American Surgical Association
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16. Intrathoracic Leaks Following Esophagectomy Are No Longer Associated With Increased Mortality
Linda W. Martin, MD, Stephen G. Swisher, MD*, Wayne Hofstetter, MD*, Arlene M. Correa, PhD*, David C. Rice, MD*, Ara A. Vaporciyan, MD*, Garrett L. Walsh, MD*, Jack A. Roth, MD
UT MD Anderson Cancer Center, Houston, TX

OBJECTIVE(S): An intrathoracic leak following esophagectomy has historically been considered a catastrophic event with a high mortality. We assessed outcomes following intrathoracic leaks from 1970 to 2004 to evaluate the impact of evolving surgical and perioperative techniques.
METHODS: A retrospective review of all esophagectomies for cancer from 1970 to 2004 (n=1223) was performed. Outcomes following intrathoracic anastomoses (n=621) were analyzed by era: Early 1970-1986 (n=145) and Modern 1987-2004 (n=476).
RESULTS: There was no difference in the frequency of leak between the time intervals (4.8% vs. 6.3%, p=0.5). Despite a significant increase in the use of preoperative chemoradiation (1% vs. 42%, p<0.0001) in the Early vs. Modern era, the overall mortality decreased from 11% to 2.5% (p<0.0001). The leak-associated mortality (LAM) was also markedly reduced from 44% to 3.3% (p=0.016). Factors associated with LAM included preoperative weight loss (HR 3.5, CI 1.5-8.2) and era in which the surgery was performed (HR 3.3, 1.3-7.9). Other differences included an increased proportion of successful reoperations for leak control (11/12 vs. 0/1, p=0.08) and use of reinforcing muscle flaps (7/11). In the Modern era, perioperative mortality is no different for patients with or without intrathoracic leaks (3.3% vs. 2.5%, p=0.5) and long-term survival is no different (p=0.10).
CONCLUSIONS: Modern surgical management of intrathoracic leaks result in no increased mortality and have no impact on long-term survival. Clinical decisions regarding the use of intrathoracic anastomoses should not be affected by concerns of increased mortality from leak.

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