Preoperative anatomic considerations for a cervical or intrathoracic anastomosis: a retrospective cohort study

Background: Continuity after esophagectomy is restored by creating an intrathoracic or cervical anastomosis. Although the single most important factor for determining the suitability for intrathoracic anastomosis is the location of the tumor, current literature only grossly distinguishes proximal, mid or distal esophageal tumors. This study offers precise anatomic considerations for the assessment of suitability for an intrathoracic anastomosis. Methods: In this anatomical cohort study, all consecutive patients after esophagectomy for cancer who underwent a postoperative endoscopy between 2010 and 2018 were analyzed. The clinical postoperative anatomy was assessed and the level of the anastomosis was measured in distance from the incisors. Computed tomography imaging was used to confirm postoperative localization. These data were compared to preoperative localization of the tumor and proximal resection margins. Results: A total of 208 patients who underwent esophageal cancer surgery were included, comprising 61 (29.3%) intrathoracic and 147 (70.7%) cervical reconstructions. The mean distance was 28.2±2.3 and 19.6±1.7 cm from the incisors for an intrathoracic and cervical anastomosis respectively (P<0.001). The proximal margin was 4.5±1.9 for intrathoracic anastomosis and 8.9±3.4 for cervical anastomosis (P=0.405). Conclusions: The difference in distance from the incisors between an intrathoracic anastomosis and a cervical anastomosis was assessed by endoscopic evaluation after esophagectomy is approximately 9 centimeters. Preoperatively, these findings enable assessing suitability for an intrathoracic anastomosis when endoscopic localization of the tumor and Barret's segment is known as well as planned radiotherapy fields.