National Analysis of Anastomotic Leak and Subsequent Failure to Rescue After Esophagectomy

Anastomotic leak is a major complication following esophagectomy, with persistently high incidence rates. A contemporary evaluation using a large national, generalizable database is warranted to identify the risk factors associated with leak development, trends in management, and contributors to subsequent failure to rescue (FTR).

The American College of Surgeons National Surgical Quality Improvement Program database was used to identify patients who underwent an esophagectomy for cancer from 2016 to 2021. Predictors for anastomotic leak and FTR were identified using multivariable logistic regression analysis.

5582 patients met the inclusion criteria; 828 (14.8%) developed an anastomotic leak and 52 (6.2%) were unable to be rescued. Anastomotic leak rates have increased from 12% in 2016 to 16% in 2021 (P < 0.001). After adjusting for covariates; smoking (adjusted odds ratio [aOR] 1.28, P = 0.013), hypertension (aOR 1.33, P = 0.002), surgical conversion to open (aOR 1.44, P = 0.027), positive margins (aOR 1.39, P = 0.033), and three-field esophagectomy (aOR 1.46, P < 0.001) were independent predictors for developing an anastomotic leak. Among the patients with an anastomotic leak, age above 65 (aOR 2.9, P = 0.002), Black race (aOR 8.56, P < 0.001), and development of an additional postoperative complication (aOR 13.62, P < 0.001) were independent predictors for FTR.

Patient characteristics such as active smoking or hypertension can inform preoperative optimization in an attempt to reduce morbidity and mortality. FTR after an anastomotic leak disproportionally affects older individuals, Black patients, and those who incur an additional postoperative complication. These patients require greater perioperative attention and prompt intervention if signs of a leak or an additional complication are identified.