Re-thinking routine critical care admission after esophagectomy

Esophagectomy is associated with a high burden of peri-operative morbidity and mortality,1 which has traditionally justified routine postoperative intensive care unit (ICU) admission. However, as surgical and anesthetic techniques have advanced, and pre-operative optimization and enhanced recovery (ERAS) pathways have become standard of care, it seems pertinent to ask whether routine postoperative ICU care remains necessary for every patient. de Mul et al. recently challenged this assumption using a data-driven approach to refining postoperative care allocation.2 By developing a preoperative prediction model, they demonstrated that a substantial proportion, perhaps as many as half, of patients undergoing elective esophagectomy might be safely managed without routine admission to the ICU. de Mul et al. retrospectively analyzed 619 consecutive patients undergoing elective eosophagectomy at a tertiary center in the Netherlands over a 10-year period. Using logistic regression, they identified preoperative predictors of postoperative ICU-level support, which was defined as the need for mechanical ventilation, high-flow oxygen, or vasopressor/inotropic therapy beyond the first postoperative morning. The final model incorporated eight readily available variables: age; diabetes; hemoglobin; renal function; forced expiratory volume; tumor stage; neoadjuvant therapy; and surgical approach.2