Failure to rescue and predictors of severe morbidity after esophagectomy: a single-center experience from a high-volume Italian referral center.

BACKGROUND

Esophagectomy for cancer remains a high-risk procedure. Failure to rescue (FTR) - death following a major complication - is a key metric for surgical quality. This study evaluates FTR incidence and predictors of severe morbidity in a high-volume center with standardized clinical pathways.

METHODS

We analyzed a prospectively maintained database of patients undergoing curative- intent esophagectomy at a high-volume Italian referral center (2017-2024). Failure to Rescue (FTR) - defined as 90-day mortality after Clavien-Dindo ≥IIIa complications - was tracked as the primary benchmark outcome. To investigate the clinical drivers behind the FTR pathway, multivariable logistic regression was specifically utilized to identify independent predictors of its mandatory clinical substrate, namely severe postoperative morbidity.

RESULTS

Out of 102 included patients, 39 (38.2%) experienced major complications. The overall 90-day mortality was 2.9% (N.=3), resulting in an FTR rate of 7.7%. Pulmonary complications (45.1%) and anastomotic leakage (10.8%) were the most frequent adverse events. On multivariable analysis, preoperative malnutrition (MUST score >2; OR 2.82, 95% CI: 1.03-7.73, P=0.044) and high comorbidity burden (aCCI ≥5; OR 3.35, 95% CI: 1.17-9.60, P=0.025) were independent predictors of severe postoperative morbidity.

CONCLUSIONS

Our FTR rate of 7.7% aligns with international high-volume benchmarks. Preoperative nutritional status and comorbidity burden are critical for risk stratification. Enhancing outcomes requires a dual strategy: proactive prehabilitation for high-risk patients and a robust, multidisciplinary rescue system to manage unavoidable complications.