title: Intrathoracic leaks following esophagectomy are no longer associated with increased mortality.
abstract: OBJECTIVE
  Assess outcomes following intrathoracic leaks after esophagectomy from 1970 to 2004 to evaluate the impact of evolving surgical and perioperative techniques on leak-associated mortality (LAM).
  
  
  BACKGROUND
  An intrathoracic leak following esophagectomy has historically been considered a catastrophic event, with mortality as high as 71%. Concerns about this complication often affect choice of surgical approach for esophagectomy.
  
  
  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: historical 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% versus 6.3%, P = 0.5). Despite a significant increase in the use of preoperative chemoradiation (1% versus 42%, P < 0.001) in the historical versus modern era, the overall mortality decreased from 11% to 2.5% (P < 0.001). The LAM was markedly reduced from 43% to 3.3% (P = 0.016). Factors associated with LAM included failure to use enteral nutrition (HR 13.22, CI 1.8-96.8) and era in which the surgery was performed (HR 18.3, 1.9-180). Other differences included an increased proportion of successful reoperations for leak control (11/30 versus 0/7, P = 0.08) and use of reinforcing muscle flaps (7/11). In the modern era, perioperative mortality is not significantly different for patients with or without intrathoracic leaks (3.3% versus 2.5%, P = 0.55), nor is long-term survival (P = 0.16).
  
  
  CONCLUSIONS
  Modern surgical management of intrathoracic leaks results in no increased mortality and has 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.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, the University of Texas MD Anderson Cancer Center, Houston, TX 77230, USA.
authors.forename: Linda W
authors.initials: LW
authors.lastname: Martin
authors.forename: Stephen G
authors.initials: SG
authors.lastname: Swisher
authors.forename: Wayne
authors.initials: W
authors.lastname: Hofstetter
authors.forename: Arlene M
authors.initials: AM
authors.lastname: Correa
authors.forename: Reza J
authors.initials: RJ
authors.lastname: Mehran
authors.forename: David C
authors.initials: DC
authors.lastname: Rice
authors.forename: Ara A
authors.initials: AA
authors.lastname: Vaporciyan
authors.forename: Garrett L
authors.initials: GL
authors.lastname: Walsh
authors.forename: Jack A
authors.initials: JA
authors.lastname: Roth
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000401:mortality; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000009:adverse effects* / Q000401:mortality*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013529:Surgical Wound Dehiscence / Q000209:etiology / Q000401:mortality*; D016019:Survival Analysis; D016896:Treatment Outcome