The Impact of Anastomosis Location in Patients with Lower Thoracic Esophageal Squamous Cell Carcinoma: A Retrospective Observational Study

Background: Several kinds of anastomoses with varying locations that can be performed after the surgical resection of lower thoracic esophageal squamous cell carcinoma. In this study, we evaluated the prognostic impact of anastomosis locations in these patients who underwent radical esophagectomy. Methods: Lower thoracic esophageal squamous cell carcinoma patients which underwent radical esophagectomy and confirmed as microscopically complete resection were retrospectively enrolled. Anastomoses below the aortic arch or below the azygos arch were defined as low anastomosis. Other anastomoses were defined as high anastomosis. Overall survival of these two kinds of anastomoses were analyzed using the log-rank test and Cox regression model. Results: Of the 781 patients enrolled, 196 and 585 were classified as the low anastomosis and high anastomosis groups, respectively. Overall, the survival time in low anastomosis group (median OS, 36.1 versus 65.4; P=0.01) was shorter than high anastomosis group but no statistical difference was observed in multivariate analysis (P=0.195). Again, no significant difference in survival between low anastomosis and high anastomosis group (median OS, 140.9 versus 124.8; P=0.345) were observed in pT1-T2 subgroup. In pT3-T4 subgroups, patients with low anastomosis group had significantly poorer survival that those with high anastomosis (median OS, 27.1 versus 42.9, P=0.003), even after controlling for other confounders (P=0.026). Notably, the impact of anastomosis location on long-term survival in pT3-4 patients was not significantly modified by nodal status. The internal validation of patients undergoing Sweet approach shown that pT3-T4 patients with high anastomosis had survival advantages (adjusted HR=0.711, 95%CI, 0.601 0.990, P=0.041) Conclusions: For lower thoracic esophageal squamous cell carcinoma with declared T3-4 status, low anastomosis is associated with worse prognosis and should be avoided.