title: Outcome, complications, and mortality of an intrathoracic anastomosis in esophageal cancer in patients without a preoperative selection with a risk score.
abstract: BACKGROUND
  Esophagectomy for esophageal cancer remains a challenge with relatively high morbidity. We analyzed outcome, complications, and mortality after abdominothoracic esophagectomy with intrathoracic anastomosis. No routine preoperative risk stratification was performed.
  
  
  METHODS
  One hundred eighty-seven consecutive patients (105 AEG I, 21 AEG II, 58 SCC, and 3 other entities) underwent standardized right abdominothoracic esophagectomy with intrathoracic anastomosis and two field lymphadenectomy between 2003 and 2009. Reconstruction was performed mostly with a gastric tube (n = 126) or a fundus rotation gastroplasty (n = 57). Seventy-four patients underwent neoadjuvant treatment (36 patients chemotherapy; 38 patients chemoradiotherapy).
  
  
  RESULTS
  Postoperative morbidity was high (73.2 %). Ninety-two patients (49.2 %) suffered from surgical complications, 50 patients had major (26.7 %), and 42 minor (22.5 %) complications. Thirty-day mortality was 9/187 (4.8 %) while in-hospital mortality was doubled with 9.6 %. Six of 19 of the patients died without surgical complications. Preoperative treatment did not increase morbidity or mortality. Surgical complications with subsequent death were tracheobronchial fistula (2/3), ischemia of the gastric tube (3/6), anastomotic leakage (6/30), chylothorax (1/6), and intraoperative bleeding from the aorta (1/1). The median overall survival was 25.0 months. The occurrence of surgical or medical complications did not influence overall survival. In multivariate analysis, cT-category, pN-category, R-category, and re-intubation were independent prognostic factors.
  
  
  CONCLUSIONS
  Abdominothoracic esophagectomy with intrathoracic anastomosis without preoperative patient selection is associated with a high risk for complications and subsequent death but ranges still within the upper range of published data. Strict patient selection is accepted to reduce postoperative morbidity and mortality but excludes a subgroup of patients from potentially curative resection.
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, INF 110, 69120, Heidelberg, Germany, ingo.alldinger@med.uni-heidelberg.de.
authors.forename: Ingo
authors.initials: I
authors.lastname: Alldinger
authors.forename: Leila
authors.initials: L
authors.lastname: Sisic
authors.forename: Marcel
authors.initials: M
authors.lastname: Hochreiter
authors.forename: Wilko
authors.initials: W
authors.lastname: Weichert
authors.forename: Susanne
authors.initials: S
authors.lastname: Blank
authors.forename: Maria
authors.initials: M
authors.lastname: Burian
authors.forename: Lars
authors.initials: L
authors.lastname: Grenacher
authors.forename: Tom
authors.initials: T
authors.lastname: Bruckner
authors.forename: Jens
authors.initials: J
authors.lastname: Werner
authors.forename: Markus W
authors.initials: MW
authors.lastname: Büchler
authors.forename: Katja
authors.initials: K
authors.lastname: Ott
mesh_terms: D000230:Adenocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D015897:Comorbidity; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D004943:Esophagogastric Junction; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008197:Lymph Node Excision / Q000379:methods*; D008207:Lymphatic Metastasis; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D018570:Risk Assessment