Variations in morbidity and mortality based on esophagectomy approach and leak status: Insights from a statewide quality collaborative

Anastomotic leak remains a major source of morbidity after esophagectomy. Cervical anastomoses have been associated with higher leak rates compared with intrathoracic anastomoses; however, cervical leaks may have a less severe clinical impact. The aim was to determine whether the patterns of leak occurrence and severity varied by surgical approach among institutions at a regional level. We retrospectively reviewed data for patients who underwent open or minimally invasive transhiatal esophagectomy or transthoracic esophagectomy for esophageal cancer between January 2015 and March 2023 at 13 centers. Patients were stratified by procedure type and leak rates, and postoperative complications were examined. Logistic regression assessed associations among the surgical technique, leak rates, and postoperative complications. A total of 1230 patients undergoing esophagectomies were reviewed: 500 (41%) with open transhiatal esophagectomy, 135 (11%) with open transthoracic esophagectomy, 258 (21%) with minimally invasive transhiatal esophagectomy, and 337 (27%) with minimally invasive transthoracic esophagectomy. Leak rates ranged from 14% to 23%, with the highest rate observed in minimally invasive transhiatal esophagectomy and the lowest in open transthoracic esophagectomy ( P = . 081). Among those with leaks, open transthoracic esophagectomy had the longest length of stay (25 days, interquartile range, 12-33) compared with transhiatal esophagectomy groups (12-14 days, P = . 003). Pneumonia (42%, P < . 001), empyema requiring intervention (21%, P = . 004), and sepsis (26%, P = . 027) were significantly higher in the open transthoracic esophagectomy group compared with other groups. In-hospital mortality after a leak was highest in open transthoracic esophagectomy (16%) compared with 3% in open transhiatal esophagectomy and 1% in minimally invasive transhiatal esophagectomy and transthoracic esophagectomy groups ( P = . 025). Although leak rates are higher with transhiatal esophagectomy, open transthoracic esophagectomy is associated with greater morbidity and mortality after leak.