In Reply With great interest we read the Letters from Nittala et al and de Steur et al, and we thank them for their thoughtful comments on our study.1
In the Letter by Nittala et al, the generalizability of the results of the ICAN trial to the subgroup of midesophageal tumors is questioned. For the ICAN trial, we believed it was important that we only included patients in which both types of anastomoses were oncologically feasible. This resulted in the exclusion of cancers situated above the level of the carina because some surgeons argue these tumors generally require a cervical anastomosis. Because of this, only a small subgroup of patients in our study had cancer in the middle third of the esophagus, and we agree this groups is by far too small to draw any robust conclusions for this subgroup. In addition, we agree that there are theoretical arguments to believe leakage rates may be different in this subgroup, although the clinical relevance of (most of) these remain to be proven in robust studies. Future studies will be needed to elucidate whether intrathoracic anastomosis also yields superior results for the subgroup of cancers in the middle third of the esophagus.