Does the Location Matter for the Anastomosis for Minimally Invasive Esophagectomy?

The morbidity and mortality associated with anastomotic leakage after esophagectomy remain high, despite improvements in surgical techniques and patient selection.¹ The great debate regarding the optimal location (cervical vs intrathoracic) for the esophagogastric anastomosis for esophagectomy has persisted for decades. In 1989, a small prospective randomized clinical trial by Chasseray et al² demonstrated that cervical anastomosis had a higher anastomotic leak rate (26% vs 4%) than intrathoracic anastomosis after open esophagectomy. In addition, there was no evidence of increased mortality in the intrathoracic anastomosis group who experienced an anastomotic leak, which debunked the myth that intrathoracic anastomotic leaks resulted in a higher mortality rate.² In another small randomized clinical trial, Ribet et al³ also demonstrated a higher anastomotic leak rate for the cervical anastomosis after esophagectomy. Despite the body of evidence demonstrating a higher anastomotic leak rate for cervical anastomosis, the technique has been used with almost equal frequency with intrathoracic anastomosis with minimally invasive esophagectomy (MIE).⁴ Until recently, to my knowledge, there was no multicenter, randomized clinical trial to compare the outcomes of intrathoracic and cervical anastomoses after MIE.