Objective: To investigate whether intrathoracic manifestations of cervical anastomotic leakage are encountered more frequently after transthoracic oesophagectomy compared with transhiatal oesophagectomy.Background data: A cervical anastomosis is required for reconstruction after transhiatal oesophagectomy and seems to reduce the intrathoracic consequences of anastomotic leakage. It is questioned whether a cervical anastomosis after transthoracic oesophagectomy harbours this advantage too. In the present study, we investigated incidence and risk factors of intrathoracic manifestations after cervical anastomotic leakage in a prospectively collected consecutive series of patients with potentially curable oesophageal carcinoma. Methods: From 1993 to 2007, all patients in the prospective database undergoing transhiatal or transthoracic oesophagectomy with a cervical anastomosis were included. All patients developing either radiological or clinical signs of anastomotic leakage were evaluated. Occurrence and outcome of intrathoracic manifestations after cervical anastomotic leakage were compared after transhiatal and transthoracic oesophagectomy. Multivariate logistic regression analysis was used to identify potential risk factors for intrathoracic manifestations including age, body mass index, tumour histology, use of neoadjuvant therapy and surgical approach.Results: In the study period, 847 patients underwent potentially curative oesophagectomy. 79/516 (15%) patients developed anastomotic leakage after transhiatal oesophagectomy versus 50/331 (15%) patients after transthoracic oesophagectomy (p=N.S.) However, significantly (p=0.041) more intrathoracic manifestations of cervical anastomotic leakage were seen after transthoracic oesophagectomy than after transhiatal oesophagectomy, 22/50 (44%) versus 21/79 (27%). Total hospital stay (p<0.001), ICU stay (p<0.001) and mortality (p=0.035) were significantly higher in patients with intrathoracic manifestations compared to patients without intrathoracic manifestations of cervical leakage. Transthoracic approach was the only independent predictive factor for development of intrathoracic manifestations in patients with cervical leakage (p=0.014, Odds Ratio 2.859).Conclusion: Intrathoracic manifestations of cervical anastomotic leakage after oesophagectomy result in longer hospital stay and higher mortality. Intrathoracic manifestations occur significantly more after a transthoracic approach than after a transhiatal approach.