Minimally Invasive Esophagectomy Followed by Intrathoracic vs Cervical Anastomosis for Esophageal Cancer

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In a Dutch trial reported in JAMA Surgery, van Workum and colleagues found that intrathoracic anastomosis following total or hybrid minimally invasive esophagectomy for esophageal cancer was associated with significantly reduced risk of anastomotic leakage requiring intervention and other complications compared with cervical anastomosis.

Study Details

In the open-label multicenter trial, 245 eligible patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were randomly assigned between April 2016 and October 2019 to receive transthoracic minimally invasive esophagectomy with intrathoracic anastomosis (n =  122) or cervical anastomosis (n = 123). The primary endpoint was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention.

Key Findings

Anastomotic leakage requiring reintervention occurred in 15 patients (12.3%) receiving intrathoracic anastomosis vs 39 patients (31.7%) receiving cervical anastomosis (risk difference = −19.4%, 95% confidence interval [CI] =  −29.5% to −9.3%, P < .001). The overall rates of anastomotic leakage were 12.3% vs 34.1% (risk difference = −21.9%, P < .001).

Intensive care unit (ICU) length of stay (median = 2 vs 2 days, P = .12), mortality rates (eg, 3.3% vs 1.6% at 90 days, P = .40) , and overall quality of life (on EORTC QLQ-C30 and esophagogastric cancer-specific EORTC QLQOG25) were similar in the two groups.

Intrathoracic anastomosis was associated with a reduced risk of severe complications (Clavien-Dindo ≥ 3b; 10.7% vs 22.0%, risk difference = −11.3%, P =.02), pleural effusion requiring drainage (9.8% vs 21.1%, risk difference = −11.3%, P = .01), recurrent laryngeal nerve palsy (0% vs 7.3%, risk difference = −7.3%, P = .003), and ICU readmission (9.0% vs 17.9%, risk difference = −8.9%, P = .04).  

Intrathoracic anastomosis was also associated with better outcomes in three quality-of-life subdomains, with mean differences in pooled scores of −12.2 (95% CI = −19.6 to −4.7)  for dysphagia,  −10.3 (95% CI = −16.4 to 4.2) for problems of choking when swallowing, and −15.3 (95% CI = −22.9 to −7.7) for trouble with talking.

The investigators concluded: “In this randomized clinical  trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic [minimally invasive esophagectomy] for midesophageal to distal esophageal or gastroesophageal junction cancer.”

Camiel Rosman, MD, PhD, and Moniek H. P. Verstegen, MD, Radboud Institute of Health Sciences, Radboud University, Nijmegen, are the corresponding authors for the JAMA Surgery article.

Disclosure: The study was supported by The Netherlands Organization for Health Research Development Health Care Efficiency Research program. For full disclosures of the study authors, visit

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