Anastomotic leak after esophagectomy for cancer in enhanced recovery protocol versus conventional care: clinical characteristics and outcomes.

BACKGROUND: Anastomotic leak (AL) is the most concerning complication after esophagectomy in the Enhanced Recovery After Surgery (ERAS) protocol. This retrospective cohort study aimed to compare the clinical characteristics and outcomes of postoperative AL in esophageal cancer patients under the ERAS protocol versus those receiving conventional care. Strategies to enhance the safety of the ERAS protocol were explored. METHODS: This retrospective study included patients with carcinoma of the esophagus or esophagogastric junction who underwent transthoracic esophagectomy with gastric conduit reconstruction and developed postoperative AL between January 2018 and August 2023.The "Non-Tube No Fasting" ERAS protocol was implemented in the ERAS group. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. RESULTS: Of the 483 patients in the ERAS group and 1,385 patients in the conventional group who underwent transthoracic esophagectomy with gastric conduit reconstruction, 33 and 140 patients, respectively, were included in the final analysis. After IPTW adjustment, among the nine early clinical manifestations of acute leukemia (AL), only tachyarrhythmia showed a significantly higher cumulative incidence in the ERAS group (P < 0.001). Both before and after IPTW adjustment, no significant differences were observed in time to diagnosis, endoscopic defect size, classification (classified as early or delayed), or severity between the two groups. Similarly, no significant differences were found in postoperative length of stay, hospital readmission rate, intensive care unit (ICU) readmission rate and corresponding ICU length of stay, defect healing rate, defect healing time, or leak-related mortality (all P > 0.05). CONCLUSIONS: The "Non-Tube No Fasting" ERAS protocol is not associated with worse clinical characteristics or outcomes of AL compared with conventional care. Further attention is warranted for patient selection strategies and improved identification of delayed AL. These findings are preliminary and should be confirmed in future studies.