Estimating hospital costs of postoperative adverse events following esophagectomy: a retrospective cohort study involving 10 high volume Canadian hospitals

Introduction

Esophageal cancer (EC) is one of the eight most prevalent cancers globally, with more than 600,000 new cases yearly (1,2). Surgical resection plays a central role in curative intent treatment of EC. Adverse events (AEs), defined as deviations from the expected recovery outcome after surgery, are common following esophagectomy despite advances in peri-operative care (3,4). Patients undergoing esophageal surgery experience a high rate of postoperative AEs with an average AE rate of 60% (4). These events influence short- and long-term patient outcomes, including increased risk of mortality (5), impaired postoperative recovery and diminished quality of life (QoL) (6), and early oncological recurrence with worsened oncological outcomes (7). All AEs, regardless of severity, are associated with prolonged hospital length of stay (LOS) and poor patient experiences (8). Other than hospital costs, this leads to a simultaneous loss of trust in the healthcare system.

Healthcare expenditure is rising worldwide and is, understandably, under increasing surveillance. Canadian annual healthcare expenditure, estimated at 330 billion Canadian dollars (CDN) (9), accounts for 12% of the nation’s gross domestic product (GDP), a quarter of which is attributed to hospital costs. Postoperative AEs correlate with hospital costs (10,11) and represent a surrogate marker for quality of care and hospital reputation (12). From a national perspective, increasing healthcare expenditure has encouraged healthcare providers to focus on improving the quality of cancer care and reducing costs (13). Recent studies consistently demonstrate that postoperative complications are associated with significant hospital resource utilization. However, there remains a notable lack of cost data from the Canadian hospital perspective, representing an important gap in the literature (14). Detailed data regarding the clinical and economic burden of post-operative complications following esophagectomy are not available. A clear understanding of the economic impact of postoperative AEs after esophagectomy would allow for the development of quality improvement (QI) and cost-reduction initiatives.

This paper describes esophagectomy-related AEs hospital costs across 10 Canadian EC centres, detailing average incidence, in-hospital costs, and the impact of incidence and AE grade on cost. The primary objective of this study is to estimate the economic burden of post-esophagectomy AEs in 10 high-volume EC centres in Canada. Secondary objectives include estimating the costs associated with the most common and costly AEs; to examine the impact of AE Clavien-Dindo grade on AE cost; and estimating the potential of cost reduction given a 1% decrease in the rate of the top 15 AEs. We present this article in accordance with the STROBE reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-15/rc).

Methods

A retrospective cohort study using data from the prospectively maintained Canadian Association of Thoracic Surgeons (CATS) national database was performed. Data from all patients undergoing elective esophagectomy for non-metastatic EC in 10 participating centres, from Jan 2017 to Dec 2022, was included. We excluded emergency operations, benign indications, metastatic disease, redo procedures, and records with missing core variables required for AE attribution (procedure type, AE occurrence/grade, or LOS). Emergency esophagectomy cases were not included in the data set. Individual hospital esophagectomy annual volume, patient demographics (age, % male/female), diagnosis, LOS, surgical procedure (technical approach), and postoperative AEs were assessed. Other data sources included the Canadian Institution for Health Information (CIHI) database, a nationally governed database reporting on annual surgical volumes across Canada. Cost estimates for specific AEs were obtained from the literature-derived index hospitalization cost of AEs (14). All cost estimates are valued in CDN adjusted to the present year’s value (CDN 2025). The risk of privacy breach was mitigated by anonymizing and de-identifying data, and no consent was required. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Ottawa Hospital Research Institute (OHRI) (No. 20220685-01H) and individual consent for this retrospective analysis was waived.

Statistical analysis

Descriptive statistics were used to describe patient and surgical data. Continuous data were first assessed for normality using the Shapiro-Wilk test and visual inspection of histograms. Normally distributed data were summarized as mean and standard deviation (SD), while non-normally distributed data were summarized as median with interquartile range (IQR) or 95% confidence interval (CI). Chi-squared and Fisher’s exact test were used for the comparison of categorical variables between complications and no-complications. The Student’s t-test was used for the comparison of continuous variables. Costs were adjusted for inflation to real dollars using the annual consumer price index for each year (CDN 2025). Overall institutional cost savings were calculated using the resulting proportional increase in hospital cost along with the estimated reduction in the complication rate. The CIHI database was assessed in the year 2019. A value of P<0.05 was considered significant.

Results

From the CATS registry (Jan 2017–Dec 2022) we identified all esophagectomies performed at 10 participating centres (Figure S1). A total of 795 patients were included in our analysis, which included all elective esophagectomies for non-metastatic EC. The average annual hospital esophagectomy volume was 63 (69.3, 91.8) cases per centre, and 78% of patients were male with an average age of 65.4 (1.6) years. The average LOS was 20.6 (7.6, 16) days. Minimally invasive esophagectomy (MIE), using both laparoscopy in the abdominal portion, and thoracoscopy in the chest portion, was the predominant technique used by included thoracic centres (85%) (Table 1). The average incidence of AEs, characterized by system, is detailed in Table 2. The three most common AE systems included anastomotic [anastomotic leak (AL), 39%; SD =31%], pulmonary (pneumonia, 25%; SD =15.7%), and cardiac (atrial arrhythmia, 23%; SD =22%). Less common AEs included respiratory (respiratory failure, 12.7%; SD =12.9), pleural-based (effusion, 13.4%; SD =18.8%), chylothorax (7%; SD =9.5%), renal (renal failure, 5%; SD =7%), and wound [surgical site infection (SSI), 4%; SD =5.1%]. Other systems involved included neurological [recurrent laryngeal nerve (RLN) injury, 2%; SD =3.1%], pleural-based (pneumothorax, 2%; SD =2.2%), and ‘other’ (sepsis, 2%; SD =2.8%). The data presented here aligns closely with other major national and international publications (3).

Most common esophagectomy AEs and cost burden

We analyzed the most common AEs associated with esophagectomy and estimated the average annual cost (CDN 2025) (Figure 1). From most common to least, with associated estimated annual cost: AL ($2,241,848), pleural effusion ($539,309), respiratory failure ($522,001), atrial arrhythmia ($405,505), pneumonia ($383,174), chylothorax ($138,976), and “other” (including atelectasis, anemia, renal failure, confusion, pulmonary embolism, infection, venous thrombosis, empyema, C-diff, recurrent nerve injury, pneumothorax, ileus, sepsis, stroke, hematoma, and myocardial infarction). Together, these contributed an estimated $6.2 million CDN in additional index-hospital costs annually.

Figure 1 Most common AEs associated with esophagectomy and estimated average annual in-hospital cost (CDN 2025). AEs, adverse events; ARDS, acute respiratory distress syndrome; CDN, Canadian dollars.

Most costly AEs and national impact

Using the literature-derived index-hospital cost of AE data (14), we analyzed the seven most costly AEs following esophagectomy, and estimated the national hospital-level impact (Figure 2). This included: AL ($2,241,848/year), renal failure ($461,294/year), empyema ($201,665), respiratory failure ($522,001), effusion ($539,309), atrial arrhythmia ($405,505), and pneumonia ($383,174). In total, these seven AEs contribute approximately $4.75 million yearly to the Canadian health care system. Of the seven most costly AEs, AL as a sole complication encompassed 47% of the yearly annual costs.

Figure 2 Seven most costly AEs following esophagectomy and estimated average annual in-hospital cost (CDN 2025). AEs, adverse events; ARDS, acute respiratory distress syndrome; CDN, Canadian dollars.

Incidence of AEs (not grade) drives cost

Costs of AEs following esophagectomy varied according to incidence, and not necessarily by grade of AE (Figure 3). While the majority of AE costs were driven by Clavien-Dindo grade III, IV, and V (major), including AL (minor: $384,779 vs. major: $2,124,876), chylothorax (minor: $223,205 vs. major: $693,872), and pneumonia minor: $546,621 vs. major: $777,042), the incidence of minor cardiac AEs far outweighed major AEs (minor: 63/year vs. major: 11/year), driving up in-hospital cost substantially (minor: $2,840,398 vs. major: $770,000).

Figure 3 Costs of AEs following esophagectomy varied according to incidence, not necessarily by grade of AEs. Minor & major complications as graded by Clavien-Dindo classification, modified by TM&M, The Ottawa Hospital. AEs, adverse events; TM&M, thoracic morbidity & mortality.

Impact across Canada

In the year 2019, approximately 1,134 esophagectomies were performed (9). We cross referenced this to the CATS database (data from 467 esophagectomies included) and estimated that all AEs combined total in excess of $6 million CDN. Scaling this cost up to 1,134 surgical cases, estimated index hospital cost of 15 most common AEs following esophagectomy would result in an additional $15 million CDN in hospital costs across Canada, annually. A reduction in the rate of these 15 AEs by 1%, could potentially save $1.5 million CDN across Canada, annually.

Discussion

The yearly hospital cost of AEs following esophagectomy from 10 Canadian esophageal centres is estimated at $15 million CDN. This represents a substantial burden to hospitals, the healthcare system and patients alike. To our knowledge, our study is the first attempt to report the increase in Canadian hospitalization costs due to esophagectomy-related AEs. While major AEs are clearly associated with significant morbidity, mortality and cost, they are less frequent and the cumulative burden of minor AEs on hospital resources, and ultimately healthcare cost and delivery, serve as excellent targets for greater cost saving and system-wide benefits. Our results are likely an underestimation of the actual financial and human impact of AEs. Specifically, we do not attempt to address the indirect cost of AE, which relate to production losses to society due to morbidity or premature mortality (15). With EC incidence rising in North America, including Canada, hospital-level AEs costs represent both an important insight for future QI initiatives aimed at reducing the most common and costly AEs, and provides an avenue to improve patient-centred care.

Healthcare spending accounts for a substantial proportion of Canada’s GDP, underscoring the importance of delivering high-value care. Achieving this goal requires alignment across all stakeholders—patients, surgeons, hospital administrators, and policymakers. Value-based healthcare (VBHC) offers a framework to maximize patient outcomes while controlling costs (16-18). At its core, value is defined as the health outcomes achieved per dollar spent (19). Value-based QI (VBQI) operationalizes this principle by reducing low-value care, minimizing unwarranted variation, and promoting cost-effective interventions that enhance quality (20). Surgical AEs serve as reliable surrogate markers of care quality (21) and, as demonstrated in our study, represent a substantial burden both in terms of patient harm and material cost. Despite significant advances in perioperative care, AEs remain common following thoracic procedures. VBQI presents a compelling mechanism to translate knowledge of AE-related costs into actionable improvements in care for patients undergoing esophagectomy. Our analysis revealed that the most common AEs contribute over $6.2 million CDN annually in additional in-hospital costs. Notably, AL alone accounts for more than 36% of this burden, making it a high-yield target for VBQI initiatives. Implementing targeted, evidence-based strategies to reduce this complication could generate meaningful benefits for all stakeholders—improved outcomes for patients, greater satisfaction for providers, cost savings for hospitals, and long-term value for society. Ultimately, these findings provide a foundational framework for leveraging cost data to inform the design and prioritization of high-impact, value-based interventions in thoracic surgery.

Delineating the index hospital costs of esophagectomy AEs is imperative for VBQI. However, avoiding low-value care requires surgeons to ‘optimize proficiency’ (21), which involves open and humble discussion amongst surgeons regarding preoperative care, intra-operative surgical techniques, and enhanced postoperative care pathways. We have championed such a culture of respect and open-communication among Canadian thoracic surgeons by way of ‘positive deviance (PD) seminars’, revealing important clinical improvements in thoracic patients (22,23). For instance, atrial arrhythmia and AL, both common AE following esophagectomy, were shown to decrease over a 6-month period following a PD seminar and incorporation of consensus recommendations (24). The PD seminar process is designed to distinguish exemplary practice performed by individuals, teams, or organizations, whose actions lead to improved safety and quality of care for patients (25). PD seminar can be scaled at a national level, and integrated into healthcare frameworks (26). It is well known that surgical excellence and improved patient outcomes rely less so on individual surgeon proficiency, but more so on multidisciplinary team efficiency, workflow dynamics and collaborative network-based care (27). Therefore, combining PD seminars with VBQI can further improve collaboration among patient-care partners, and represents an efficient and sustainable means of enhancing healthcare delivery.

Stratifying costs of AEs by incidence and severity revealed that incidence was a major driver of the overall cost burden. This was most exemplified by cardiac complications, which had more minor than major occurrences (minor =63 on average/annually, major =11 on average/annually). This resulted in AE cost burden for minor grades of approximately $2,840,398/year, nearly four times greater than the major complication grade ($770,000/year). Consequently, a focus on minor complications can translate into significant cost-savings. This is in contrast to other studies which have shown cost of in-hospital complications are linked to the severity of complications (10,28). This information offers critical insight into how healthcare resources and efforts may be utilized and provides an additional direction for QI initiatives. Our findings gain even more significance in the context of the rising rates of EC in the Western world (29), and Canada (30). There is an urgent need for Canada’s healthcare system to address these AEs from a clinical and financial perspective. As Canadian’s age and incidence of EC rises, the incidence (and, as a corollary, the financial burden) of esophagectomy-related AEs will only intensify. Our results underscore the importance of planning for patient-centred care in conjunction with minimizing the financial burden of AEs, which emphasizes the need for hospital and governmental bodies to actively support, invest, and implement VBQI initiatives. A multi-dimensional approach, focusing on the dual goals of patient-centric outcomes and managing healthcare expenditures will be pivotal in addressing the challenges posed by rising postoperative esophageal complications and changing Canadian demographics.

Limitations

Limitations exist which may impact the generalizability of our finding, specifically on the economic implications of AEs following esophagectomy across Canada. First, we used literature-derived index-hospital cost, which each AEs having a range of attributable costs, to estimate the overall cost of AEs following esophagectomy. This limited our ability to perform a sensitivity analysis for the included costs. A little more than half of the studies included for the cost estimations (11/20) were from the United States, with none originating from Canada. Consequently, we may be unable to represent Canadian or international costs accurately. This limitation may undermine the accuracy of the financial analysis from a Canadian healthcare system perspective. Furthermore, the scope of our cost estimation is restricted to in-hospital costs during index admission. We do not account for post-discharge costs in our analysis; such costs, especially those incurred at a societal level, are likely significant. Post-discharge costs (emergency department visits, readmissions, rehabilitation, reinterventions, home care, as well as long-term medication use) are likely equal or even exceed those incurred during the initial hospitalization, especially patients who experience an AL. Future studies should adopt a comprehensive, episode-of-care approach—capturing 30-day, 90-day, and 1-year post-operative costs—ideally using linked administrative databases and prospective resource utilization tracking. In addition, to accurately determine actual cost savings to provide actionable feedback for improving clinical outcomes, institutional-level data is needed. This will be most aided by standardized AE incidence and grade reporting at an institutional level, as well as a focus on patient-centred outcomes, including quality-of-life, patient satisfaction and long-term survival. Such standardization and documentation will facilitate benchmarking of clinical outcomes, ultimately enabling more detailed cost-related analyses, and improvement in surgical care. It is important to also acknowledge that the observed incidence of AEs across high-volume centres may be influenced by patient and case selection, rather than solely reflecting variation in care quality. High-volume thoracic surgery centres often serve as referral hubs and may manage a disproportionate number of complex cases. As a result, higher AE rates at these institutions may be driven in part by increased clinical complexity rather than deficiencies in surgical or perioperative care. Future analyses should incorporate validated case-mix adjustment models or risk stratification tools to better contextualize AE rates and associated costs, ensuring fair comparisons across institutions. Finally, a key limitation of our study is the inability to perform a formal sensitivity analysis. This stems from our reliance on literature-derived estimates for the index hospitalization costs of AEs, which are aggregated from multiple sources and lack access to granular, patient-level cost distributions. As such, we were unable to model variability in unit costs across different institutions or care settings. While our use of peer-reviewed and CIHI-supported sources strengthens the external validity of the estimates, it limits the capacity to assess how uncertainty in cost inputs may affect overall conclusions. Future work should aim to incorporate institution-level costing data, such as case costing systems or micro-costing methodologies, which would allow for both deterministic and probabilistic sensitivity analyses.

Conclusions

In summary, AEs following esophagectomy are common and costly, posing substantial financial strain on Canada’s healthcare system. AEs represent an excellent target for QI interventions. In the year 2019 alone, esophagectomy-related AEs from only 10 Canadian centres contributed $15 million to hospital costs. Even a modest reduction of 1% in the most common 15 AEs could lead to an annual saving of $1.5 million across Canada. It would be wise for both hospitals and governments to proactively support VBQI programs. Together, hospital- and government-level support will lay a foundation for improving the quality of care for patients, while reducing cost burden.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-15/rc

Data Sharing Statement: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-15/dss

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-15/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-15/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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the ethics committee of Ottawa Hospital Research Institute (OHRI) (No. 20220685-01H) and individual consent for this retrospective analysis was waived.

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/.

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