Analysis of in-hospital mortality following transthoracic esophagectomy for cancer

Abstract In-hospital mortality following esophagectomy for cancer has markedly decreased over the last few decades, with reported death rates below 5% considered a benchmark for quality of care. Although large registry studies have focused on reaching this benchmark, little is known about the underlying cause of death and the possibility of preventing a lethal outcome. The aim of this multicenter study was to perform an in-depth analysis of in-hospital mortality following esophagectomy for cancer. Data were obtained from four European esophageal cancer centers analyzing their prospective databases between January 2010 and June 2020. All patients with an in-hospital lethal postoperative course (Clavien–Dindo V) following elective transthoracic esophagectomy were included. Data collection comprised baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications, and their management. In each participating center, cases were retrospectively assessed for (1) the selection of patients for esophagectomy based on their individual comorbidities, (2) intraoperative, and (3) postoperative complications and their management to finally classify the management of each section as adequate, non-adequate, or undetermined. One hundred and twenty-one out of 3899 patients died following esophagectomy, amounting to an in-hospital mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18–60). Following surgery, a total of 294 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often in 65 patients (53.7%). AL was considered as leading cause of death in 44 patients (36.4%) followed by acute respiratory distress syndrome (ARDS) in 15 patients (12.4%). Assessment of preoperative patient selection revealed a non-adequate workup in only two patients (1.4%). During surgery, six patients (4.6%) suffered complications, which were deemed adequately treated in retrospective assessment. In eight patients (6.6%), postoperative management was deemed non-adequate; in seven of eight cases, recognition and initiation of treatment for AL were considered delayed. Despite technical advances, AL remains the leading cause of death following esophagectomy, contributing to a significantly prolonged clinical course and lethal outcome. In contrast to other published series, assessment of this homogenous patient cohort in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, modification of AL management might be considered to reduce the overall death rate.