OA05.2. Protocolized Rescue Transforms Esophagectomy Mortality—But Anastomotic Leak Remains an Oncologic Liability

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ID: 326102
2026
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Ranked #225 of 453 articles by views in diseases of the esophagus : official journal of the international society for diseases of the esophagus

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Abstract
Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – long term outcomes Background Reducing esophagectomy mortality from national benchmarks of ~3% toward zero requires more than technical excellence—it demands comprehensive rescue capabilities. This study identified the specific interventions, resource requirements, and systems infrastructure necessary to achieve near-zero mortality, demonstrating that aggressive management of catastrophic complications preserves long-term survival without causing treatment-related harm. Methods We reviewed 1,474 consecutive esophagectomies (2006–2023) from a prospectively maintained registry. High-risk complications were defined a priori by 90-day mortality risk ratios compared to patients without the complication (RR>2, p<0.05, N≥10). Rescue was defined as 90-day survival among patients with at least one major complication requiring escalation of care. Analyses included complication phenotype mapping, Kaplan-Meier survival with log-rank testing, and propensity-score matching to evaluate return-to-OR outcomes. Supervised models ranked drivers of complications and mortality. Cancer-specific mortality within two years was compared between patients with and without major complications, with focused analysis on anastomotic leak and its association with early cancer-related death. Results Overall 90-day mortality was 3.5% (52/1,474), declining to 1.1% in recent quartiles. Thirty-day in-hospital mortality was 1.3%, with only 4 deaths in the past 7 years. Thirty-two patients were directly salvaged through emergent escalation: 17 urgent returns to OR for hemorrhage, 4 ECMO for severe ARDS, 1 pulmonary artery thrombectomy, 2 emergent cardiac catheterizations, and 8 urgent reoperations for conduit complications with sepsis. Without these rescues, mortality would have approached 5.6% overall and 3.7% recently. Seven complications met high-risk criteria, led by ARDS (RR 13.33, 41.2% mortality). Among 200 patients with major complications, rescue succeeded in 95.0% at 30 days and 88.5% at 90 days. Propensity-matched return-to-OR analysis (34 pairs) increased length of stay by 11 days (p<0.001) without increasing 90-day failure or 1-year mortality. Patients with major complications and anastomotic leak faced 20% cancer-related mortality within two years despite successful operative rescue. Conclusion Protocolized rescue drives esophagectomy mortality from 3% toward 1% without excess procedural mortality. However, complications—particularly anastomotic leak—carry 20% cancer-related mortality within two years, even after successful salvage. The path to zero demands not only disciplined rescue infrastructure but relentless complication prevention to protect both operative and oncologic survival.
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Authors Feredun Azari, Daniel Cloonan, Andrew Conner, Subin Lee, Gregory Jones, Monisha Sudarshan, Daniel Raymond, Sudish Murthy, Siva Raja
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Journal diseases of the esophagus : official journal of the international society for diseases of the esophagus
Year 2026
DOI
10.1093/dote/doag077.036
URL
https://academic.oup.com/dote/article-pdf/39/Supplement_1/doag077.036/70760789/doag077.036.pdf
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