BACKGROUND: The surgical approach to esophageal cancer continues to be controversial. A transthoracic approach is often advocated for better oncologic staging and improved survival. A transhiatal approach is often preferred due to a perceived decreased operative morbidity and mortality. METHODS: Using the American College of Surgeons-National Surgical Quality Improvement Project (ACS-NSQIP) participant-use file, patients were identified who underwent either a transhiatal or transthoracic esophagectomy for cancer at participating hospitals from 2005 to 2011. Demographic, clinical, intra-operative variables, and 30-day morbidity and mortality were collected. RESULTS: Of the 1,428 patients that had esophagectomy, 750 (52.5%) had a transhiatal (TH) resection and 678 (47.5%) had a transthoracic (TT) resection. The transhiatal group was older (66 vs. 63 years, P = 0.003) with a lower ASA class (2.84 vs. 2.91, P = 0.025). Operative time was greater in the TT group (364 vs. 298 min, P < 0.001). There was no significant difference in 30 day overall mortality (TH = 2.9%, TT = 4.7%, P = 0.095) however a trend favored the TH group. Serious morbidity remains clinically significant in both groups (TH = 39.6%, TT = 43.5%, P = 0.146). The TH group had a significantly higher superficial wound infection rate (11.6% vs. 6.2%, P < 0.001) while the TT group required more perioperative blood transfusions (12.5% vs. 8.9%, P = 0.032) and returns to operating room (14.5% vs. 10.9%, P = 0.046). CONCLUSION: Serious morbidity continues to be high for both types of esophagectomy. There needs to be continued efforts to diminish these complications.