BACKGROUND:Rectal cancer is one of the most common cancers in the Western world. The path toward personalized treatments in medicine includes further determination of sex-associated differences. OBJECTIVE:The objective of this study is to explore sex-related differences in the outcome of rectal surgery. SETTINGS:All patients in the German StuDoQ|Rectum Registry who underwent rectal cancer surgery between 2013 and 2023 were included. DESIGN:Propensity score matching was performed to account for comorbidities and factors influencing the surgery-associated outcome. Mediation analysis was performed to show the direct effect of sex on surgical and general complications. MAIN OUTCOME MEASURES:The main outcomes were morbidity and mortality. PATIENTS:The total cohort included 19,664 patients (36.9% women), of whom 15,011 patients were included in this retrospective study. After propensity score matching, 10,362 patients were analyzed. RESULTS:Compared with men, women had fewer surgical complications (eg, anastomotic leakage, 6.4% vs 12.0%, p < 0.001), lower rates of ileus (2.3% vs 5.7%, p < 0.001), and fewer general complications (eg, pneumonia (1.5% vs 3.6%, p < 0.001). In the propensity score-matched cohort (n = 10,362), female patients had significantly lower odds of experiencing any complication (Clavien-Dindo grade I-V vs 0) in a matched conditional logistic regression analysis (adjusted OR = 0.614; 95% CI, 0.566-0.666). Despite the strong influence of anastomotic leakage on morbidity, the protective effect of female sex was an independent factor for most complications in this cohort in mediation analysis. LIMITATIONS:Our study is limited by its retrospective design and the lack of some information, such as preoperative nicotine and alcohol consumption or the heterogenous definitions of some conditions, such as pelvic abscesses. CONCLUSIONS:In this retrospective multicenter registry study, female sex was associated with favorable outcomes after surgery for rectal cancer. See Video Abstract . COMPLICACIONES TRAS LA CIRUGA DEL CNCER RECTAL TIENEN LAS PACIENTES MEJORES RESULTADOS UN ANLISIS RETROSPECTIVO DE COHORTES EMPAREJADAS:ANTECEDENTES:El cáncer de recto es uno de los cánceres más comunes en el mundo occidental. El camino hacia los tratamientos personalizados en medicina incluye una mayor determinación de las diferencias asociadas al sexo.OBJETIVO:El objetivo del estudio es explorar las diferencias relacionadas con el sexo en los resultados de la cirugía rectal.ÁMBITO:Se incluyó a todos los pacientes del Registro alemán StuDoQ|Rectum que se sometieron a cirugía rectal por cáncer de recto entre 2013 y 2023.DISEÑO:Se realizó un emparejamiento por puntuación de propensión para tener en cuenta las comorbilidades y los factores que influyen en el resultado asociado a la cirugía. Se llevó a cabo un análisis de mediación para mostrar el efecto directo del sexo sobre las complicaciones quirúrgicas y generales.PRINCIPALES MEDIDAS DE RESULTADO:Los principales resultados son la morbilidad y la mortalidad.PACIENTES:La cohorte total incluyó a 19.664 pacientes (36,9% mujeres), y en este estudio retrospectivo se incluyó a 15.011 pacientes. Tras el emparejamiento por puntuación de propensión, se analizaron 10.362 pacientes.RESULTADOS:Las mujeres presentaron menos complicaciones quirúrgicas (p. ej., fuga anastomótica: 6,4% frente a 12,0%; p < 0,001; íleo: 2,3% frente a 5,7%; p < 0,001) y menos complicaciones generales (p. ej., neumonía: 1,5% frente a 3,6%; p < 0,001). En la cohorte emparejada por puntuación de propensión (n = 10.362), las mujeres tuvieron una probabilidad significativamente menor de experimentar cualquier complicación (Clavien-Dindo I-V frente a 0) en el análisis de regresión logística condicional emparejada (odds ratio ajustado = 0,614; IC del 95%: 0,566-0,666). A pesar de la fuerte influencia de la fuga anastomótica (AL) en la morbilidad, el efecto positivo del sexo femenino constituyó un factor independiente para la mayoría de las complicaciones en esta cohorte, según el análisis de mediación.LIMITACIONES:Nuestro estudio se ve limitado por su diseño retrospectivo y por la falta de cierta información, como el consumo preoperatorio de nicotina y alcohol, o la definición heterogénea de ciertas condiciones (p. ej., los abscesos pélvicos).CONCLUSIONES:En este estudio de registro multicéntrico y retrospectivo, el sexo femenino se asoció con resultados favorables tras la cirugía por cáncer de recto. (AI-generated translation ).

Objectives: Robotic assisted minimally invasive esophagectomy (RAMIE) has demonstrated advantages over open esophagectomy, including reduced morbidity and comparable oncological outcomes. However, predicting which patients achieve a "perfect outcome" remains unclear. This study evaluates postoperative outcomes in RAMIE patients and identifies parameters associated with an uncomplicated recovery in a German high-volume center. Methods: We conducted a retrospective analysis of 249 RAMIE cases performed between April 2017 and January 2023. Patients were divided into two groups: Clavien-Dindo grade 0(n=87) and Clavien-Dindo>0(n=162). Preoperative demographics, intraoperative metrics, and postoperative outcomes were compared. Key postoperative metrics included ICU/hospital stay duration, removal of catheters, initiation of oral feeding, and C-reactive protein (CRP) levels on postoperative days (POD) 3, 5, and 7. Results: No significant differences were found in preoperative factors. Intraoperative parameters, including operative time and single-lung ventilation duration, were similar between groups. CRP levels were significantly lower in complication-free patients on POD3 (105.7 vs. 132.6 mg/L; p=0.0009), POD5 (66.0 vs.130.0 mg/L; p<0.0001), and POD7 (44.1 vs. 111.4 mg/L; p<0.0001). Patients with a perfect outcome had earlier removal of peridural catheters (POD6 vs.POD8; p=0.0021), chest drains (POD6 vs. POD7; p=0.0009), and initiation of oral feeding (POD6 vs. POD9; p<0.0001). Importantly, 66 % of complications occurred before POD6. Conclusions: A perfect outcome following RAMIE is associated with earlier catheter removal, and oral feeding initiation by POD6, alongside CRP levels below 70 mg/L. The sixth postoperative day appears pivotal for predicting outcomes, as complications predominantly manifest before this timeframe. These findings highlight the importance of targeted postoperative management to identify low-risk patients suitable for early discharge, improving recovery and resource utilization.

Oligometastasis describes an intermediate stage between localized and systemic tumor disease, in which a limited number of metastases with restricted organ involvement still appear amenable to local treatment. Despite its growing relevance and numerous publications, a unified definition for gastrointestinal (GI) tumors is lacking. The aim of this work was to summarize the existing definitions and current therapeutic standards for oligometastasis in the GI tract. Based on current studies and guidelines it becomes evident that local treatment is currently being investigated for gastric, esophageal, colorectal, pancreatic, hepatocellular and cholangiocellular carcinomas. Initial data suggest a possible improvement in survival through combined systemic and local treatment approaches. The results of most prospective studies are still pending. In the future, molecular markers and biological tumor characteristics are expected to contribute to better patient selection and further improve the integration of local treatment.

Die Oligometastasierung beschreibt ein intermediäres Stadium zwischen lokalisierter und systemischer Tumorerkrankung, in dem eine begrenzte Anzahl von Metastasen mit limitierten Organmanifestationen noch lokal behandelbar erscheint. Trotz zunehmender Relevanz und zahlreicher Publikationen fehlt für gastrointestinale (GI) Tumoren eine einheitliche Definition. Ziel dieser Arbeit war es, die bestehenden Definitionen und aktuellen Therapiestandards der Oligometastasierung im GI-Trakt zusammenzufassen. Basierend auf einer Analyse aktueller Studien und Leitlinien zeigt sich, dass lokale Therapien aktuell beim Magen‑, Ösophagus‑, Kolon‑, Pankreas-, hepatozellulären und cholangiozellulären Karzinom untersucht werden. Erste Daten deuten auf eine mögliche Verlängerung des Überlebens durch kombinierte systemisch-lokale Ansätze hin. Die Daten der meisten prospektiven Studien stehen hierbei noch aus. Zukünftig sollen molekulare Marker und biologische Tumorcharakteristika zur besseren Patientenselektion beitragen und die Integration lokaler Therapien weiter präzisieren.

Abstract Spatial-omics workflows enable molecular analysis within tissue spatial context. Despite the prognostic value of tissue stiffness, these approaches have not incorporated direct, absolute mechanical measurements. This omission reflects several challenges, including sample requirements, low throughput, specialized equipment, and complex data registration. Here, we introduce MechanoMaST (mechanics mapped to spatial transcriptomics), the first workflow to combine absolute mechanical measurements with spatial-omics. It pairs atomic force microscopy-based nanoindentation stiffness maps with spatial transcriptomics maps from adjacent tissue cryosections. The two modalities are computationally co-registered to enable direct spatial correlation at 100 µm resolution, with mapping accuracy quantified through error propagation, providing ground-truth mechanical data directly linked to spatial gene expression. We demonstrate MechanoMaST in human colorectal cancer liver metastasis, generating a spatial resource from 10 patients and revealing a four-gene stiffness signature. MechanoMaST is readily adaptable to other tissues across development and disease, and extendable to additional spatial-omics modalities in adjacent sections.

Background: Achieving negative resection margins (R0) is considered essential for curative surgery in pancreatic ductal adenocarcinoma (PDAC). However, in the setting of complex multivisceral pancreatic resections, the prognostic relevance of margin status and its association with perioperative morbidity and long-term survival remain uncertain. We aimed to evaluate the association between resection margin status (R0 vs R1) and short-term and long-term outcomes in patients undergoing multivisceral pancreatic resections for PDAC. Methods: In this retrospective, international, multicentre cohort study, we analysed data from the largest global database of multivisceral pancreatic resections. Patients were recruited from multiple high-volume centres across several countries. Eligible participants were adults undergoing multivisceral pancreatic resection for histologically confirmed PDAC. Patients with incomplete key covariate data were excluded from propensity score matching (PSM). Clinical and pathological data were retrieved from institutional medical records and prospectively maintained databases.Propensity score matching (1:1) was performed using age, sex, body mass index, Charlson Comorbidity Index, ASA score, ECOG performance status, tumour stage, type of resection, and number of resected organs. The primary outcome was overall survival (OS). Secondary outcomes included 90-day mortality, perioperative morbidity (Clavien–Dindo classification), postoperative pancreatic fistula, delayed gastric emptying, reoperation, intraoperative complications, and ICU length of stay. Findings: After matching, 186 patients were analysed (93 R0; 93 R1). Ninety-day mortality was identical in both groups (6·5%). Rates of major morbidity, postoperative pancreatic fistula, delayed gastric emptying, reoperation, blood loss, operative time, and ICU stay were comparable between groups. Median OS was 23·6 months (95% CI 18·7–39·3) in the R0 group and 14·5 months (9·0–22·8) in the R1 group. After adjustment for residual imbalances, R1 resection was independently associated with poorer survival (HR 1·57, 95% CI 1·05–2·35; p=0·027). Interpretation: R0 resection in multivisceral pancreatic surgery is independently associated with improved long-term survival without increased perioperative morbidity or mortality. Margin-negative resection should remain the surgical goal in specialised high-expertise centres.

Gastrointestinal cancers account for a substantial share of global cancer burden. We assessed the significance of MTAP loss across 1545 resected tumors (cholangiocarcinoma, esophageal and gastric adenocarcinoma, pancreatic ductal adenocarcinoma). MTAP protein was evaluated by immunohistochemistry compared with CDKN2A status by fluorescence in situ hybridization and with overall survival. Immunohistochemical MTAP loss consistently co-occurred with homozygous CDKN2A deletion and was present in 25.5% of cholangiocarcinomas, 9.3% of esophageal adenocarcinomas, 10.3% of gastric carcinomas, and 30.2% of pancreatic adenocarcinomas. In gastric carcinomas, MTAP loss was associated with worse survival (p = 0.024), particularly in those who underwent primary surgery (p = 0.008). MTAP loss proved to be an independent factor for worse overall survival in patients with gastric adenocarcinoma. 10% of esophageal adenocarcinomas showed intratumoral heterogeneity, but we did not see intertumoral heterogeneity between the primary tumor and corresponding lymph node metastases. These data indicate that a considerable subset of gastrointestinal cancers exhibits MTAP loss, highlight prognostic relevance in gastric carcinoma, and delineate a potentially actionable subgroup for PRMT5 inhibitor therapy.

While many ergonomic challenges traditionally faced in open and laparoscopic surgery have been overcome by robotic surgery, new challenges have been created. This study aims to identify and compare the ergonomic characteristics of a variety of robotic systems to ultimately lay the foundation for ergonomic guidelines. Measurements evaluating the surgeon and their interaction with the new technology were applied in either a laboratory or a real-life setting. A video camera was used to capture the surgeon at the console during surgery. For evaluation of the images, axes were placed along the joints of the surgeon. Corresponding angles were calculated based on the position of the individual axes in relation to each other and compared to recommendations for a healthy workspace. A total of 13 surgeries were measured during actual cases using the DaVinci with a total of n = 20,250 pictures used for analysis; 2 surgeries were measured using the Dexter, with a total of 1,994 pictures used for analysis; 17 measurements were taken with the Hugo™ RAS System in a simulation setting, with a total of 1,179 pictures used for analysis. In addition, a total of 327 pictures from a simulation setting were used for analysis of the Hinotori. Corresponding angles for knee, elbow, and back were within recommendations for all systems; hip angles were not within recommendations for any system, and the neck posture was only within recommendations for the Hinotori. A variety of different robotic systems differ in ergonomic requirements. The neck can be identified as an area of need for improvement for most systems. Future studies, particularly in a randomized controlled fashion, need to be performed to further analyze ergonomic features of the different systems, and guidelines displaying the variety of systems need to be implemented to create a healthy and safe workplace.

Die chirurgischen Optionen und insbesondere die perioperativen Therapien haben sich bei gastroösophagealen Karzinomen erheblich weiterentwickelt. Durch kurative multimodale Therapiekonzepte bei lokal fortgeschrittenen Karzinomen kann mittlerweile eine 5‑Jahres-Überlebensrate von nahezu 50

Minimally invasive surgery is currently undergoing a paradigm shift from the classical laparoscopic approach to robot-assisted minimally invasive surgery. Robotic surgery has made significant progress in various surgical disciplines in recent years and is increasingly being used. This is due to the increasing clinical availability of robotic systems as well as better visualization, an increased surgical precision and a higher degree of freedom of the robotic instruments used, compared to classical laparoscopy, resulting in a flatter learning curve and better ergonomics for the surgeon. This article examines the current status of robot-assisted liver surgery, highlights the technical and clinical challenges and discusses future perspectives and potential developments in this dynamic field.

Supplementary Figure from eQTL Set–Based Association Analysis Identifies Novel Susceptibility Loci for Barrett Esophagus and Esophageal Adenocarcinoma

BACKGROUND:Liver hydatid cysts (LHC) liver requires effective surgical treatment. Open closed total pericystectomy removes the entire echinococcus cyst while preserving healthy liver tissue. AIM:To evaluate the outcomes of pericystectomy and its efficacy as a treatment modality for cystic echinococcosis (CE). METHODS:Thirty-eight patients were analyzed after open total pericystectomy at the University Hospital of Cologne between January 2006 and January 2024. Demographic, clinical, and laboratory parameters were collected retrospectively. Intraoperative data and postoperative complications were documented and classified using the Clavien-Dindo classification. Throughout the follow-up period, patients underwent regular clinical, serological, and sonographic evaluations both at the outpatient department and by their general physicians. RESULTS:Fifty-four cysts were treated with open total pericystectomy. Multiple cysts were found in 42.2% of cases. Singular cysts occurred in 57.8%. The right hepatic lobe was affected in 66.7%. Ectopic cysts occurred in 4 patients in the lung (n = 3) and spleen (n = 1). Median cyst size was 6.78 cm × 5.92 cm (range: 1.4-20.0 cm). The median surgical time of pericystectomy was 189 minutes (range: 78-455 minutes) with a median blood loss of 400 mL (range: 100-1400 mL). The complication rate (Clavien-Dindo > III) was 21.1%. The average hospital stay was 12.5 days. No recurrent disease could be detected after a median follow-up time of 97 months (range: 4-216 months). No recurrent cyst manifestation, postoperative liver failure or death was observed. CONCLUSION:The presented surgical procedure known as open total pericystectomy is a safe surgical technique in treatment of cystic echinococcosis.

Robotic-assisted minimally invasive esophagectomy (RAMIE) has become an increasingly adopted approach for the treatment of esophageal cancer. However, the impact of intraoperative fluid therapy on postoperative outcomes remains poorly defined. Whereas fluid overload has been linked to pulmonary and anastomotic complications, restrictive strategies may impair tissue perfusion and organ function. This study investigates the association between intraoperative fluid balance and postoperative morbidity in patients undergoing RAMIE. We conducted a retrospective single-center cohort study including 254 consecutive patients who underwent elective RAMIE between 2019 and 2024. Intraoperative fluid balance was calculated in mL/kg/h and analyzed as a continuous variable. Primary endpoints included pulmonary complications, anastomotic leakage, postoperative atrial fibrillation (POAF), and acute kidney injury (AKI). Secondary endpoints comprised ICU length of stay (LOS), postoperative delirium, delayed gastric emptying (DGE), and complication severity according to the Clavien-Dindo classification. Multivariable regression models were adjusted for age, sex, BMI, and ASA status. Pulmonary complications (23.2

Die Behandlung von onkologischen Patienten mit soliden Tumoren ist ein Schwerpunkt der modernen Chirurgie. Multimodale Konzepte eröffnen neue Behandlungsoptionen von Patienten mit fortgeschrittenen Tumorerkrankungen. Hierbei stellen Patienten mit einer limitierten Metastasierung bzw. Oligometastasierung eine Gruppe dar, die trotz formal systemischer Erkrankung zunehmend auch aggressiv chirurgisch im Sinne synchroner und metachroner Metastasenresektionen therapiert werden können. Im vorliegenden Übersichtsartikel wird der aktuelle Kenntnisstand zur chirurgischen Therapie bei Patienten mit Oligometastasierung im Gastrointestinaltrakt dargelegt. Die Begriffsdefinition der Oligometastasierung, ausgehend von den Ursprungsorganen, wird betrachtet, und Indikationen chirurgischer Therapie werden erläutert. Zugrunde liegend sind aktuelle Leitlinien sowie wissenschaftliche Arbeiten zur chirurgischen Therapie der Oligometastasierung. Relevante chirurgische Techniken werden als Überblick zusammengefasst. Aktuell besteht keine einheitliche Definition der Oligometastasierung, die eine Indikation für die chirurgische Therapie unabhängig vom Primärtumor rechtfertigt. Oligometastasierung wird sowohl definiert als insgesamt geringe Metastasenlast, auch in mehr als einem Organ, oder als eine limitierte Metastasierung in einem Organ. Beim kolorektalen Karzinom liegen bislang die besten Daten hinsichtlich einer aggressiven Metastasenchirurgie vor. Beim Ösophagus- und Magenkarzinom liegen vielversprechende retrospektive Daten vor. Die RENNAISANCE-Studie für das Magenkarzinom konnte diese Daten prospektiv nicht reproduzieren. Für das Pankreaskarzinom laufen aktuell Studien. Die chirurgische Behandlung oligometastasierter Patienten ist eine Herausforderung. Vielversprechende retrospektive Daten bilden die Grundlage für prospektive Studien. Die Tumorbiologie sowie der „test of time“ im Rahmen der multimodalen Behandlung sollten für die Indikationsstellungen insbesondere beachtet werden.

Summary Early delayed gastric conduit emptying (DGCE) is a frequent complication after Ivor-Lewis esophagectomy (ILE). Despite its relevance, few studies are published using the international consensus criteria. Therefore, we aimed to assess predictors and clinical consequences of DGCE in patients after ILE. This analysis represents a retrospective, single-center cohort study of patients who underwent ILE (2016–2021). DGCE was assessed by the international consensus criteria. Univariable and a multivariable penalized LASSO logistic regression model was applied to identify predictors of DGCE, whereas postoperative outcomes were assessed by group comparisons. The incidence of early DGCE was 15.6% (46/294 included patients). Of all tested preoperatively known and treatment related factors, only minimally invasive surgery was associated with lower odds for the occurrence of DGCE (OR 0.33, 95%CI:0.12–0.77, P = 0.017) when compared to open surgery. When DGCE occurred, the impact on major postoperative morbidity was limited (DGCE 39.1% vs. non-DGCE 33.1%, P = 0.425), especially there were no differences in starting adjuvant treatment (DGCE 50% vs. non-DGCE 46%; P = 0.615) or overall survival (Log-Rank P = 0.995). The results of this study suggest that the impact of DGCE might have been overestimated in the past. The only factor found to be significantly associated with decreased DGCE was minimally invasive surgery. Therefore, individual patient selection for preventive interventions is difficult and routine preventive interventions only seem justified when they can be performed with low adverse outcomes and at low cost. Higher evidence from randomized controlled trials is needed to assess the optimal strategy to prevent and treat DGCE.

4172 Background: Aim of the prospective single arm HOLIPANC trial (NCT04617457) is to evaluate the efficacy and safety of multimodal treatment in pancreatic oligometastatic disease. Methods: Patients with hepatic oligometastatic pancreatic cancer receive up to 8 cycles of a combination of liposomal irinotecan (nal-IRI, 50mg/m 2 ) with 5-fluouracil (5-FU 2400mg/m 2 )/folinic acid (FA, 400mg/m 2 ) and oxaliplatin (OX, 60mg/m 2 ) (Nal-IRIFOX) as neoadjuvant therapy followed by curative intended surgical resection of the primary tumor and liver metastases. Here, we present the first preplanned safety analysis with patients (pts) that were enrolled between 10/2021 and 04/2024. Results: A total of 56 pts were included in the analysis, of which 43 (77%) pts received at least 4 cycles and 16 (29%) pts 8 cycles of chemotherapy. Dose reductions of nal-IRI were required in 24 (43%) pts. Treatment-emergent adverse events (TEAE) were observed in 52 (93%) pts, 40 (72%) TEAEs were related to the neoadjuvant chemotherapy. Grade 3-4 TEAEs occurred in 30 (54%) pts, most common were gastrointestinal disorders, i.e. diarrhoea (n = 5), vomiting (n = 4) and nausea (n = 4). Hepatobiliary disorders (cholangitis (n = 5), cholestasis (n = 4)) and increased gamma-glutamyltransferase (n = 4) were also frequent but generally not considered in relation to the chemotherapy. Grade 3 anemia and leukopenia were observed in 3 (5%) and 2 (4%) pts respectively. Serious TEAEs occurred in 23 patients (41%). Next to the above mentioned gastrointestinal and hepatobiliary disorders, dehydration (n = 3) and infections (n = 2) were the remaining recurring events. At the time of analysis, resection was performed in 20 pts (36%). Overall postoperative complications occurred in 7 pts (35%), n = 2 (10%) were classified as Dindo-Clavien grade ≥ 3. Clinically relevant pancreatic fistula was shown in 1 patient (5%). While there were no deaths related to chemotherapy or surgery, 2 pts died because of tumor progression during follow-up within 28 days of chemotherapy administration or surgery. Conclusions: This analysis shows for the first time safety data from a prospective clinical trial of multimodal treatment in oligometastatic pancreatic cancer. As we show, the concept of neoadjuvant chemotherapy followed by surgery is safe, the toxicity and overall morbidity is not elevated compared to available data from the NAPOLI-3 trial, even in combination with a following tumor resection after neoadjuvant treatment. Clinical trial information: NCT04617457 .

In-hospital mortality following esophagectomy for cancer has markedly decreased over the last few decades, with reported death rates below 5% considered a benchmark for quality of care. Although large registry studies have focused on reaching this benchmark, little is known about the underlying cause of death and the possibility of preventing a lethal outcome. The aim of this multicenter study was to perform an in-depth analysis of in-hospital mortality following esophagectomy for cancer. Data were obtained from four European esophageal cancer centers analyzing their prospective databases between January 2010 and June 2020. All patients with an in-hospital lethal postoperative course (Clavien-Dindo V) following elective transthoracic esophagectomy were included. Data collection comprised baseline characteristics, preoperative comorbidities, surgical procedures, postoperative complications, and their management. In each participating center, cases were retrospectively assessed for (1) the selection of patients for esophagectomy based on their individual comorbidities, (2) intraoperative, and (3) postoperative complications and their management to finally classify the management of each section as adequate, non-adequate, or undetermined. One hundred and twenty-one out of 3899 patients died following esophagectomy, amounting to an in-hospital mortality rate of 3.1%. Patients deceased on a median of 32 days after surgery (IQR: 18-60). Following surgery, a total of 294 major complications were identified in the 121 patients (mean 2.4 ± 1.2) with anastomotic leakage (AL) reported most often in 65 patients (53.7%). AL was considered as leading cause of death in 44 patients (36.4%) followed by acute respiratory distress syndrome (ARDS) in 15 patients (12.4%). Assessment of preoperative patient selection revealed a non-adequate workup in only two patients (1.4%). During surgery, six patients (4.6%) suffered complications, which were deemed adequately treated in retrospective assessment. In eight patients (6.6%), postoperative management was deemed non-adequate; in seven of eight cases, recognition and initiation of treatment for AL were considered delayed. Despite technical advances, AL remains the leading cause of death following esophagectomy, contributing to a significantly prolonged clinical course and lethal outcome. In contrast to other published series, assessment of this homogenous patient cohort in expert centers revealed only a low rate of preventable mortality with respect to the preoperative patient selection and postoperative complication management. However, modification of AL management might be considered to reduce the overall death rate.