Should oesophagectomy be performed with cervical or intrathoracic anastomosis?

A best evidence topic was written according to a structured protocol. The question addressed was: In [patients undergoing oesophagectomy for oesophageal cancer] is a [cervical anastomosis or intrathoracic anastomosis] superior in terms of [post-operative outcomes]. In total, 47 papers were found suitable using the reported search, and nine of these represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. We conclude that there is no convincing evidence that cervical anastomosis is superior to intrathoracic anastomosis with respect to post-operative outcomes. Only one prospective study showed significantly increased risk of anastomotic leak with cervical anastomosis, but this study was significantly limited due to patient selection and variations in surgical approach and technique. Cervical anastomosis was also shown to increase pharyngeal reflux on pH monitoring compared with intrathoracic anastomosis, but this did not influence symptoms or development of subsequent anastomotic complications. One randomized study showed intrathoracic anastomosis significantly increased risk of respiratory complications, but in this study patient treatment was variable and study design was limited. Intrathoracic anastomosis was also shown to correlate with anastomotic stricture formation and this was attributed to increased anastomotic stapling in this patient group compared with cervical anastomosis. Post-operative pain as measured by grouped symptom scales significantly increased with intrathoracic anastomosis compared with cervical anastomosis. This did not correlate with development of other cardiorespiratory complications and the difference between the two groups resolved within 24 months. Overall, there is currently insufficient evidence to show a significant difference between cervical and intrathoracic anastomosis with respect to post-operative complications and hospital mortality. The wide variety in methodology and outcomes reinforce the need for further randomized trials to more accurately establish significant differences in outcomes.