The impact of postoperative atrial fibrillation on complications and mortality following Ivor Lewis esophagectomy for esophageal cancer

Abstract

Postoperative atrial fibrillation (POAF) is a common complication following transthoracic esophagectomy, with an incidence rate between 12% and 37%. POAF has been associated with adverse outcomes, including pulmonary complications, anastomotic leakage, prolonged ICU stays and increased in-hospital mortality. This study investigates the impact of POAF on postoperative outcomes in a high-volume center and evaluates its role as a predictor of postoperative complications following Ivor-Lewis esophagectomy.This retrospective, single-center cohort study was conducted at the University Hospital of Cologne, Germany. Patients, who underwent elective Ivor-Lewis esophagectomy for cancer, were included (n = 617). Perioperative data were extracted retrospectively from a prospectively maintained database, capturing demographic, surgical, and postoperative variables. POAF was defined as a hemodynamically significant tachyarrhythmia absoluta that occurs within the first 7 days postoperatively and has been confirmed via ECG. Statistical analyses included univariate and multivariate logistic regression to identify associations between POAF and postoperative outcomes.POAF occurred in a significant proportion of patients (n = 79, 12,8%) and was strongly associated with adverse outcomes. Patients with POAF demonstrated higher rates of pulmonary complications (24.0% vs. 11.2%, *p < .01), anastomotic leakage (32.9% vs. 10.5%, *p < .01), and prolonged ICU stays (median 7 days vs. 2 days, *p < .01). The in-hospital mortality rate in the POAF group was 7.6%, compared to 1% in patients without POAF (*p < .01). Independent predictors of POAF included older age, pre-existing atrial fibrillation and beta-blocker therapy. Postoperative atrial fibrillation (POAF) was a significant predictor of adverse postoperative outcomes. Logistic regression analysis revealed that POAF was associated with higher odds of anastomotic leakage (OR = 3.11, *p < .01), ICU readmission (OR = 6.80, *p < .01), in-hospital mortality (OR = 6.76, *p < .01) and 90-Day mortality ( OR = 5.44, *p < .01). In our cohort, POAF was not significantly associated with oncological recurrence (OR = 0.71; p = .219). These findings highlight the critical role of POAF in predicting postoperative complications.POAF is both - a complication and a potential marker - for systemic stress, predicting further adverse events such as anastomotic leakage and respiratory insufficiency. Although some studies suggest that POAF does not affect long-term survival, its pronounced impact on short-term morbidity underscores the necessity of early identification and focused management. Preoperative risk stratification and intraoperative strategies, such as goal-directed fluid therapy, could mitigate the impact of POAF. Postoperative atrial fibrillation (POAF) significantly influences recovery after esophagectomy, serving as a marker for increased morbidity and mortality. Advanced age, hypertension, and respiratory complications emerged as key independent risk factors. Additionally, POAF was linked to longer hospital stays, in-hospital and 90-day mortality and a heightened incidence of postoperative complications, including pneumonia and anastomotic leakage. These results highlight the critical importance of implementing targeted perioperative strategies to reduce risks and enhance outcomes in this high-risk patient population.

Keywords: Anastomotic leakage; Ivor-Lewis esophagectomy; Postoperative atrial fibrillation; Postoperative morbidity; Pulmonary complications.