Official reprint from UpToDate®
www.uptodate.com ©2015 UpToDate®

Complications of esophageal resection

Daniel P Raymond, MD
Section Editor
Joseph S Friedberg, MD
Deputy Editor
Wenliang Chen, MD, PhD


Operations that resect the esophagus and restore gastrointestinal continuity are technically challenging procedures. The rates for morbidity and mortality depend on many factors (eg, patient comorbidities, operative approach, hospital/surgeon volume) but vary widely between publications. A review of all publications between 2005 and 2009 found that no single complication was reported in all papers, and in-hospital mortality, the most common term for postoperative death, had six different definitions [1].

The systemic and procedure-specific complications of esophageal resection are reviewed here. Methods by which surgical resection is accomplished are reviewed separately. (See "Surgical management of resectable esophageal and esophagogastric junction cancers".)


The overall incidence of postoperative complications varies widely between 20 and 80 percent and includes systemic complications (eg, pneumonia, myocardial infarction), and complications specific to the surgical procedure (eg, anastomotic leaks, recurrent laryngeal nerve injury) [2-13]. Pulmonary complications are the most common postoperative complications occurring in 16 to 67 percent of patients [7,14-16], but anastomotic leak is the most dreaded, occurring in 0 to 40 percent of patients [7,17,18]. (See 'Anastomotic leak' below and 'Pulmonary' below.)

A multivariate analysis identified several preoperative factors that increased the risk of complications following esophageal resection and reconstruction [3]. Some of these included increasing age, conditions associated with compromised pulmonary function (eg, chronic obstructive pulmonary disease), malnutrition, renal or hepatic dysfunction, and emergency surgery. The preoperative indication for surgery (ie, malignant or benign disease) was not associated with increased morbidity. Patients with malignant disease had similar 30-day morbidity rates compared with patients with benign disease (49.0 versus 51.1 percent).

Comorbid illnesses increase the risk of postoperative complications (eg, cardiorespiratory complications, anastomotic leakage, reoperation rates, wound infection), and death following esophagectomy [8,19,20]. As an example, in a prospective study of 615 patients, those with comorbid illness had an increased overall rate of postoperative complications or major anastomotic leaks compared with patients without comorbidities (28 versus 18 percent, and 11 versus <1 percent, respectively) [8]. In addition, a metaregression from a separate study showed the risk of anastomotic leakage or atrial fibrillation in obese patients with diabetes was significantly higher compared with obese patients without diabetes [19].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Oct 2015. | This topic last updated: Jun 25, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2015 UpToDate, Inc.
  1. Blencowe NS, Strong S, McNair AG, et al. Reporting of short-term clinical outcomes after esophagectomy: a systematic review. Ann Surg 2012; 255:658.
  2. Metzger R, Bollschweiler E, Vallböhmer D, et al. High volume centers for esophagectomy: what is the number needed to achieve low postoperative mortality? Dis Esophagus 2004; 17:310.
  3. Bailey SH, Bull DA, Harpole DH, et al. Outcomes after esophagectomy: a ten-year prospective cohort. Ann Thorac Surg 2003; 75:217.
  4. Seely AJ, Ivanovic J, Threader J, et al. Systematic classification of morbidity and mortality after thoracic surgery. Ann Thorac Surg 2010; 90:936.
  5. Shen KR, Harrison-Phipps KM, Cassivi SD, et al. Esophagectomy after anti-reflux surgery. J Thorac Cardiovasc Surg 2010; 139:969.
  6. Hulscher JB, Tijssen JG, Obertop H, van Lanschot JJ. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg 2001; 72:306.
  7. Biere SS, Maas KW, Cuesta MA, van der Peet DL. Cervical or thoracic anastomosis after esophagectomy for cancer: a systematic review and meta-analysis. Dig Surg 2011; 28:29.
  8. Rutegård M, Lagergren P, Rouvelas I, et al. Surgical complications and long-term survival after esophagectomy for cancer in a nationwide Swedish cohort study. Eur J Surg Oncol 2012; 38:555.
  9. Morita M, Nakanoko T, Fujinaka Y, et al. In-hospital mortality after a surgical resection for esophageal cancer: analyses of the associated factors and historical changes. Ann Surg Oncol 2011; 18:1757.
  10. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240:205.
  11. Swisher SG, Deford L, Merriman KW, et al. Effect of operative volume on morbidity, mortality, and hospital use after esophagectomy for cancer. J Thorac Cardiovasc Surg 2000; 119:1126.
  12. Lagarde SM, Reitsma JB, Maris AK, et al. Preoperative prediction of the occurrence and severity of complications after esophagectomy for cancer with use of a nomogram. Ann Thorac Surg 2008; 85:1938.
  13. Connors RC, Reuben BC, Neumayer LA, Bull DA. Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients. J Am Coll Surg 2007; 205:735.
  14. Inoue J, Ono R, Makiura D, et al. Prevention of postoperative pulmonary complications through intensive preoperative respiratory rehabilitation in patients with esophageal cancer. Dis Esophagus 2013; 26:68.
  15. Schieman C, Wigle DA, Deschamps C, et al. Patterns of operative mortality following esophagectomy. Dis Esophagus 2012; 25:645.
  16. Swanson SJ, Batirel HF, Bueno R, et al. Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg 2001; 72:1918.
  17. Saluja SS, Ray S, Pal S, et al. Randomized trial comparing side-to-side stapled and hand-sewn esophagogastric anastomosis in neck. J Gastrointest Surg 2012; 16:1287.
  18. Law S, Fok M, Chu KM, Wong J. Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: a prospective randomized controlled trial. Ann Surg 1997; 226:169.
  19. Kayani B, Okabayashi K, Ashrafian H, et al. Does obesity affect outcomes in patients undergoing esophagectomy for cancer? A meta-analysis. World J Surg 2012; 36:1785.
  20. Koppert LB, Lemmens VE, Coebergh JW, et al. Impact of age and co-morbidity on surgical resection rate and survival in patients with oesophageal and gastric cancer. Br J Surg 2012; 99:1693.
  21. Atkins BZ, Shah AS, Hutcheson KA, et al. Reducing hospital morbidity and mortality following esophagectomy. Ann Thorac Surg 2004; 78:1170.
  22. Markar SR, Karthikesalingam A, Thrumurthy S, Low DE. Volume-outcome relationship in surgery for esophageal malignancy: systematic review and meta-analysis 2000-2011. J Gastrointest Surg 2012; 16:1055.
  23. Kuo EY, Chang Y, Wright CD. Impact of hospital volume on clinical and economic outcomes for esophagectomy. Ann Thorac Surg 2001; 72:1118.
  24. Orringer MB, Marshall B, Chang AC, et al. Two thousand transhiatal esophagectomies: changing trends, lessons learned. Ann Surg. Sep 2007; 246:363.
  25. Rodgers M, Jobe BA, O'Rourke RW, et al. Case volume as a predictor of inpatient mortality after esophagectomy. Arch Surg 2007; 142:829.
  26. Varghese TK Jr, Wood DE, Farjah F, et al. Variation in esophagectomy outcomes in hospitals meeting Leapfrog volume outcome standards. Ann Thorac Surg 2011; 91:1003.
  27. Martin LW, Hofstetter W, Swisher SG, Roth JA. Management of intrathoracic leaks following esophagectomy. Adv Surg 2006; 40:173.
  28. Kumagai K, Rouvelas I, Tsai JA, et al. Meta-analysis of postoperative morbidity and perioperative mortality in patients receiving neoadjuvant chemotherapy or chemoradiotherapy for resectable oesophageal and gastro-oesophageal junctional cancers. Br J Surg 2014; 101:321.
  29. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med 2002; 346:1128.
  30. van Lanschot JJ, Hulscher JB, Buskens CJ, et al. Hospital volume and hospital mortality for esophagectomy. Cancer 2001; 91:1574.
  31. Dimick JB, Cattaneo SM, Lipsett PA, et al. Hospital volume is related to clinical and economic outcomes of esophageal resection in Maryland. Ann Thorac Surg 2001; 72:334.
  32. Begg CB, Cramer LD, Hoskins WJ, Brennan MF. Impact of hospital volume on operative mortality for major cancer surgery. JAMA 1998; 280:1747.
  33. Gordon TA, Bowman HM, Bass EB, et al. Complex gastrointestinal surgery: impact of provider experience on clinical and economic outcomes. J Am Coll Surg 1999; 189:46.
  34. Verhoef C, van de Weyer R, Schaapveld M, et al. Better survival in patients with esophageal cancer after surgical treatment in university hospitals: a plea for performance by surgical oncologists. Ann Surg Oncol 2007; 14:1678.
  35. Reavis KM, Smith BR, Hinojosa MW, Nguyen NT. Outcomes of esophagectomy at academic centers: an association between volume and outcome. Am Surg 2008; 74:939.
  36. Brusselaers N, Mattsson F, Lagergren J. Hospital and surgeon volume in relation to long-term survival after oesophagectomy: systematic review and meta-analysis. Gut 2014; 63:1393.
  37. Derogar M, Sadr-Azodi O, Johar A, et al. Hospital and surgeon volume in relation to survival after esophageal cancer surgery in a population-based study. J Clin Oncol 2013; 31:551.
  38. Meguid RA, Weiss ES, Chang DC, et al. The effect of volume on esophageal cancer resections: what constitutes acceptable resection volumes for centers of excellence? J Thorac Cardiovasc Surg 2009; 137:23.
  39. Gillison EW, Powell J, McConkey CC, Spychal RT. Surgical workload and outcome after resection for carcinoma of the oesophagus and cardia. Br J Surg 2002; 89:344.
  40. Rouvelas I, Lindblad M, Zeng W, et al. Impact of hospital volume on long-term survival after esophageal cancer surgery. Arch Surg 2007; 142:113.
  41. Avendano CE, Flume PA, Silvestri GA, et al. Pulmonary complications after esophagectomy. Ann Thorac Surg 2002; 73:922.
  42. Hulscher JB, van Sandick JW, de Boer AG, et al. Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 2002; 347:1662.
  43. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012; 379:1887.
  44. Briez N, Piessen G, Torres F, et al. Effects of hybrid minimally invasive oesophagectomy on major postoperative pulmonary complications. Br J Surg 2012; 99:1547.
  45. Bhayani NH, Gupta A, Dunst CM, et al. Esophagectomies with thoracic incisions carry increased pulmonary morbidity. JAMA Surg 2013; 148:733.
  46. Murthy SC, Law S, Whooley BP, et al. Atrial fibrillation after esophagectomy is a marker for postoperative morbidity and mortality. J Thorac Cardiovasc Surg 2003; 126:1162.
  47. Vaporciyan AA, Correa AM, Rice DC, et al. Risk factors associated with atrial fibrillation after noncardiac thoracic surgery: analysis of 2588 patients. J Thorac Cardiovasc Surg 2004; 127:779.
  48. Boyle NH, Pearce A, Hunter D, et al. Intraoperative scanning laser Doppler flowmetry in the assessment of gastric tube perfusion during esophageal resection. J Am Coll Surg 1999; 188:498.
  49. Beitler AL, Urschel JD. Comparison of stapled and hand-sewn esophagogastric anastomoses. Am J Surg 1998; 175:337.
  50. Collard JM, Romagnoli R, Goncette L, et al. Terminalized semimechanical side-to-side suture technique for cervical esophagogastrostomy. Ann Thorac Surg 1998; 65:814.
  51. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000; 119:277.
  52. Kim RH, Takabe K. Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review. J Surg Oncol 2010; 101:527.
  53. Hsu HH, Chen JS, Huang PM, et al. Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a prospective randomized controlled trial. Eur J Cardiothorac Surg 2004; 25:1097.
  54. Briel JW, Tamhankar AP, Hagen JA, et al. Prevalence and risk factors for ischemia, leak, and stricture of esophageal anastomosis: gastric pull-up versus colon interposition. J Am Coll Surg 2004; 198:536.
  55. Sepesi B, Swisher SG, Walsh GL, et al. Omental reinforcement of the thoracic esophagogastric anastomosis: an analysis of leak and reintervention rates in patients undergoing planned and salvage esophagectomy. J Thorac Cardiovasc Surg 2012; 144:1146.
  56. Price TN, Nichols FC, Harmsen WS, et al. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann Thorac Surg 2013; 95:1154.
  57. Kassis ES, Kosinski AS, Ross P Jr, et al. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 2013; 96:1919.
  58. Blackmon SH, Correa AM, Wynn B, et al. Propensity-matched analysis of three techniques for intrathoracic esophagogastric anastomosis. Ann Thorac Surg 2007; 83:1805.
  59. Baba M, Aikou T, Natsugoe S, et al. Appraisal of ten-year survival following esophagectomy for carcinoma of the esophagus with emphasis on quality of life. World J Surg 1997; 21:282.
  60. Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 2014; 208:536.
  61. Chang AC, Ji H, Birkmeyer NJ, et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008; 85:424.
  62. De Boer AG, Genovesi PI, Sprangers MA, et al. Quality of life in long-term survivors after curative transhiatal oesophagectomy for oesophageal carcinoma. Br J Surg 2000; 87:1716.
  63. McLarty AJ, Deschamps C, Trastek VF, et al. Esophageal resection for cancer of the esophagus: long-term function and quality of life. Ann Thorac Surg 1997; 63:1568.
  64. Ercan S, Rice TW, Murthy SC, et al. Does esophagogastric anastomotic technique influence the outcome of patients with esophageal cancer? J Thorac Cardiovasc Surg 2005; 129:623.
  65. Williams VA, Watson TJ, Zhovtis S, et al. Endoscopic and symptomatic assessment of anastomotic strictures following esophagectomy and cervical esophagogastrostomy. Surg Endosc 2008; 22:1470.
  66. Schipper PH, Cassivi SD, Deschamps C, et al. Locally recurrent esophageal carcinoma: when is re-resection indicated? Ann Thorac Surg 2005; 80:1001.
  67. Wright CD, Zeitels SM. Recurrent laryngeal nerve injuries after esophagectomy. Thorac Surg Clin 2006; 16:23.
  68. Baba M, Natsugoe S, Shimada M, et al. Does hoarseness of voice from recurrent nerve paralysis after esophagectomy for carcinoma influence patient quality of life? J Am Coll Surg 1999; 188:231.
  69. — Bolger C, Walsh TN, Tanner WA, et al. Chylothorax after oesophagectomy. The British journal of surgery. May 1991;78(5):587-588.
  70. Shah RD, Luketich JD, Schuchert MJ, et al. Postesophagectomy chylothorax: incidence, risk factors, and outcomes. Ann Thorac Surg 2012; 93:897.
  71. Hou X, Fu JH, Wang X, et al. Prophylactic thoracic duct ligation has unfavorable impact on overall survival in patients with resectable oesophageal cancer. Eur J Surg Oncol 2014; 40:1756.
  72. — Staats BA, Ellefson RD, Budahn LL, Dines DE, Prakash UB, Offord K. The lipoprotein profile of chylous and nonchylous pleural effusions. Mayo Clinic proceedings. Mayo Clinic. Nov 1980;55(11):700-704.
  73. — Dugue L, Sauvanet A, Farges O, Goharin A, Le Mee J, Belghiti J. Output of chyle as an indicator of treatment for chylothorax complicating oesophagectomy. Br J Surg. Aug 1998;85(8):1147-1149.
  74. — Merigliano S, Molena D, Ruol A, et al. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation. J Thorac Cardiovasc Surg. Mar 2000;119(3):453-457.
  75. Marthaller KJ, Johnson SP, Pride RM, et al. Percutaneous embolization of thoracic duct injury post-esophagectomy should be considered initial treatment for chylothorax before proceeding with open re-exploration. Am J Surg 2015; 209:235.
  76. Merigliano S, Molena D, Ruol A, et al. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation. J Thorac Cardiovasc Surg 2000; 119:453.
  77. Headrick JR, Nichols FC 3rd, Miller DL, et al. High-grade esophageal dysplasia: long-term survival and quality of life after esophagectomy. Ann Thorac Surg 2002; 73:1697.
  78. Greene CL, DeMeester SR, Worrell SG, et al. Alimentary satisfaction, gastrointestinal symptoms, and quality of life 10 or more years after esophagectomy with gastric pull-up. J Thorac Cardiovasc Surg 2014; 147:909.
  79. Donington JS. Functional conduit disorders after esophagectomy. Thorac Surg Clin 2006; 16:53.
  80. Martin JT, Federico JA, McKelvey AA, et al. Prevention of delayed gastric emptying after esophagectomy: a single center's experience with botulinum toxin. Ann Thorac Surg 2009; 87:1708.
  81. Aly A, Jamieson GG. Reflux after oesophagectomy. Br J Surg 2004; 91:137.
  82. Yuasa N, Sasaki E, Ikeyama T, et al. Acid and duodenogastroesophageal reflux after esophagectomy with gastric tube reconstruction. Am J Gastroenterol 2005; 100:1021.
  83. Dresner SM, Griffin SM, Wayman J, et al. Human model of duodenogastro-oesophageal reflux in the development of Barrett's metaplasia. Br J Surg 2003; 90:1120.
  84. Burt M, Scott A, Williard WC, et al. Erythromycin stimulates gastric emptying after esophagectomy with gastric replacement: a randomized clinical trial. J Thorac Cardiovasc Surg 1996; 111:649.
  85. Penning C, Vecht J, Masclee AA. Efficacy of depot long-acting release octreotide therapy in severe dumping syndrome. Aliment Pharmacol Ther 2005; 22:963.
  86. Geer RJ, Richards WO, O'Dorisio TM, et al. Efficacy of octreotide acetate in treatment of severe postgastrectomy dumping syndrome. Ann Surg 1990; 212:678.
  87. Peyre CG, DeMeester SR, Rizzetto C, et al. Vagal-sparing esophagectomy: the ideal operation for intramucosal adenocarcinoma and barrett with high-grade dysplasia. Ann Surg 2007; 246:665.
  88. Price TN, Allen MS, Nichols FC 3rd, et al. Hiatal hernia after esophagectomy: analysis of 2,182 esophagectomies from a single institution. Ann Thorac Surg 2011; 92:2041.
  89. Kent MS, Luketich JD, Tsai W, et al. Revisional surgery after esophagectomy: an analysis of 43 patients. Ann Thorac Surg 2008; 86:975.
  90. Ganeshan DM, Correa AM, Bhosale P, et al. Diaphragmatic hernia after esophagectomy in 440 patients with long-term follow-up. Ann Thorac Surg 2013; 96:1138.