Preservation of the right bronchial artery by maintaining the azygos arch during minimally invasive esophagectomy: a two-center retrospective cohort study.

Background: Postoperative pneumonia remains one of the most frequent and clinically important complications after esophagectomy for esophageal cancer. Research suggests that preservation of the bronchial arterial blood supply reduces pulmonary complications; however, a reproducible surgical strategy applicable to routine practice has yet been established. This study aimed to evaluate whether intentional preservation of the azygos arch as a structural strategy was associated with a reduced incidence of postoperative pneumonia. Methods: We retrospectively analyzed patients who underwent minimally invasive McKeown esophagectomy for esophageal cancer at two institutions between April 2015 and December 2023. Patients were classified according to whether an intentional azygos arch-preservation strategy was applied to structurally protect the right bronchial artery (RBA). Postoperative pneumonia was the primary outcome. Multivariable logistic regression analysis was performed to identify factors independently associated with postoperative pneumonia, adjusting for patient background, tumor characteristics, surgical approach, reconstruction route, preoperative treatment, year of surgery, and institution. Results: Postoperative pneumonia occurred less frequently in patients managed with the azygos arch-preservation strategy than in those who underwent resection (8% Conclusions: An intentional azygos arch-preservation strategy during minimally invasive esophagectomy was independently associated with a reduced risk of postoperative pneumonia without compromising oncological adequacy. This reproducible surgical approach represents a practical strategy to improve postoperative respiratory outcomes in esophageal cancer surgery.