Impact of Upper Mediastinal Anatomy and Anastomotic Position on Anastomotic Leakage After Transcervical-Hiatal Subtotal Esophagectomy With Posterior Mediastinal Reconstruction.
Anastomotic leakage (AL) after esophagectomy increases morbidity and mortality. Although mediastinal anatomy has been implicated in AL, no prior study has evaluated this issue in transcervical-hiatal subtotal esophagectomy (closed mediastinum). We investigated whether the scaled upper mediastinal anteroposterior diameter (sAPD) and anastomotic height (AH) influence AL.
We retrospectively studied 224 patients who underwent transcervical-hiatal subtotal esophagectomy with mediastinoscopy-assisted mediastinal lymphadenectomy and posterior mediastinal reconstruction using a subtotal gastric conduit; the pleura was preserved (closed mediastinum). sAPD was measured on preoperative CT and AH on the first postoperative CT obtained 3-6 months postoperatively. Associations with AL were assessed by logistic regression, and receiver operating characteristic (ROC)-derived cutoffs defined four sAPD × AH risk groups. Two comparison cohorts (transthoracic, n = 91; narrow gastric conduit, n = 20) were also analyzed.
AL occurred in 31/224 (13.8%). Narrower sAPD and higher AH were independently associated with AL (odds ratio [OR] 0.86, p = 0.002; OR 1.15, p = 0.049); risk was highest in the narrow-sAPD/high-AH group (35.9%; OR 12.32). Airway-gastric fistula occurred in five patients (2.2%), all with a narrow sAPD. AH alone was associated with AL in the transthoracic cohort; AL was 5.0% in the narrow gastric conduit cohort.
sAPD and AH are practical, imaging-based predictors of AL after transcervical-hiatal subtotal esophagectomy. The association between narrow sAPD and airway-gastric fistula supports conduit-space mismatch as a mechanism. Combined assessment stratifies risk and may guide conduit design and anastomotic level.
We retrospectively studied 224 patients who underwent transcervical-hiatal subtotal esophagectomy with mediastinoscopy-assisted mediastinal lymphadenectomy and posterior mediastinal reconstruction using a subtotal gastric conduit; the pleura was preserved (closed mediastinum). sAPD was measured on preoperative CT and AH on the first postoperative CT obtained 3-6 months postoperatively. Associations with AL were assessed by logistic regression, and receiver operating characteristic (ROC)-derived cutoffs defined four sAPD × AH risk groups. Two comparison cohorts (transthoracic, n = 91; narrow gastric conduit, n = 20) were also analyzed.
AL occurred in 31/224 (13.8%). Narrower sAPD and higher AH were independently associated with AL (odds ratio [OR] 0.86, p = 0.002; OR 1.15, p = 0.049); risk was highest in the narrow-sAPD/high-AH group (35.9%; OR 12.32). Airway-gastric fistula occurred in five patients (2.2%), all with a narrow sAPD. AH alone was associated with AL in the transthoracic cohort; AL was 5.0% in the narrow gastric conduit cohort.
sAPD and AH are practical, imaging-based predictors of AL after transcervical-hiatal subtotal esophagectomy. The association between narrow sAPD and airway-gastric fistula supports conduit-space mismatch as a mechanism. Combined assessment stratifies risk and may guide conduit design and anastomotic level.
Authors
Kuroda Kuroda, Yajima Yajima, Asaoka Asaoka, Sugawara Sugawara, Higashizono Higashizono, Okamoto Okamoto, Oya Oya, Miwa Miwa, Yagi Yagi, Baba Baba
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