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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. 2021;156(7):601-610doi: 10.1001/jamasurg.2021.1555.
van Workum, F., Verstegen, M. H. P., Klarenbeek, B. R., Bouwense, S. A. W., van Berge Henegouwen, M. I., Daams, F., Gisbertz, S. S., Hannink, G., Haveman, J. W., Heisterkamp, J., Jansen, W., Kouwenhoven, E. A., van Lanschot, J. J. B., Nieuwenhuijzen, G. A. P., van der Peet, D. L., Polat, F., Ubels, S., Wijnhoven, B. P. L., Rovers, M. M., Rosman, C. (2021). Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer: A Randomized Clinical Trial. JAMA surgery, 156(7), 601-610. https://doi.org/10.1001/jamasurg.2021.1555
van Workum, Frans, et al. "Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer: A Randomized Clinical Trial." JAMA surgery vol. 156,7 (2021): 601-610. doi: https://doi.org/10.1001/jamasurg.2021.1555
van Workum F, Verstegen MHP, Klarenbeek BR, Bouwense SAW, van Berge Henegouwen MI, Daams F, Gisbertz SS, Hannink G, Haveman JW, Heisterkamp J, Jansen W, Kouwenhoven EA, van Lanschot JJB, Nieuwenhuijzen GAP, van der Peet DL, Polat F, Ubels S, Wijnhoven BPL, Rovers MM, Rosman C. Intrathoracic vs Cervical Anastomosis After Totally or Hybrid Minimally Invasive Esophagectomy for Esophageal Cancer: A Randomized Clinical Trial. JAMA Surg. 2021 Jul 01;156(7):601-610. doi: 10.1001/jamasurg.2021.1555. PMID: 33978698; PMCID: PMC8117060.
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JAMA Surg. 2021 Jul 01;156(7):601-610. doi: 10.1001/jamasurg.2021.1555.

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

JAMA surgery

Frans van Workum, Moniek H P Verstegen, Bastiaan R Klarenbeek, Stefan A W Bouwense, Mark I van Berge Henegouwen, Freek Daams, Suzanne S Gisbertz, Gerjon Hannink, Jan Willem Haveman, Joos Heisterkamp, Walther Jansen, Ewout A Kouwenhoven, Jan J B van Lanschot, Grard A P Nieuwenhuijzen, Donald L van der Peet, Fatih Polat, Sander Ubels, Bas P L Wijnhoven, Maroeska M Rovers, Camiel Rosman,

Affiliations

  1. Department of Surgery, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
  2. Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands.
  3. Department of Surgery, Amsterdam UMC, location AMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands.
  4. Department of Surgery, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands.
  5. Department of Operating Rooms, Radboud Institute of Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands.
  6. Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
  7. Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.
  8. Department of Surgery, Ziekenhuisgroep (Hospital Group) Twente, Almelo, the Netherlands.
  9. Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands.
  10. Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
  11. Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands.

PMID: 33978698 PMCID: PMC8117060 DOI: 10.1001/jamasurg.2021.1555

Abstract

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.

TRIAL REGISTRATION: Trialregister.nl Identifier: NL4183 (NTR4333).

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