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INTRODUCTION: A thoracic approach is not required for all esophagectomies. Some research suggests an increased risk of pulmonary morbidity when a thoracic incision is used. We studied the impact of a thoracic incision on complications after esophagectomy through a national database. This represents the largest analysis of pulmonary morbidity after esophagectomy. METHODS: The National Surgical Quality Improvement Project (NSQIP) database was queried for non-emergent esophagectomies with reconstruction from 2005-2010. Patients with metastatic disease were excluded. Patient who underwent trans-hiatal esophagectomy (THE) were compared to those who had a thoracic incision. The THORACIC group was patients with Ivor-Lewis (thoracic & abdominal incisions) or McKeown (cervical, abdominal & thoracic incisions) techniques. The primary outcome was pulmonary morbidity; secondary outcomes were death, overall morbidity, infection, and thrombo-embolic complications. Multivariable regression models controlled for age, smoking, chronic obstructive pulmonary disease, hypertension, diabetes, American Society of Anesthesiology class 3 or higher, malignancy, and preoperative weight loss. RESULTS: Of 1568 patients, 717 (46%) underwent THE and 851(54%) were in the THORACIC group (487 / 31% Ivor-Lewis & 364 / 23% McKeown). The overall population was 80% male, with a mean age of 63 years. Patients undergoing THE were older (p=0.02). Pre-operative co-morbidities were similar except for more diabetes (16% v. 11%, p=0.02) in the THORACIC group. Malignancy was more common in THORACIC patients, 91% v. 87% (p=0.01). Overall, morbidity was 46.5% and mortality was 3.1% without a difference between groups. Length of stay was 1.6 days shorter (p=0.009) for THE patients. On multivariable analysis, the use of a thoracic incision was associated with an increase in pneumonia (47%, p=0.007), ventilator dependence >48 hours (34%, p=0.04), and septic shock (86%, p=0.001). Mortality, surgical site infections, and thrombo-embolic events were similar. On subgroup analysis of the THORACIC group, the McKeown approach increased the odds of superficial surgical site infection by 71% (p=0.02) but showed similar odds of septic shock compared to the Ivor-Lewis technique. CONCLUSION: Esophagectomies carry an acceptable mortality rate but have significant morbidity. We show that the thoracic incision is associated with increased pneumonia, ventilator dependence, and septic shock. This septic shock is unlikely due to anastamotic leaks, given the similar among of septic shock between McKeown and Ivor-Lewis patients. When appropriate, avoiding a thoracic incision may decrease pulmonary morbidity and resulting septic shock. A limitation is the inability to distinguish between traditional versus thoracoscopic approaches; the impact of a minimally invasive thoracic approach remains unclear.