Esophageal resection and restoration of gastrointestinal continuity operations are technically challenging procedures. This topic will discuss the clinical and nonclinical risk factors associated with an increased risk of morbidity and mortality and the management of the complications following an esophagectomy. The surgical resection procedures are reviewed separately. (See "Surgical oncologic principles for management of resectable esophageal cancer".)
MORBIDITY AND MORTALITY
Morbidity and mortality rates vary, depending upon hospital and/or surgeon volume, patient comorbidities, and operative approach (eg, open, minimally invasive, tri-incisional) [1-4]. A review of all publications between 2005 and 2009 reporting on the morbidity and mortality of an esophagectomy (n = 57,299 patients) found heterogeneous and inconsistent reporting of data and a lack of methodological rigor . For example, no one single complication was reported in all papers, and in-hospital mortality, the most common term for postoperative death, had six different definitions. Meaningful cross study comparisons and analyses are challenging.
Overall morbidity — The overall postoperative morbidity rates range from 20 to 80 percent and include respiratory (eg, pneumonia) and cardiac (eg, infarction, failure, atrial fibrillation) complications, anastomotic leaks, recurrent laryngeal nerve injury, and minor complications (eg, urinary tract infections, atelectasis) [2-4,6-13]. The most common serious complications include a major anastomotic leak, which occurs in 0 to 40 percent [7,14,15] and postoperative pulmonary complications, which occur in 16 to 67 percent of patients [7,16-18].
Overall mortality — The overall in-hospital mortality rates range from 0 to 22 percent [1,2,7,19-23]. The overall 30-day mortality rates (excluding in-hospital deaths) range from <1 to 6 percent . In a prospective study of 615 patients who underwent an esophagectomy, the median survival was significantly shorter in patients who sustained surgical complications compared with those without complications (15 versus 22 months) . Including only those who survived 90 days or longer postoperatively (n = 567), the risk of mortality was significantly increased in patients who sustained postoperative complications (hazard ratio [HR] = 1.29, 95% CI 1.02-1.63). Most patients who die following an esophagectomy experience multiple serious complications (median 2.5, range 1 to 8) rather than a single event .
Risk factors — Based upon a multivariable logistic regression analysis of a prospective study that included 1777 patients undergoing an esophagectomy, several independent preoperative clinical factors have been identified that increase the risk of morbidity and mortality .