Impact of Prophylactic Corticosteroid Use on In-hospital Mortality and Respiratory Failure After Esophagectomy for Esophageal Cancer

Abstract

Objective: To assess the effect of preoperative prophylactic corticosteroid use on short-term outcomes after oncologic esophagectomy. Background: Previous studies have shown that prophylactic corticosteroid use may decrease the risk of respiratory failure following esophagectomy by attenuating the perioperative systemic inflammation response. However, its effectiveness has been controversial, and its impact on mortality remains unknown. Methods: Data of patients who underwent oncologic esophagectomy between July 2010 and March 2019 were extracted from a Japanese nationwide inpatient database. Stabilized inverse probability of treatment weighting, propensity score matching, and instrumental variable analyses were performed to investigate the associations between prophylactic corticosteroid use and short-term outcomes, such as in-hospital mortality and respiratory failure, adjusting for potential confounders. Results: Among 35,501 eligible patients, prophylactic corticosteroids were used in 22,620 (63.7%) patients. In-hospital mortality, respiratory failure, and severe respiratory failure occurred in 924 (2.6%), 5440 (15.3%), and 2861 (8.1%) patients, respectively. In stabilized inverse probability of treatment weighting analyses, corticosteroids were significantly associated with decreased in-hospital mortality [odds ratio (OR) = 0.80; 95% confidence interval (CI): 0.69-0.93], respiratory failure (OR = 0.84; 95% CI: 0.79-0.90), and severe respiratory failure (OR = 0.87; 95% CI: 0.80-0.95). Corticosteroids were also associated with decreased postoperative length of stay and total hospitalization costs. The proportion of anastomotic leakage did not differ with the use of Propensity score matching and instrumental variable analysis demonstrated similar results. Conclusions: Prophylactic corticosteroid use in oncologic esophagectomy was associated with lower in-hospital mortality as well as decreased respiratory failure and severe respiratory failure, suggesting a potential benefit for preoperative corticosteroid use in esophagectomy.

Antimicrobial Prophylaxis with Ampicillin-sulbactam Compared with Cefazolin for Esophagectomy

“…This method can avert some potential limitations of classic propensity scoring methods (eg, inverse probability of treatment weighting and matching) with respect to the target population, covariate balance, and precision, and mimics the properties of a randomized clinical trial 31 . The propensity score was estimated using a multivariable logistic regression model based on the patient-related background factors (sex, age, body mass index, 32 smoking index, Barthel index, Charlson comorbidity index, hypertension, diabetes, chronic obstructive pulmonary disease, renal failure, liver disease, corticosteroid use before surgery, preoperative transfusion, and clinical cancer stage), treatment factors (preoperative chemotherapy, preoperative radiotherapy, field of lymph node dissection, thoracic approach, vessel reconstruction, epidural anesthesia, 27 prophylactic corticosteroid administration, 26 prophylactic neutrophil elastase inhibitor administration, duration of anesthesia, and transfusion on the day of surgery), and hospital factors (hospital type, hospital volume, hospitals’ early extubation proportion, 28 and fiscal year); Supplemental Appendix 1 Supplemental Digital Content 1, http://links.lww.com/SLA/E975 presents the detailed definitions of the background factors. Absolute standardized differences were calculated to examine the balance in the baseline covariates of patients between the 2 groups before and after adjustment: a difference of <10% was considered acceptable 33 .…”

“…The primary outcomes were SSI, anastomotic leakage, and respiratory failure (defined as mechanical ventilation use lasting > 2 days after surgery 26 ). The secondary outcomes included severe respiratory failure (defined as mechanical ventilation use lasting > 7 days after surgery 26 ), any respiratory complications, Clostridioides difficile colitis, noninfectious complications, in-hospital mortality, 30-day mortality, postoperative length of stay, and total hospitalization cost.…”

“…The primary outcomes were SSI, anastomotic leakage, and respiratory failure (defined as mechanical ventilation use lasting > 2 days after surgery 26 ). The secondary outcomes included severe respiratory failure (defined as mechanical ventilation use lasting > 7 days after surgery 26 ), any respiratory complications, Clostridioides difficile colitis, noninfectious complications, in-hospital mortality, 30-day mortality, postoperative length of stay, and total hospitalization cost. We designated pneumothorax, chylothorax, ileus/bowel obstruction/symptomatic hernia (hiatal or diaphragmatic), pulmonary embolism, acute coronary syndrome, heart failure, stroke, and acute kidney injury as noninfectious complications.…”

“…We used respiratory failure, severe respiratory failure, and any respiratory complications as the respiratory outcomes instead of pneumonia, in line with our previous studies. [26][27][28] This is because, despite the existence of an internationally accepted definition of pneumonia, 29 pneumonia and other respiratory complications (eg, atelectasis, acute respiratory distress syndrome, and aspiration pneumonitis) can be indistinguishable from each other in critically ill patients, such as those developing systemic inflammatory response syndrome after esophagectomy. 30…”

“…hospitalization cost, US$ 29,866(26,689) 29,499 (25,977-35,193) 0.014 30,536 (26,568-38,286) 29,456 (25,961-35,076) −3208 (−3992 to −2425) < 0.001 *After overlap weighting, one individual no longer represents one data entity; thus, the raw counts are not reported after overlap weighting. †Respiratory failure was defined as mechanical ventilation use lasting > 2 days after surgery.…”