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Examining the relationship between preoperative nutritional and symptom assessment and postoperative atrial fibrillation in esophageal squamous cell carcinoma patients: a retrospective cohort study

BMC Surgery volume 24, Article number: 298 (2024) Cite this article

Abstract

Objective

The study aimed to examine the relationship between preoperative nutritional status, symptom burden, and the occurrence of postoperative atrial fibrillation in Esophageal Squamous Cell Carcinoma patients.

Methods

The study, conducted in the Department of Thoracic Surgery at the Affiliated Huai’an No. 1 People’s Hospital of Nanjing Medical University, applied the NRS 2002, SGA and MSAS scoring systems as measures of nutritional status and symptom occurrence in patients diagnosed with ESCC. Univariate and multivariate logistic regression analysis were performed to evaluate the association between nutritional scores, symptom scores, and postoperative complications.

Results

The research found a significant correlation between high MSAS scores and postoperative atrial fibrillation. Patients with high symptom burden also tended to have nutritional risk or malnutrition according to the NRS2002 and SGA scores.

Conclusion

There is a need for healthcare providers to pay attention to ESCC patients’ physical and psychological symptoms. Close monitoring of nutritional status and timely nutritional interventions should be integrated into these patients’ care plans as they have been found to be related to postoperative complications such as atrial fibrillation.

Peer Review reports

Introduction

Esophageal Squamous Cell Carcinoma (ESCC) is a prevalent and aggressive malignancy within the digestive system, especially in China, posing a significant healthcare challenge [1,2,3]. Patients often present with nonspecific early symptoms and by the time typical symptoms such as dysphagia, coughing, and pain manifest, the disease is frequently in an advanced stage [4,5,6,7]. The ESCC’s impact on nutritional status and physical well-being is profound, and preoperative symptoms have been recognized as an independent factor influencing postoperative survival rates [8,9,10,11].

The incidence of postoperative atrial fibrillation (POAF) in ESCC patients remains a critical issue. Recent studies, including the work of Chaoyang Tong et al., have indicated that POAF is the most common cardiac dysrhythmia following thoracoscopic anatomical lung cancer surgery, which can increase morbidity and mortality rates significantly [12]. Moreover, POAF has been shown to not only be an independent predictor of arrhythmia postoperatively but also to correlate with increased hospitalization duration, stressing the urgency of this complication [13]. Feng He et al. have found, specifically in ESCC patients, that lower preoperative albumin levels (P = 0.028) are significantly associated with the occurrence of POAF [14]. Furthermore, factors such as increasing age, preoperative hypertension, and respiratory complications have been identified as independent risk factors for POAF, which is pertinent to lengthened hospital stays and may amplify the risk of other postoperative difficulties [15,16,17]. Thus, the phenomenon of POAF in the context of ESCC surgeries holds substantial importance and warrants an in-depth study to elucidate its associations with preoperative nutritional and symptom assessments.

Given the high metabolic demands imposed by ESCC and its associated symptoms which adversely affect food intake, patients often experience malnutrition [18]. The effects of malnutrition, including deficiencies in critical nutrients such as selenium, iron, and magnesium, have been implicated in various cardiovascular disorders and mitochondrial cardiomyocyte dysfunction—a connection underscored by Ali A. Al-Mubarak et al., particularly in non-smokers [19]. Moreover, the nutritional assessments using tools such as the Controlling Nutritional Status (CONUT) score and the Geriatric Nutritional Risk Index (GNRI) have shown a higher incidence of atrial fibrillation post-ablation in malnourished individuals, as reported by Shijie Zhu et al. [20]. This underpins the need to closely monitor nutrition-related factors which may serve as independent predictors of postoperative cardiac complications such as atrial fibrillation.

Clinicians and healthcare providers employ the NRS 2002, SGA, and MSAS to assess and address cancer patients’ nutritional status and symptomatology [21,22,23]. However, the detailed interplay between nutritional risk, global nutritional status, symptom burden, and the particular incidence of atrial fibrillation as a postoperative complication has not been systematically explored within this population. By investigating this association in the specific context of ESCC, our study endeavors to establish a knowledge base that informs the clinical approach to managing and possibly mitigating the risks of POAF through preemptive nutritional and symptom assessment. This fills a critical gap in the current understanding and may lead to improved patient outcomes, shorter hospital stays, and reduced postoperative complications.

Materials and methods

Study design and participants

This retrospective cohort study aimed to examine the association between preoperative MASA score, NRS2002 score, and SGA score, and the incidence of postoperative atrial fibrillation in patients with esophageal squamous cell carcinoma. The study was carried out at the Department of Thoracic Surgery, Affiliated Huai’an No. 1 People’s Hospital of Nanjing Medical University, from January 2018 to December 2019, as illustrated in Fig. 1. The study participants were patients with esophageal squamous cell carcinoma who underwent thoracoscopic and laparoscopic esophagectomy. To ensure the accuracy and reliability of the study, a series of inclusion and exclusion criteria were used to select appropriate study subjects. The inclusion and exclusion criteria for this study were as follows: Exclusion criteria: (A) Patients with other malignant tumors were excluded to avoid interference with the study results. (B) Patients without preoperative CT imaging data were not eligible for inclusion, as these data are necessary for the evaluation of tumor conditions. (C) Patients receiving neoadjuvant therapy were excluded because this may have additional effects on patients’ dietary behavior, interfering with our analysis of cause and effect. (D) Patients without pre- and postoperative clinical pathological data were also excluded, as these data are key indicators for evaluating treatment effectiveness and patient prognosis. (E) Patients with missing data relevant to the scores or outcomes being analyzed or with preoperative atrial fibrillation were excluded from the study. Inclusion criteria: (A) Patients included in the study must have undergone preoperative endoscopy examination and have pathological confirmation of squamous cell carcinoma. (B) All subjects must have undergone chest and abdomen CT enhanced scanning within one week before surgery at our hospital. These scan data are crucial for clinical staging. (C) Clinical staging of all patients will be evaluated according to the 8th edition of TNM classification and recorded during the study period. This study complied with the guiding principles of the Helsinki Declaration and obtained approval from the Ethics Committee of Nanjing Medical University (KY-2024-115-01).

Fig. 1
figure 1

Study Flow Diagram. Out of a total cohort of 198 ESCC patients assessed for eligibility, 167 were included in the final analysis after applying strict inclusion and exclusion criteria

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Implementation methods

We collected data using questionnaire methods within 24 h of patient admission. Nutritional Risk Screening 2002 (NRS 2002) was used to assess patients’ nutritional risk (Supplementary Table 1) [24]. NRS 2002 was developed by the European Society for Clinical Nutrition and Metabolism in 2002 and is mainly used to screen for nutritional risk in adult hospitalized patients. NRS2002 was selected for its capability to better evaluate the nutritional risk in hospitalized patients. It consists of four aspects: body mass index (BMI), recent body weight change, dietary intake change, and the severity of the impact of the primary disease on nutritional status. For patients over 70 years old, 1 point is added to the total score. A score of ≥ 3 indicates the presence of nutritional risk and the need to develop a nutrition support plan. A score of < 3 indicates no immediate need for nutrition support but regular nutritional risk screening should be conducted.

Subjective Global Assessment (SGA) was used to assess patients’ nutritional deficiencies. SGA is a clinical nutrition evaluation method developed in 1987 by Detsky et al. based on medical history and physical examination (Supplementary Table 2) [25]. It includes eight items: body weight change, dietary intake, gastrointestinal symptoms, functional abnormalities, disease and related nutritional requirements, subcutaneous fat, muscle wasting, and edema. Each item is graded as A, B, or C. A represents good nutritional status, B represents mild to moderate malnutrition, and C represents severe malnutrition. Patients with five items graded as B or C can be classified as moderately or severely malnourished.

Symptoms were recorded using the Memorial Symptom Assessment Scale (MSAS). This scale is a multidimensional symptom assessment scale developed by the Memorial Sloan Kettering Cancer Center in New York, used to assess patients’ physical and psychological symptoms (Supplementary Table 3) [26]. MSAS was chosen for its ability to comprehensively assess symptom burden. Patients assess the presence of symptoms based on their own condition and further evaluate the frequency, severity, and distress caused by the symptoms. The scale consists of 32 symptoms, with 24 symptoms measuring frequency, severity, and distress, and the remaining 8 symptoms measuring only severity and distress. Frequency is rated as very rare (1 point), sometimes (2 points), frequent (3 points), and nearly continuous (4 points). Severity is rated as mild (1 point), moderate (2 points), severe (3 points), and very severe (4 points). Distress is rated as symptom absent (0 point), a little (1 point), some (2 points), quite a bit (3 points), and very much (4 points). The scores of the first 24 symptoms are the average of the sum of the frequency, severity, and distress, and the scores of the last 8 symptoms are the sum of severity and distress. The mean score of the 32 symptoms is the overall MSAS score (range 0–4), with higher scores indicating higher frequency, severity, or distress of symptoms. In order to create comparable groups for assessing the impact of preoperative nutritional and symptom assessment on postoperative atrial fibrillation, our cohort was stratified based on the MSAS score. The cut-off value of 1.89 was selected as it represents the average MSAS score within our patient population. This stratification allowed for the equal distribution of patients, ensuring that both groups were well-matched in terms of their baseline clinical and pathological characteristics.

Surgical procedures and perioperative management

We performed thoracoscopic and laparoscopic esophagectomies following our institution’s standardized protocol. A brief overview of the surgical steps is as follows: The patient was placed in the left decubitus and semi-prone position. Five thoracic ports were used to perform the thoracic portion of the operation. The esophagus was mobilized entirely, with the thoracic duct typically ligated. Mediastinal lymphadenectomy was completed, and the specimen was resected. The abdominal part involved the creation of the gastric conduit through an upper midline laparotomy or an additional small incision, followed by the laparoscopic mobilization of the stomach and abdominal lymphadenectomy. The gastric conduit was then brought into the thoracic cavity and anastomosed with the remaining esophagus. Postoperative care focused on early mobilization, pulmonary hygiene, and pain management. Nutritional support began with enteral feeding through a jejunostomy tube on the first postoperative day, progressing to an oral diet as tolerated. Postoperative medications included analgesics, proton pump inhibitors, and any necessary cardiovascular drugs. Prophylactic antibiotics were administered 30 min before incision and continued for 48 h postoperatively to prevent surgical site infections.

Diagnostic criteria for postoperative atrial fibrillation

Postoperative atrial fibrillation (POAF) was defined according to the Society of Thoracic Surgeons’ guidelines [27]. POAF was diagnosed when an abnormal cardiac rhythm with no P waves and irregular R-R intervals was detected on an electrocardiogram (ECG) or telemetry, lasting for at least 30 s [28]. Continuous cardiac monitoring was implemented for all patients for a minimum of 72 h postoperatively, with daily 12-lead ECGs for the first five postoperative days or until discharge. POAF occurrence was also reviewed and confirmed by a cardiologist. The threshold for intervention, typically with rate control and/or rhythm normalization medications, was determined based on the patient’s hemodynamic stability and symptomatology.

Statistical analysis

We applied statistical tests—t-test, ANOVA, chi-square—to evaluate links between scale scores and postoperative atrial fibrillation (POAF), considering P < 0.05 as significant. Confounders like age, sex, comorbidities, and ESCC staging were identified based on their known impacts on nutrition, symptoms, and POAF risk. Multivariable logistic regression, informed by univariate p-values and using stepwise selection (AIC), discerned these factors’ independent effects on POAF. Adjusted odds ratios from this analysis and sensitivity checks using complete data cases and multiple imputation underscored result robustness. To visualize and assess the potential nonlinear relationship between the Memorial Symptom Assessment Scale (MSAS) scores and the incidence of postoperative atrial fibrillation, we employed multivariate restricted cubic spline (RCS) regression models. The restricted cubic spline regression was performed using the ‘rms’ package in R, which included the following steps: (i) Selection of the number of knots and their placement at specific percentiles of the MSAS scores based on recommended practices; (ii) Fitting of the RCS model to the data, with adjustment for potential confounders; (iii) Calculation and plotting of the predicted probabilities of POAF at varying levels of the MSAS score while holding other variables constant at their means. The RCS models allow for a flexible modeling of non-linear associations without assuming a specific form for the relationship between the MSAS score and POAF. Four knots were placed at the 5th, 35th, 65th, and 95th percentiles of the MSAS scores, based on Harrell’s recommendation. The models were adjusted for identified confounders, including age, sex, comorbidities, and ESCC staging. These results were then visualized to facilitate the interpretation of the associations between continuous MSAS scores and the occurrence of POAF. All statistical analyses were conducted using Free Statistics software version 1.9 and the R software package (http://www.R-project.org, R Foundation). Differences were considered statistically significant when P < 0.05.

Results

Baseline characteristics based on the average MSAS score

Of the 167 individuals analyzed in the retrospective cohort, patients were divided into two distinct groups based on the average Memorial Symptom Assessment Scale (MSAS) score, as detailed in Table 1. The cohort with a score of ≤ 1.89 included 125 patients, while the remaining 42 patients registered scores > 1.89. Both groups were comparable with respect to baseline characteristics, including age (mean age 64.7 ± 6.6 years; P = 0.483), gender distribution (45.5% females in the total group; P = 0.164), and pulmonary function as measured by FEV1/FVC% (mean 89.2 ± 19.7; P = 0.734). Comorbidities such as diabetes mellitus and hypertension appeared uniformly across groups (P = 0.973 and P = 0.2, respectively), as did lifestyle factors like smoking and drinking habits (P = 0.899 and P = 0.431, respectively). Similarly, pre-albumin levels showed no significant differences between the two groups (mean 268.5 ± 21.4; P = 0.434). When considering postoperative complications, no significant distinctions surfaced between the cohorts for incidences of atrial fibrillation or pulmonary infection (P = 0.068 and P = 0.188, respectively). However, the substantive divergence in symptom burden was evidenced by the MSAS score itself, averaging 0.9 ± 0.5 in lower score group and considerably higher at 2.0 ± 0.1 in the group with scores > 1.89, a difference reaching statistical significance (P < 0.001). Furthermore, nutritional risk and global nutritional status, as evaluated by the NRS2002 and SGA scores respectively, also differed significantly; substantially more patients in the > 1.89 MSAS score group were classified as nutritionally at risk (100%) or malnourished (69%) compared to the ≤ 1.89 group (49.6% at nutritional risk; 43.2% malnourished) (P < 0.001 and P = 0.004, respectively).

Table 1 Classification and clinical characteristics of patients based on MSAS score
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Univariate and multivariate logistic regression analyses of postoperative atrial fibrillation based on the average MSAS score

The presence of atrial fibrillation as a postoperative complication appeared to increase in patients with higher symptom burdens, but these outcomes were not statistically significant when assessed in unadjusted and adjusted models using logistic regression (Table 2). Specifically, a higher MSAS score (> 1.89) was not accompanied by significantly increased odds of atrial fibrillation after adjustment (adjusted OR = 0.59, 95% CI = 0.18–1.92, P = 0.384). Nutritional status, quantified by NRS2002 and SGA scores, presented a trend towards increased risk for atrial fibrillation, particularly after adjusting for confounders, but did not assert statistical significance (NRS2002 adjusted OR = 3.85, 95% CI = 0.86–17.31, P = 0.079; SGA adjusted OR = 3.5, 95% CI = 1.16–10.58, P = 0.067). Other analyzed factors including age, gender, FEV1/FVC%, diabetes, hypertension, smoking status, alcohol consumption, pre-albumin levels, and ESCC staging did not demonstrate a strong association with the occurrence of postoperative atrial fibrillation.

Table 2 Results of univariable/multivariable logistic regression analysis and predictors of atrial fibrillation
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Baseline characteristics combining NRS2002 score and SGA score

Comparing 82 patients based on a combined assessment of NRS2002 and SGA, two groups were identified: one cohort exhibited normal nutritional status (n = 31) and the other abnormal nutritional status (n = 51). Among the groups detailed in Table 3, no significant differences were reported in age, gender composition, FEV1/FVC ratios, prevalence of diabetes, hypertension, smoking or drinking habits, pre-albumin levels, tumor and nodal staging, intraoperative blood loss, surgical duration, and coronary heart disease presence. Nevertheless, patients with abnormal nutritional status were marked by a heightened average MSAS score (1.9 ± 0.2) compared to those with a normal nutritional status (0.4 ± 0.2), and this variation attained statistical significance (P < 0.001), illustrating a stark contrast in reported symptom burden based on nutritional status.

Table 3 Classification and clinical characteristics of patients combined NRS2000 score and SGA score
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Univariate and multivariate logistic regression analyses of postoperative complications combining NRS2002 score with SGA score

The statistical analysis painted a nuanced picture of the factors that may predict the onset of postoperative atrial fibrillation, as delineated in Table 4. Here, the MSAS score stood out as a significant predictor; individuals with higher MSAS scores demonstrated an increased likelihood of developing atrial fibrillation (univariable analysis crude OR = 2.15, 95% CI = 1.05–4.39, P = 0.037; multivariable analysis adjusted OR = 3.49, 95% CI = 1.39–8.77, P = 0.008). Other variables including age, gender, lung function, presence of diabetes or hypertension, smoking, drinking, pre-albumin levels, and pT and pN staging lacked a significant link to atrial fibrillation in both unadjusted and adjusted models. Pulmonary infection, although linked to higher odds of atrial fibrillation, did not reach statistical significance, suggesting an area for future focused research.

Table 4 Results of univariable/multivariable logistic regression analysis and predictors of atrial fibrillation
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Restricted cubic spline analysis of MSAS scores and POAF

To elucidate the potential nonlinear relationship between MSAS scores and the incidence of postoperative atrial fibrillation (POAF), we performed restricted cubic spline (RCS) regression modeling. The RCS model depicted in Fig. 2 highlights the adjusted relationship between MSAS scores and POAF incidence. The spline plot demonstrates that as the MSAS score increases, there is an associated increase in the risk of POAF in a nonlinear manner, with a more pronounced risk observed at higher MSAS scores. Specifically, the spline curve indicated a rapidly increasing risk threshold around an MSAS score of approximately 2.0. Beyond this point, the risk of POAF continues to climb but at a more moderate trajectory. These findings suggest a complex relationship where higher symptom burdens assessed by the MSAS significantly correlate with increased odds of developing POAF, especially at elevated MSAS scores. These results align with the hypothesis that preoperative symptom burden, as quantified through the MSAS, acts as a significant predictor of POAF. The nonlinearity of this relationship underscores the importance of detailed symptom assessment and its implications for postoperative outcomes. This visualization contributes a deeper understanding of how preoperative symptom burden may interface with clinical trajectories post-ESCC surgery.

Fig. 2
figure 2

Relationship between MSAS Score and Odds Ratio of Postoperative Atrial Fibrillation in Patients with ESCC. The restricted cubic spline (RCS) regression model illustrating the nonlinear association between preoperative MSAS scores and the risk of developing POAF, adjusted for potential confounders including age, sex, comorbidities, and ESCC staging

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Discussion

Recently, the primary focus during the perioperative period for esophageal cancer remains on pulmonary complications and anastomotic leakage, especially their impact on post-esophagectomy mortality, prolonged hospital stay, and readmission rates [29]. Studies indicate that reducing the occurrence of pulmonary complications and anastomotic leakage may have a significant impact on post-esophagectomy prognosis. Additionally, there is currently a lack of research on preoperative functional assessment in patients [29, 30]. The research team led by Daniel P. Raymond is dedicated to studying and establishing a multi-variable risk model for the perioperative period of esophageal cancer, aiming to provide enhanced risk stratification and quality improvement measures. The study revealed that patients with preexisting comorbidities like congestive heart failure had higher rates of pulmonary complications and mortality following esophageal cancer surgery in 164 participating centers [31]. In our study, we evaluated the relationship between preoperative nutritional status, symptom burden, and postoperative atrial fibrillation in patients with Esophageal Squamous Cell Carcinoma. Our significant finding is the positive correlation between high MSAS scores, indicating a high symptom burden, and postoperative atrial fibrillation. Furthermore, we found that patients with high MSAS scores also tended to have nutritional risk on the NRS2002 or malnutrition on the Subjective Global Assessment, which are well-studied scales used to assess nutritional status in cancer patients.

Considerable research has been undertaken into the NRS2002, SGA, and MSAS in the realm of oncology [32,33,34]. NRS2002 is geared towards assessing a patient’s nutritional risk, with a higher score indicating an increased risk of nutrition-related complications.

In recent years, NRS2002 has gained increasing attention in research related to cancer.

The study conducted by Rong Yong et al. demonstrates that the construction of a nomogram model based on age, NRS2002, NLR, AFR, and PNI holds significant predictive value for postoperative delayed neurocognitive recovery in elderly patients with gastric cancer [35]. The study conducted by Xing Wei et al. demonstrates that the NRS2002 nutritional risk score exhibits significant predictive value for the occurrence of postoperative complications in patients with bladder cancer, thereby providing a scientific foundation for perioperative nutritional support [36]. The research conducted by Bo Shi et al. demonstrates that sarcopenia can lead to severe malnutrition and increase the risk of perioperative complications [37]. Therefore, it is important to evaluate both sarcopenia and the NRS2002 nutritional score during preoperative nutritional screening and evaluation for patients with gastric cancer [38].

SGA consists of evaluating the patients’ nutritional status based on medical history and physical examination [39]. These two nutrition scales have been confirmed in several studies affirming their potential in predicting the consequences of malnutrition in cancer patients, including postoperative complications, treatment response, length of hospital stay, and survival rate [40]. In order to investigate the impact of postoperative and radiotherapy swallowing training and nutritional intervention on the nutritional status and quality of life of patients with glottic cancer, SGA is used as an important measurement criterion involved in the study [41]. Meanwhile, in a meta-analysis study, timely nutritional screening is considered crucial due to cancer-associated malnutrition being a significant health complication. The study evaluated the diagnostic accuracy of SGA in adult cancer patients. The research findings indicated an overall sensitivity of 0.69 and specificity of 0.80 for SGA [42].

On the other hand, MSAS, which directly considers the patients’ physical and psychological symptoms, was also found to have a notable correlation with the aforementioned outcomes, hence directly or indirectly corresponding to nutritional status [26]. In recent years, the role of the MSAS has been gradually recognized and valued in clinical practice. In a study conducted during the chemotherapy treatment of acute leukemia, the Memorial Symptom Assessment Scale was used to survey patients, and the results of the survey were then analyzed using principal component analysis to identify symptom clusters [43]. An association network study was conducted to describe the relationships between symptoms and clusters, and a multiple linear model was used to investigate the factors associated with the severity of overall symptoms and each symptom cluster. In a cross-sectional study, data were collected using the Memorial Symptom Assessment Scale on 519 older adult hospice patients with cancer [44]. Subsequently, exploratory factor analysis and hierarchical multiple regression analysis were performed. The study found that in older adults with cancer, especially those receiving hospice care, regular monitoring of fatigue symptoms using standardized scales should be conducted to help reduce psychological distress and prevent functional decline.

From a mechanistic perspective, malnutrition in esophageal cancer patients postoperatively predisposes to atrial fibrillation through multifaceted mechanisms. Firstly, malnutrition can induce electrolyte imbalance and cardiac cell dysfunction, increasing the risk of atrial fibrillation [45]. Secondly, malnutrition may trigger inflammatory responses and oxidative stress, disrupting cardiovascular system stability and heightening the incidence of atrial fibrillation [46]. Additionally, malnutrition may alter cardiac cell structure and function, exacerbating cardiac damage and promoting atrial fibrillation development [47]. Lastly, malnutrition may disturb the balance of the autonomic nervous system, increasing the risk of arrhythmias, including atrial fibrillation [48]. Therefore, the mechanisms underlying the prevention and management of postoperative atrial fibrillation are a complex multifactorial process that necessitates comprehensive consideration of factors such as nutritional support, inflammation modulation, and myocardial protection. Moreover, heart diseases themselves may exacerbate the risk of postoperative complications, such as heart failure and arrhythmias, influencing recovery and prognosis [49]. Additionally, heart diseases may impose additional cardiac burden during and after surgery, imposing extra stress on the heart and circulatory system, escalating the risk of cardiovascular events and mortality [50]. Furthermore, concomitant heart diseases may affect postoperative immune function and overall health status, impacting surgical recovery and healing processes [51]. Therefore, through a comprehensive evaluation and intervention of factors including concomitant heart diseases, it is feasible to effectively predict post-esophagectomy disease occurrence and mortality rates, offering essential references for clinical decision-making and treatment, thereby promoting optimized surgical outcomes and increased patient survival rates.

To our knowledge, there are no published reports on the integration of NRS2002, SGA, and MSAS in understanding and predicting the implications of malnutrition and symptom distress in ESCC patients’ perioperative complications, especially postoperative atrial fibrillation. This study provides insights into this unexplored field, indicating the feasibility and potential advantages of integrating these three scales to offer more comprehensive and precise care management in ESCC patients. However, our study has some limitations that need to be addressed. Firstly, this study is a retrospective analysis, which may have selection bias and may not accurately represent the symptoms of ESCC patients’ changing over time. Secondly, patients were classified into groups based on their average MSAS score, which may not comprehensively reflect the entire range of individual symptoms experienced by the patients. Moreover, the assessment of nutritional status and symptoms were subjective, potentially introducing bias. Finally, our sample size was relatively small. Hence, larger, multicenter prospective cohort studies are warranted for more precise confirmation of our findings.

In conclusion, our study provides valuable insights into the potential role of nutritional status and symptom assessment in predicting postoperative atrial fibrillation in ESCC patients. The high MSAS score, indicating severe symptom distress, was associated with a high incidence rate of postoperative arrhythmia. These findings underline the necessity for healthcare providers to give heed to not only the physical but also psychological symptoms of ESCC patients. Further, routine monitoring of nutritional status and timely nutritional interventions should be incorporated in ESCC patients’ care plans.

Availability of data and materials

The corresponding author can be contacted to request access to the datasets used and/or analyzed during the current study. Please reach out to the corresponding author for further information regarding the availability of the datasets.

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Acknowledgements

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Funding

This work was supported by Nanjing Medical University Science and Technology Development Fund (NMUB20230112).

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Authors and Affiliations

  1. Department of Thoracic Surgery, The Affiliated Huaian No. 1 People’s Hospital of Nanjing Medical University, Huaian, 223300, China

    Yunyun Chen, Yan Ma, Haiyan Wu, Xinqi Wei, Zhiyun Xu & Qingmei Wang

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  1. Yunyun Chen
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  2. Yan Ma
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  3. Haiyan Wu
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  4. Xinqi Wei
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Contributions

Qingmei Wang and Zhiyun Xu designed the study. Yunyun Chen and Yan Ma collected the data. Haiyan Wu and Xinqi Wei analyzed the data. Zhiyun Xu and Yunyun Chen interpreted the result. Zhiyun Xu wrote the first draft of the manuscript. Qingmei Wang contributed to the refinement of the manuscript. The final manuscript has been read and approved by the authors.

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Correspondence to Zhiyun Xu or Qingmei Wang.

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Ethics approval and consent to participate

The study adhered to the guidelines outlined in the Declaration of Helsinki and received approval from the Ethics Committee of Nanjing Medical University. All procedures described in this study were carried out in accordance with relevant guidelines and regulations. Informed consent was not required for this retrospective study and was waived by the Ethics Committee of Nanjing Medical University. The study protocol was reviewed by the Ethics Committee of Nanjing Medical University, which granted the exemption from informed consent based on their assessment that the study met the necessary criteria.

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Chen, Y., Ma, Y., Wu, H. et al. Examining the relationship between preoperative nutritional and symptom assessment and postoperative atrial fibrillation in esophageal squamous cell carcinoma patients: a retrospective cohort study. BMC Surg 24, 298 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02609-7

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12893-024-02609-7

Keywords

BMC Surgery

ISSN: 1471-2482

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