TY - JOUR
T1 - Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer A Randomized Clinical Trial
AU - van Workum, F.
AU - Verstegen, M.H.P.
AU - Klarenbeek, B.R.
AU - Bouwense, S.A.W.
AU - Henegouwen, M.I.V.
AU - Daams, F.
AU - Gisbertz, S.S.
AU - Hannink, G.
AU - Haveman, J.W.
AU - Heisterkamp, J.
AU - Jansen, W.
AU - Kouwenhoven, E.A.
AU - van Lanschot, J.J.B.
AU - Nieuwenhuijzen, G.A.P.
AU - van der Peet, D.L.
AU - Polat, F.
AU - Ubels, S.
AU - Wijnhoven, B.P.L.
AU - Rovers, M.M.
AU - Rosman, C.
AU - ICAN collaborative research group
PY - 2021/7/1
Y1 - 2021/7/1
N2 - BACKGROUND Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE.OBJECTIVE To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial.DESIGN, SETTING, AND PARTICIPANTS This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020.INTERVENTION Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis.MAIN OUTCOMES AND MEASURES The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life.RESULTS Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 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 comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]).CONCLUSIONS AND RELEVANCE In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer.
AB - BACKGROUND Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE.OBJECTIVE To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial.DESIGN, SETTING, AND PARTICIPANTS This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020.INTERVENTION Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis.MAIN OUTCOMES AND MEASURES The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life.RESULTS Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 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 comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]).CONCLUSIONS AND RELEVANCE In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer.
KW - QUALITY-OF-LIFE
KW - IVOR LEWIS
KW - ESOPHAGOGASTRIC JUNCTION
KW - EUROPEAN-ORGANIZATION
KW - LEARNING-CURVE
KW - RESECTION
KW - ADENOCARCINOMA
KW - COMPLICATIONS
KW - MULTICENTER
KW - MCKEOWN
U2 - 10.1001/jamasurg.2021.1555
DO - 10.1001/jamasurg.2021.1555
M3 - Article
C2 - 33978698
SN - 2168-6254
VL - 156
SP - 601
EP - 610
JO - JAMA Surgery
JF - JAMA Surgery
IS - 7
ER -