Frans van Workum1, Moniek H P Verstegen1, Bastiaan R Klarenbeek1, Stefan A W Bouwense1,2, Mark I van Berge Henegouwen3, Freek Daams4, Suzanne S Gisbertz3, Gerjon Hannink5, Jan Willem Haveman6, Joos Heisterkamp7, Walther Jansen7, Ewout A Kouwenhoven8, Jan J B van Lanschot9, Grard A P Nieuwenhuijzen10, Donald L van der Peet4, Fatih Polat11, Sander Ubels1, Bas P L Wijnhoven9, Maroeska M Rovers5, Camiel Rosman1. 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.
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).
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).
Authors: E M de Groot; G M Kuiper; A van der Veen; L Fourie; L Goense; S van der Horst; J W van den Berg; R van Hillegersberg; J P Ruurda Journal: Updates Surg Date: 2022-08-17
Authors: Minke L Feenstra; Lily Alkemade; Janneke E van den Bergh; Suzanne S Gisbertz; Freek Daams; Mark I van Berge Henegouwen; Wietse J Eshuis Journal: Ann Surg Oncol Date: 2022-10-10 Impact factor: 4.339
Authors: Benjamin Babic; Dolores T Müller; Jin-On Jung; Lars M Schiffmann; Paula Grisar; Thomas Schmidt; Seung-Hun Chon; Wolfgang Schröder; Christiane J Bruns; Hans F Fuchs Journal: Surg Endosc Date: 2022-05-03 Impact factor: 3.453