Interpreting esophagectomy outcomes at the intersection of risk profile and operative approach

For patients with resectable esophageal cancer, esophagectomy is the gold standard of treatment and offers a superior chance of cure (1). However, esophageal surgery is associated with an increased risk for postoperative complications, including pneumonia, anastomotic leakage, and surgical site infections (2,3). Among patients who underwent esophagectomy, pneumonia is the most common cause for postoperative morbidity, with a varying incidence ranging from 15–30% (4). Several risk factors for the occurrence of postoperative complications after esophagectomy are known, including smoking, obesity, or a high American Society of Anesthesiology score (3).

Unfortunately, smoking is widespread among esophageal cancer patients. Approximately 50% of patients with esophageal carcinoma have a history of smoking (5). Smoking is a well-defined factor for worse postoperative outcomes after cancer-related surgery. Even after esophagectomy, smoking is known to be associated with an increased risk for postoperative complications (6).

Over decades, open esophagectomy was the surgical technique of choice for either Ivor-Lewis or McKeown esophagectomy. In the last twenty years, minimally invasive esophagectomy has become more and more widespread and is associated with comparable oncological outcomes compared to open esophagectomy. In particular, robot-assisted minimally invasive esophagectomy (RAMIE) is nowadays the standard approach in many expert centers. RAMIE is associated with reduced postoperative complications compared to minimally invasive and open esophagectomy (7).

The manuscript by Gilbert and co-workers entitled “Minimally invasive versus open esophagectomy: Comparing the combined effects of smoking burden and operative approach on outcomes in esophagectomy” deals with the impact of patients’ history of smoking on postoperative outcome among patients who received either open or minimally invasive esophagectomy (8). The authors analyzed over 26,000 patients from the Society of Thoracic Surgeons General Thoracic Surgery Database. Gilbert and colleagues evaluated the combined effects of smoking status and surgical approach on perioperative outcomes (Table 1). Patients were stratified into never (25.4%), former (60.3%), and current smokers (14.3%) and further divided according to operative technique (open vs minimally invasive esophagectomy). Overall postoperative morbidity occurred in 28.0% of patients, respiratory complications in 13.8%, and operative mortality in 3.5%, with a striking 20% mortality among patients who developed respiratory complications. Current smokers demonstrated the highest risk, with respiratory complication rates of 18.5% compared with 14.0% in former smokers and 10.5% in never-smokers. After multivariable risk adjustment, current smokers undergoing open esophagectomy had a twofold increased risk of respiratory complications compared with never-smokers undergoing open surgery [adjusted odds ratio (aOR) 2.01, 95% confidence interval (CI): 1.73–2.33], a finding that persisted for current smokers undergoing minimally invasive esophagectomy (aOR 1.68, 95% CI: 1.41–2.01). Minimally invasive esophagectomy was associated with modestly lower rates of respiratory complications and major morbidity compared with open surgery within identical smoking strata; however, these differences were largely not statistically significant. Importantly, a significant reduction in operative mortality was observed exclusively in never-smokers undergoing minimally invasive esophagectomy (aOR 0.60, 95% CI: 0.43–0.84), whereas minimally invasive techniques did not offset the increased morbidity and mortality risk associated with former or current smoking. These findings highlight that a history of smoking is a significant and independent predictor of postoperative outcomes, outweighing any potential benefits associated with the surgical approach.

The results of this study provide two major conclusions. First, as expected, smoking is detrimental to health. Smokers, in particular, may benefit from minimally invasive esophagectomy, which is associated with fewer complications compared to open surgery. However, it is important to note that this difference did not reach statistical significance. Second, smoking cessation should be strongly encouraged and considered essential for patients with esophageal cancer who are candidates for esophagectomy. The data provided by Gilbert and co-workers are in line with the results presented in a meta-analysis this year (6). Here, cessation of smoking at least four weeks before surgery among cancer patients was associated with improved outcome and fewer complications (6). Similar data showing less complications after esophagectomy depending on smoking habits have been published before (9,10). The work of Gilbert and co-workers underlines superiority of minimally invasive esophagectomy. Although without statistical significance, respiratory complications were lower in patients who underwent minimally-invasive surgery. Equivalent data were obtained in a Japanese study demonstrating that smoking cessation at least 31 days before minimally invasive esophagectomy reduces postoperative complications (11).

Enhanced recovery after surgery (ERAS) programs represent a cornerstone of contemporary perioperative care in esophagectomy, aiming to attenuate surgical stress, preserve physiological function, and accelerate postoperative recovery through a multimodal, evidence-based approach. Core ERAS elements, including preoperative patient education, smoking cessation, nutritional optimization, standardized anesthesia and analgesia, early mobilization, and early enteral feeding, have been consistently associated with reductions in postoperative complications, particularly pulmonary morbidity, as well as shorter length of hospital stay without compromising oncological outcomes. International ERAS Society guidelines specifically tailored to esophagectomy emphasize the importance of protocolized perioperative pathways and multidisciplinary teamwork to improve both short-term recovery and overall quality of care. Importantly, ERAS implementation appears especially relevant for high-risk populations, such as smokers and frail patients, in whom optimized perioperative management may mitigate procedure-related morbidity and enhance functional recovery (12-14).

The present manuscript does not provide data on differences among patients who underwent robot-assisted or standard laparoscopic-thoracoscopic minimally invasive esophagectomy. Given that respiratory complications after robot-assisted esophagectomy are less compared to the laparoscopic-thoracoscopic approach, a further benefit for patients, including smokers, former smokers and non-smokers, is possible. Based on the current literature, this observation is rather speculative. Moreover, institutional and team-level practices, including whether smoking cessation is mandated, and the extent of structured preoperative optimization or prehabilitation, could not be assessed and may represent relevant confounders. Therefore, more data focused on this issue should be generated for evidence-based decision-making.

From a clinical perspective, these data further support the implementation of structured, mandatory preoperative smoking cessation programs as part of standardized pathways for esophagectomy. Smoking cessation should not be viewed as an optional recommendation, but rather as an integral component of perioperative risk reduction, comparable to cardiopulmonary assessment or nutritional optimization. Importantly, smoking cessation rarely occurs in isolation. Centers mandating smoking cessation are also more likely to implement comprehensive prehabilitation strategies, including respiratory training, nutritional optimization, and structured ERAS protocols (14). Prospective, multicenter studies focusing on standardized perioperative pathways are needed to clarify whether the potential advantages of robotic esophagectomy can be amplified in high-risk populations such as current and former smokers. All efforts needed to achieve the best possible outcome after that type of surgery should be made by both patients and health care professionals. Patients have to be encouraged and supported by the attempt to quit smoking as early as possible if surgery is planned.

Ultimately, optimizing outcomes after esophagectomy requires not only technical refinement in the operating room but also institutional commitment to comprehensive perioperative optimization long before the first incision is made.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-76/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-2025-1-76/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Porschen R, Fischbach W, Gockel I, et al. S3-Leitlinie – Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. Z Gastroenterol 2019;57:336-418. [Crossref] [PubMed]
2. Low DE, Alderson D, Cecconello I, et al. International Consensus on Standardization of Data Collection for Complications Associated With Esophagectomy: Esophagectomy Complications Consensus Group (ECCG). Ann Surg 2015;262:286-94. [Crossref] [PubMed]
3. Markar S, Gronnier C, Duhamel A, et al. Pattern of Postoperative Mortality After Esophageal Cancer Resection According to Center Volume: Results from a Large European Multicenter Study. Ann Surg Oncol 2015;22:2615-23. [Crossref] [PubMed]
4. Berry MF, Atkins BZ, Tong BC, et al. A comprehensive evaluation for aspiration after esophagectomy reduces the incidence of postoperative pneumonia. J Thorac Cardiovasc Surg 2010;140:1266-71. [Crossref] [PubMed]
5. Ledda AL, Tarantino I, Schiefer S, et al. Patterns of infectious complications and their implication on health system costs after esophagectomy for esophageal cancer: Real-world data from three European centers. Langenbecks Arch Surg 2025;410:138. [Crossref] [PubMed]
6. Wong C, Mohamad Asfia SKB, Myles PS, et al. Smoking and Complications After Cancer Surgery: A Systematic Review and Meta-Analysis. JAMA Netw Open 2025;8:e250295. [Crossref] [PubMed]
7. Rebelo A, Wadewitz E, Sunami Y, et al. Approaches for esophagectomy for esophageal cancer: a Network Meta-Analysis. Eur J Surg Oncol 2025;51:110529. [Crossref] [PubMed]
8. Gilbert A, Xie R, Bonnell LN, et al. Minimally invasive versus open esophagectomy: Comparing the combined effects of smoking burden and operative approach on outcomes in esophagectomy. J Thorac Cardiovasc Surg 2025;169:777-86.e9.
9. Liu L, Huang C, Liao W, et al. Smoking behavior and smoking index as prognostic indicators for patients with esophageal squamous cell carcinoma who underwent surgery: A large cohort study in Guangzhou, China. Tob Induc Dis 2020;18:9. [Crossref] [PubMed]
10. Yoshida N, Eto K, Horinouchi T, et al. Preoperative Smoking Cessation and Prognosis After Curative Esophagectomy for Esophageal Cancer: A Cross-Sectional Study. Ann Surg Oncol 2022;29:8172-80. [Crossref] [PubMed]
11. Yoshida N, Nakamura K, Kuroda D, et al. Preoperative Smoking Cessation is Integral to the Prevention of Postoperative Morbidities in Minimally Invasive Esophagectomy. World J Surg 2018;42:2902-9. [Crossref] [PubMed]
12. Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg 2017;152:292-8. [Crossref] [PubMed]
13. Low DE, Allum W, De Manzoni G, et al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS(®)) Society Recommendations. World J Surg 2019;43:299-330. [Crossref] [PubMed]
14. Rubinkiewicz M, Witowski J, Su M, et al. Enhanced recovery after surgery (ERAS) programs for esophagectomy. J Thorac Dis 2019;11:S685-91. [Crossref] [PubMed]