Incidence and treatment of anastomotic leakage after esophagectomy in German acute care hospitals: a retrospective cohort study

Background: Anastomotic leakage (AL) is a major concern following esophagectomy due to the associated morbidity and mortality. The impact of hospital volume on postoperative outcomes after esophagectomy has previously been reported. The aim of this study was to analyze the current trends in postoperative anastomotic leakage and associated failure-to-rescue after esophagectomy in relation to hospital volume in German acute care hospitals using real-world data from the German Diagnosis-Related Groups (G-DRG) database. Materials and methods: A retrospective secondary data analysis of the G-DRG database was performed for all in-hospital cases of patients undergoing esophagectomy from 2013 to 2021. AL and in-house mortality rates were assessed in relation to hospital case volume and endoscopic treatment modalities. Results: The study included 32 335 cases. The mean reported AL rate was 17.1% with a mean failure-to-rescue rate of 18.9%. AL rates did not differ between hospitals with an annual case-volume ≤ 25 procedures/year vs. >25 procedures/year (16.8% vs. 17.6%, OR 1.06, P = 0.07). However, in high-volume centers (> 25 procedures/year), in-hospital mortality for cases with AL (failure-to-rescue) was lower compared to medium-volume (10-25 cases/year) and low-volume (1-9 cases/year) centers (14.2% vs. 21.5% vs. 25.1%). The use of endoscopic vacuum therapy (EVT) increased over time, reaching 58.1% of AL cases in 2021 compared to 14.2% in 2013, while the use of self-expanding metal stents (SEMS) decreased from 37.0% in 2013 to 9.3% in 2021. Conclusions: AL rates after esophagectomy remain high. In-house mortality is significantly lower in high-volume hospitals highlighting the importance to consider improvements in centralization of procedures. Further efforts are needed to reduce AL rates and improve outcomes after esophagectomy.