Intrathoracic vs Cervical Anastomosis Following Transthoracic MIE for Esophageal Cancer

Esophageal cancer
Investigators compared outcomes of intrathoracic vs cervical anastomosis following transthoracic minimally invasive esophagectomy.

Compared with cervical anastomosis, intrathoracic anastomosis resulted in better outcomes for patients treated with transthoracic minimally invasive esophagectomy (MIE) for midesophageal to distal esophageal or gastrophageal junction cancer. These findings were reported in Jama Surgery.

Transthoracic MIE is increasingly used as part of curative multimodality treatment. To date, no randomized clinical trial has evaluated the outcomes of intrathoracic anastomosis vs cervical anastomosis following transthoracic MIE. Based on the aforementioned gaps, investigators compared these 2 anastomosis locations in an open, multicenter, randomized clinical superiority trial (Netherlands Trial Register Identifier: NL4183 [NTR4333]).

The trial locations consisted of 9 Dutch high-volume hospitals. Adult patients with midesophageal, distal esophageal, or gastroesophageal junction cancer scheduled for curative resection were enrolled. Study participants were randomly assigned (1:1) to either transthoracic MIE with intrathoracic anastomosis or transthoracic MIE with cervical anastomosis. Data was collected from April 2016 to February 2020. The primary end point was anastomotic leakage within 30 days after esophagectomy for which endoscopic, radiologic, or surgical reintervention was required.

From April 2016 to October 2019, 262 patients were randomly assigned to study groups. In total, 245 patients were eligible for analysis. According to investigators, anastomotic leakage necessitating reintervention occurred in 15 patients (12.3%) in the intrathoracic anastomosis group and 39 patients (31.7%) in the cervical anastomosis group (risk difference, −19.4%; 95% CI, −29.5% to −9.3%).

The overall anastomotic leakage rate was determined to be 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, −21.9%; 95% CI, −32.1% to −11.6%).

Intensive care unit length of stay, mortality rates, and overall quality of life were found to be similar between both groups.

The intrathoracic anastomosis group was associated with lower incidence of recurrent laryngeal nerve palsy (risk difference, −7.3%; 95% CI, −12.1% to −2.5%), less severe complications (risk difference, −11.3%; 95% CI, −20.4% to −2.2%), and shorter median hospital length of stay (median [interquartile range], 10.0 [7] days vs 11.5 [9] days; P =.003). The intrathoracic anastomosis group reported fewer problems of dysphagia, (mean difference, −12.2; 95% CI, −19.6 to −4.7), fewer problems with choking when swallowing (mean difference, −10.3; 95% CI, −16.4 to 4.2), and fewer problems with talking (mean difference, −15.3; 95% CI, −22.9 to −7.7).

Limitations of this study included the possibility of unknown selection bias. Additionally, confounders were not corrected for. Finally, it cannot be ruled out that outcomes may have been influenced by a learning curve, especially in the intrathoracic group.

“The results of this trial support implementation of intrathoracic anastomosis in patients undergoing minimally invasive esophagectomy, although the choice for anastomotic location should be individualized for each patient and each surgeon,” the study authors wrote.

Disclosure: Some study authors declared affiliations with the industry. Please see the original reference for a full list of authors’ disclosures. 

Disclosure: This research was supported by the Netherlands Organization for Health Research Development Health Care Efficacy Research program (ZonMw: grant 843002607). Please see the original reference for a full list of disclosures.


Van Workum F, Verstegen MHP, Klarenbeek BR, et al. Intrathoracic vs cervical anastomosis after totally or hybrid minimally invasive esophagectomy for esophageal cancer: a randomized clinical trial. JAMA Surg. Published online May 12, 2021. doi: 10.1001/jamasurg.2021.1555