P1.248. When the Conduit Won't Reach: Comparing the Rarely Performed Low Thoracic Anastomosis to Cervical Anastomosis in Thoracoabdominal Esophagectomy

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ID: 326214
2026
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Abstract
Abstract Topic Esophageal Cancer: Surgical Treatment of Esophageal Cancer – technique Background When gastric conduit length is insufficient for cervical or intrathoracic anastomosis, low thoracic esophagogastrostomy below the left inferior pulmonary vein may avoid total gastrectomy, though prevailing but unsubstantiated concerns exist regarding oncologic adequacy and reflux control. We compared perioperative, oncologic, and functional outcomes between low thoracic and cervical anastomosis. Methods From 1/2012–1/2025, 324 patients underwent thoracoabdominal esophagectomy at our institution: 259 cervical anastomosis, 39 low thoracic anastomosis below the left inferior pulmonary vein when conduit length precluded tension-free cervical reach, and 26 total gastrectomy with Roux-en-Y esophagojejunostomy. Most (99.4%) were for malignancy.Signet ring pathology was present in 3.9%, 12.8%, and 44.0% of cervical, low thoracic, and Roux-en-Y malignancies. On pre-induction endoscopy, median gastric extent (cm) was 0 (IQR 0–2), 3 (1–4.5), and 5 (2–8) for cervical, low thoracic, and Roux-en-Y groups; esophageal extent was 4 (2–6), 2 (0.5–4), and 1.5 (0–3). Clinical staging, nodal disease, and performance status were similar; neoadjuvant regimens differed. Outcomes included lymph node yield, resection margins, anastomotic leak, mortality, length of stay, overall survival, disease-free survival, and longitudinal reflux esophagitis by LA grade and symptom status from 1399 postoperative endoscopies. Nonlinear mixed-effects modeling compared esophagitis prevalence between groups. Results Oncologic outcomes were comparable between low thoracic and cervical groups, including lymph node yield (22.5±11.7 vs 23.9±11.5 nodes, P=.47) and positive resection margins (7.7% vs 5.0%, P=.45). Perioperative outcomes were also similar, including clinical anastomotic leak requiring intervention (7.7% vs 8.1%, P=.93), mortality (0% vs 1.9%, P=.38), and median length of stay (9 vs 9 days, P=.21). Five-year overall survival (P=.43, Figure 1a) and disease-free survival (P=.29, Figure 1b) did not differ. Reflux esophagitis prevalence was higher in the low thoracic group (Figure 2), though when present, it was predominantly grade A (low thoracic 51.7% vs cervical 74.7%, P=.006) and asymptomatic (62.1% vs 70.7%, P=.30). The Roux-en-Y group represented more locally advanced disease vs low thoracic (pT4a: 29.2% vs 0%; pN3: 29.2% vs 10.3%) and higher positive margin rates (32.0% vs 7.7%), with comparable perioperative outcomes (leak: 4.2%; no mortality), though analyses were limited by small sample size. Conclusion Thoracoabdominal esophagectomy with low thoracic anastomosis just below the left inferior pulmonary vein is a reasonable option when conduit length precludes cervical or standard intrathoracic anastomosis, achieving equivalent perioperative and survival outcomes while avoiding total gastrectomy. While postoperative reflux esophagitis is more prevalent with low thoracic anastomosis, it remains predominantly mild and asymptomatic, representing an acceptable and clinically manageable trade-off compared to the morbidity of total gastrectomy with Roux-en-Y reconstruction in appropriately selected patients.
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Authors Andrew Conner, Snigdha Gulati, Subin Lee, Gregory Jones, Andrew Feczko, Daniel P. Raymond, Siva Raja, Sudish C. Murthy, Monisha Sudarshan
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Journal diseases of the esophagus : official journal of the international society for diseases of the esophagus
Year 2026
DOI
10.1093/dote/doag077.396
URL
https://academic.oup.com/dote/article-pdf/39/Supplement_1/doag077.396/70760529/doag077.396.pdf
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