Anastomotic Leak After Esophagectomy: Analysis of the STS General Thoracic Surgery Database

Anastomotic leak after esophagectomy is a major cause of morbidity and mortality. We sought to identify the prevalence of anastomotic leak, stratified by operative approach and disease etiology, as well as risk factors for leak.

A retrospective cohort analysis using The Society of Thoracic Surgeons General Thoracic Surgery Database was conducted on patients who underwent esophagectomy with gastric reconstruction between 2009 and 2021. Baseline characteristics and postoperative outcomes were compared between patients who did and did not develop an anastomotic leak. Multivariable mixed effects logistic regression models identified risk factors for leak.

Of 18,419 patients, 3416 (19%) developed an anastomotic leak. Patients who leaked had more comorbidities, including obesity and diabetes. There was no difference in leak based on disease etiology (P = .435.) Patients with anastomotic leak had increased 30-day mortality (7% vs 4%, P < .001), reoperation (58% vs 10%, P < .001), and longer lengths of stay (18 vs 10 days, P < .001). On multivariable analysis, obesity (odds ratio [OR], 1.27; 95% CI, 1.16-1.38; P < .001), diabetes (OR, 1.14; 95% CI, 1.04-1.25; P = .006), and smoking (OR, 1.26; 95% CI, 1.15-1.37; P < .001) were independently predictive of anastomotic leak. Compared with an open 2-field, a transhiatal (OR, 1.35; 95% CI, 1.17-1.55; P < .001) or 3-field esophagectomy (OR, 1.46; 95% CI, 1.25-1.70; P < .001) was more likely to leak. A robotic approach was associated with an increased risk of leak (OR, 1.28; 95% CI, 1.03-1.08; P < .001), however lost significance in a modern subgroup from 2018-2021.

Obesity, diabetes, smoking, pulmonary hypertension, and a cervical anastomosis are risk factors for anastomotic leak regardless of disease etiology. These important clinical risk factors identify an opportunity for modifiable risk reduction with aggressive medical optimization perioperatively.