Introduction
Data about failure-to-rescue (FTR) after esophagectomy for cancer and its association with patient and procedure-related risk factors are sparse. Aim of the study was to analyze such aspects, particularly focusing on the impact of pneumonia and anastomotic leak on FTR.
Material & Methods
All patients who underwent a transthoracic esophagectomy for cancer between 2007 and 2022 in two high-volume European centers were prospectively identified. Patients were classified and compared according to the type of operation (open, hybrid-laparoscopic, hybrid-robotic, standard minimally invasive or robotic-minimally-invasive). Failure-to rescue was defined as in-hospital death following a complication. Risk factors for in-hospital mortality were analyzed and identified with a univariable model. Mortality after pneumonia and anastomotic leak were calculated and compared across the groups.
Results
In total, 708 patients were included. Median operative time was 268 minutes (IQR 239-305). There were 355 (50.1%) open, 204 (28.8%) hybrid-laparoscopic, 121 (17.1%) hybrid-robotic, 15 (2.1%) standard minimally-invasive and 11 (1.6%) robotic minimally-invasive procedures. Overall morbidity was 60%, in-hospital mortality 4.8% and failure-to-rescue rate 4.5%. Anastomotic leak, pneumonia, postoperative bleeding, sepsis, pulmonary embolism, arrhythmia and need for blood transfusion were the risk factors significantly associated with in-hospital mortality (p<0.05). There was no particular type of operation significantly more associated with mortality (p=0.42). Pneumonia and leak associated failure-to-rescue rates did not significantly differ among the groups (p=0.99).

Conclusion
Transthoracic esophagectomy for cancer still represents a complex operation with high morbidity and mortality, and challenging postoperative management. Despite their complexity, the use of hybrid, minimally-invasive or robotic methods do not seem to negatively affect the FTR rates, hence implementation of minimally-invasive procedures should be supported. However, effective perioperative care and not surgical approach itself seems to play a greater role with regard to short-term outcomes.

Markus Diener

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