing Sigmaplot® version 12.3.

Results: Of total 245 esophagectomies performed during this period, 192 (147 males, mean age of 62 ± 11.12 years) were included in the final analysis and 53 were excluded [25 Roux-en-Y reconstruction (including 3 Merendino procedures), 20 had AF before surgery and 8 with staged esophagectomy]. Of 192 esophagectomies, 160 had malignancy (138 adenocarcinoma and 22 Squamous cell carcinoma). One hundred and six patients received neo-adjuvant therapy.

There were 78 three-hole esophagectomy [34 Minimally Invasive (MIE), 37 open and 7 Hybrid], 56 Ivor Lewis esophagectomy (31 MIE, 10 Open, 15 Hybrid) and 58 Transhiatal Esophagectomy (16 MIE and 42 Open). Gastric conduit was used in 185 patients and colonic conduit in 7 patients. Overall 30-day or in-hospital mortality was 3.6% (7/192).

Forty five (23.4%) patients with esophagectomy developed new onset AF. They were older (65.7 vs. 61.3, p = 0.021), with medical co-morbidities (thyroid disorder, hyperlipidemia and coronary artery disease; p < 0.05) and stayed longer in hospital (19 vs 14 days, p<0.001) with severe post-operative complications (Clavien score ≥ III) (69% vs. 35.3%, p<0.001). The intra-operative fluid requirements, blood loss and the length of surgery were not significantly different between the new onset AF patients and non-AF patients (p>0.05).

Median onset of AF was post-op day 3 (range: Post-op day 0 to 32). Majority underwent medical management (n=37, 82.2%), five needed temporary pacemakers (n=5), two needed cardioversion (n=2) and 1 patient with transient AF did not require any active intervention. Early (< 3 days) vs. late onset (> 3 days) AF patients did not have any significant difference in perioperative complications or length of stay.

Open surgery was not associated with high incidence of developing AF compared to the Minimally Invasive Surgery (p=0.355), however transthoracic approach showed the trend compared to the transhiatal approach (27.6% vs. 13.8%, p=0.059).

Multiple logistic regression analysis showed transthoracic approach (OR =2.85, CI = 1.05 – 7.7, p=0.038), thyroid disorder (OR 5.32, CI = 1.5-17.47, p = 0.007), and severe post-op complications (OR=3.2, CI = 1.29 – 8.1, p=0.012) to be significantly associated with the development of new onset of AF.

Conclusions: Transthoracic approach is an independent risk factor for the development of new onset of AF after esophagectomy. New onset AF is associated with severe post-operative complications and longer hospital stay. Minimally invasive approach does not decrease the incidence of new development of AF.

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