Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer A Randomized Clinical Trial

F. van Workum, M.H.P. Verstegen*, B.R. Klarenbeek, S.A.W. Bouwense, M.I.V. Henegouwen, F. Daams, S.S. Gisbertz, G. Hannink, J.W. Haveman, J. Heisterkamp, W. Jansen, E.A. Kouwenhoven, J.J.B. van Lanschot, G.A.P. Nieuwenhuijzen, D.L. van der Peet, F. Polat, S. Ubels, B.P.L. Wijnhoven, M.M. Rovers, C. Rosman*ICAN collaborative research group

*Corresponding author for this work

Research output: Contribution to journalArticleAcademicpeer-review


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.
Original languageEnglish
Pages (from-to)601-610
Number of pages10
JournalJAMA Surgery
Issue number7
Publication statusPublished - 1 Jul 2021




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