Outcomes of Radical Esophagectomy with Left Cervical Tubular Gastric T-Type Anastomosis for Esophageal Cancer: A Single-Center Retrospective Cohort Study

Outcomes of Radical Esophagectomy with Left Cervical Tubular Gastric T-Type Anastomosis for Esophageal Cancer: A Single-Center Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Method Article Outcomes of Radical Esophagectomy with Left Cervical Tubular Gastric T-Type Anastomosis for Esophageal Cancer: A Single-Center Retrospective Cohort Study Yayun Sheng, Yonghui Quan, Shouqiang Yu, Zhiliang Zhou, Kunpeng Wu, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9129760/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Esophageal cancer, predominantly squamous cell carcinoma, remains a major health burden in China. Cervical anastomosis after esophagectomy offers a wider proximal margin but has historically been linked with higher leakage rates. We sought to evaluate the short- and long-term outcomes of a standardized left cervical T-type linear-stapled esophagogastric anastomosis using a narrow tubular gastric conduit through a small oblique incision, combined with two-field lymphadenectomy without routine cervical node dissection. Methods We retrospectively reviewed data from 36 consecutive patients with esophageal cancer who underwent radical esophagectomy with left cervical T-type anastomosis between January 2021 and June 2025. Perioperative complications (Clavien–Dindo), overall survival (OS), recurrence-free survival (RFS), and health-related quality of life (HRQoL; EORTC QLQ-C30 and QLQ-OES18) were analyzed. Cox proportional hazards models were used to identify independent prognostic factors. Results Median age was 70.5 years; 88.9% were male and had squamous cell carcinoma. R0 resection was achieved in 91.7%, with a median lymph node yield of 23. Any complication occurred in 15 patients (41.7%); anastomotic leak occurred in three (8.3%), all managed conservatively without reoperation. One patient developed intraoperative shock secondary to hemorrhage from the short gastric vessels, and another two patients (5.6%) required reoperation for bleeding. No 30-day or in-hospital mortality occurred. At a median follow-up of 18.5 months, nine patients (25.0%) died and 13 (36.1%) developed recurrence. In our multivariable models, lymphovascular invasion (LVI) and tumor length independently predicted worse RFS (HR 6.10, P = 0.015; HR 2.07, P = 0.032), while LVI (HR 5.74, P = 0.023) and adjuvant therapy (HR 0.08, P = 0.023) were independent predictors for OS. HRQoL global health status improved significantly from baseline to 12 months (mean 65.6 to 82.6, P = 0.026). In patients with complete data (n = 9), BMI trajectory showed a significant decrease from preoperative 22.2 ± 3.0 kg/m² to 20.1 ± 2.7 kg/m² at 3 months postoperatively (P = 0.003), with subsequent stabilization. Conclusions Left cervical T-type esophagogastric anastomosis with a tubular gastric conduit without routine cervical node dissection is safe, associated with a low rate of severe complications, and yields meaningful improvements in quality of life. A significant 3-month postoperative BMI decline (despite later stabilization) underscores the importance of standardized postoperative nutritional support. Adjuvant therapy independently improves overall survival. Omitting routine cervical lymphadenectomy is acceptable for most mid/distal tumors, though surveillance for cervical recurrence is warranted. Esophageal Cancer Esophagectomy Cervical Anastomosis T-type Anastomosis Complications Quality of Life Recurrence Figures Figure 1 Figure 2 Introduction Esophageal cancer continues to be a major clinical challenge, with high morbidity and mortality despite therapeutic advances [ 1 ] . In China, esophageal squamous cell carcinoma (ESCC) predominates, often presenting at locally advanced stages requiring multimodal treatment [ 2 – 4 ] . Surgical resection via esophagectomy is the cornerstone of curative therapy, but outcomes are heavily influenced by anastomotic technique, conduit geometry, and extent of lymphadenectomy [ 5 , 6 ] . Cervical esophagogastric anastomosis offers a more proximal resection margin and easier management of anastomotic leaks; however, it has historically been associated with higher leakage rates compared with intrathoracic anastomoses [ 7 ] . Recent refinements, such as linear-stapled “T-type” side-to-side techniques and narrow tubular gastric conduits (3–4 cm width), have emerged to reduce stricture formation and reflux while preserving conduit perfusion [ 8 – 13 ] . The totally mechanical Collard (TMC) method, a linear-stapled side-to-side anastomosis with stapled closure of the common enterotomy, has been shown to lower stricture rates compared with circular stapling [ 11 ] . At our center, we have standardized a left cervical approach using a tubular gastric conduit and T-type linear-stapled anastomosis through a small oblique incision [ 11 ] , combined with two-field lymphadenectomy without routine cervical node dissection [ 14 ] . This technique aims to balance oncological radicality with reduced morbidity and improved quality of life. Our primary objective was to assess the short- and long-term outcomes of this standardized approach in a consecutive cohort of patients with esophageal cancer. We report perioperative complications graded by the Clavien–Dindo classification, survival and recurrence patterns, and longitudinal HRQoL using validated EORTC instruments. Methods Study design and patients We performed a retrospective review of patients treated at Nanjing Lishui People’s Hospital and included all 36 consecutive patients with histologically confirmed esophageal cancer who underwent elective radical esophagectomy between January 2021 and June 2025. Inclusion criteria required complete clinicopathological data and a minimum follow-up of three months. Patients with incomplete records were excluded. The study protocol was approved by the Institutional Ethics Committee of Nanjing Lishui People’s Hospital (Approval #2025-KY-0424-01); the requirement for individual informed consent was waived because of the retrospective nature. Surgical technique (T-type anastomosis) All patients underwent minimally invasive Ivor-Lewis esophagectomy and left cervical tubular gastric T-type anastomosis. The stomach was mobilized and tubularized along the greater curvature to a width of 3–4 cm, ensuring preservation of the right gastroepiploic arcade. The esophagogastric anastomosis was uniformly performed in the left neck through a 4–5 cm oblique incision. A linear stapler was used to create a T-shaped, side-to-side, functional end-to-end anastomosis based on the totally mechanical Collard (TMC) principle (Fig. 2 in reference [ 11 ] ). Briefly, the tip of the gastric conduit (the most ischemic portion) was resected 3–5 cm from the top. The posterior wall of the gastric conduit and the remnant esophagus were aligned side by side. A 45-mm or 60-mm linear stapler was inserted through separate gastrotomy and esophagotomy to create a V-shaped posterior wall anastomosis. After placing a nasogastric tube, the anterior wall was closed using a 60-mm linear stapler in an everted fashion, thereby creating a T-shaped configuration (two perpendicular staple lines). The staple lines were routinely reinforced with interrupted 3 − 0 Vicryl sutures. A standard two-field lymphadenectomy (mediastinal and abdominal) was performed in all cases; cervical lymph nodes were not routinely dissected. R0 resection was defined as absence of tumor cells at all microscopic margins. Data collection and outcomes We collected baseline demographics, comorbidities, neoadjuvant/adjuvant therapy, operative details, and pathological data (8th-edition TNM, lymphovascular invasion [LVI], perineural invasion [PNI], lymph node yield). Postoperative complications were documented and graded according to the Clavien–Dindo classification. Primary endpoints were overall survival (OS) and recurrence-free survival (RFS). Recurrence sites were confirmed by imaging or biopsy. HRQoL was prospectively assessed at baseline, 3, 6, and 12 months postoperatively using the EORTC QLQ-C30 and QLQ-OES18 in a subset of 23 patients who completed all time points. Body mass index (BMI) was recorded at the same intervals in the subset of patients with complete longitudinal data (n = 9). Statistical analysis Continuous variables were described as median (interquartile range, IQR) or mean ± SD; categorical variables as frequencies. OS and RFS curves were generated using the Kaplan–Meier method, and differences were assessed by log-rank test. Univariable and multivariable Cox proportional hazards models were used to identify independent prognostic factors for OS and RFS. Variables with P < 0.10 on univariable analysis were entered into multivariable models. For HRQoL, overall changes across time points were evaluated by Friedman test, and linear mixed-effects models with Sidak correction for pairwise comparisons. BMI changes were analyzed by repeated-measures ANOVA. A two-sided P < 0.05 was considered significant. Analyses were performed using Stata/MP 16.0 and SPSS 22.0. Results Patient characteristics and perioperative outcomes Thirty-six patients were included. Patient demographics and clinical features are detailed in Table 1 . Median age was 70.5 years (IQR 65.5–75.5); 88.9% were male and 88.9% had squamous cell carcinoma. Median operative time was 235 min (IQR 190–305), estimated blood loss 100 mL (IQR 100–200). R0 resection was achieved in 33 patients (91.7%). Median lymph node yield was 23 (IQR 16–30); 18 patients (50.0%) were pN0. Table 1 Baseline and perioperative characteristics (N = 36) Characteristic Value Age, median (IQR), years 70.5 (65.5–75.5) Male, n (%) 32 (88.9) BMI, median (IQR), kg/m² 23.2 (20.3–24.3) Hypertension, n (%) 18 (50.0) Diabetes, n (%) 7 (19.4) COPD, n (%) 3 (8.3) Histology: SCC, n (%) 32 (88.9) Tumor length, median (IQR), cm 4 (3–5) Tumor location (cervical/upper/mid/lower), n 2/10/18/6 pT1/2/3/4a, n 3/5/24/4 pN0/1/2/3, n 18/10/6/2 LVI, n (%) 9 (25.0) PNI, n (%) 12 (33.3) Neoadjuvant therapy, n (%) 2 (5.6) Adjuvant therapy, n (%) 17 (47.2) R0 resection, n (%) 33 (91.7) Operative time, median (IQR), min 235 (190–305) Blood loss, median (IQR), mL 100 (100–200) Lymph node yield, median (IQR) 23 (16–30) ICU stay, median (IQR), h 17.5 (13.3–19) Postoperative stay, median (IQR), days 18 (15–24) Readmission, n (%) 3 (8.3) BMI, body mass index; COPD, chronic obstructive pulmonary disease; SCC, squamous cell carcinoma; LVI, lymphovascular invasion; PNI, perineural invasion; IQR, interquartile range; ICU, intensive care unit. Postoperative complications Any complication occurred in 15 patients (41.7%); severe (Clavien–Dindo ≥ III) in seven (19.4%). Pulmonary infection was most frequent (11 patients, 30.6%). Anastomotic leak occurred in three patients (8.3%); all were managed conservatively (endoscopic stenting or drainage), none required reoperation for leak. One patient developed intraoperative shock secondary to hemorrhage from the short gastric vessels. Management included intraoperative transfusion of 4 units of packed red blood cells, compression hemostasis, and postoperative blood transfusion. Another two patients (5.6%) underwent unplanned reoperation for bleeding (one thoracotomy on postoperative day 9 for aortoesophageal branch hemorrhage, one laparotomy on postoperative day 10 for short gastric vessel bleeding). No 30-day or in-hospital mortality occurred. Survival and recurrence Median follow-up was 18.5 months (range 3–55). During follow-up, nine patients (25.0%) died and 13 (36.1%) developed recurrence at a median of 13.0 months. Patterns of initial recurrence: locoregional (n = 6), distant (n = 6), both (n = 1). Notably, among 13 recurrences, three (23.1%) were isolated cervical lymph node metastases (undissected field) and three (23.1%) were anastomotic/perianastomotic. OS and RFS curves are illustrated in Fig. 1 . Prognostic factor analysis For RFS, univariable analysis showed tumor length (HR 1.87 per cm; 95% CI 1.05–3.32; P = 0.032), LVI (HR 7.44; 95% CI 2.16–25.65; P = 0.001), and nodal positivity (HR 6.99; 95% CI 1.55–31.59; P = 0.012) as predictors. In the multivariable model including tumor length, LVI, and N stage (Table 2 ), tumor length (adjusted HR 2.07; 95% CI 1.06–4.01; P = 0.032) and LVI (adjusted HR 6.10; 95% CI 1.42–26.18; P = 0.015) remained independent; N stage yielded HR 2.63 (95% CI 0.46–15.15; P = 0.279). Univariable Cox regression for OS identified LVI (HR 5.85; 95% CI 1.50–22.78; P = 0.011) and adjuvant therapy (HR 0.08; 95% CI 0.01–0.67; P = 0.003) as significant. In multivariable analysis adjusting for LVI and adjuvant therapy, both remained independent: LVI (adjusted HR 5.74; 95% CI 1.27–25.92; P = 0.023) and adjuvant therapy (adjusted HR 0.08; 95% CI 0.01–0.71; P = 0.023). Table 2 Multivariable Cox analysis for recurrence-free survival Variable Adjusted HR (95% CI) P value Tumor length (per cm) 2.07 (1.06–4.01) 0.032 LVI (present vs absent) 6.10 (1.42–26.18) 0.015 N stage (positive vs negative) 2.63 (0.46–15.15) 0.279 Model likelihood ratio χ²=19.56, P = 0.0002. Proportional hazards assumption satisfied (global P = 0.84). Health-related quality of life Longitudinal HRQoL data (23 patients) showed significant improvement in global health status (mean 65.6 baseline to 82.6 at 12 months, Friedman P = 0.026). Dysphagia and eating difficulties scores decreased markedly (both P < 0.001), with improvements sustained from three months onward (Fig. 2 ). BMI trajectory In patients with complete data (n = 9), BMI decreased from preoperative 22.2 ± 3.0 kg/m² to 20.1 ± 2.7 at three months (P = 0.003) and stabilized thereafter. Discussion This single-center series of 36 patients undergoing radical esophagectomy with a standardized left cervical T-type linear-stapled anastomosis with two-field lymphadenectomy without routine cervical node dissection demonstrates that this technique yields an acceptably low anastomotic leak rate (8.3%), no in-hospital mortality, and significant improvement in HRQoL by 12 months. The T-type (modified Collard) anastomosis, by creating a wider, compliant orifice, likely contributes to the low stricture rates and excellent functional recovery observed, consistent with prior reports comparing linear-stapled to circular stapled techniques [ 15 ] . All leaks were managed non-operatively, underscoring the reliability of this configuration. Three patients experienced massive intraoperative or postoperative hemorrhage, and two required reoperation. These findings emphasize the critical role of meticulous hemostasis, particularly in high-risk patients undergoing neoadjuvant therapy or extensive mediastinal dissection. The relatively higher hemorrhagic rate in our cohort may, at least in part, be associated with heterogeneity in surgeons’ intraoperative hemostatic preferences. At critical anatomical sites, some surgeons tend to perform preventive ligation or suture ligation, whereas others may rely primarily on energy-based devices without further reinforcement. In addition, differences in the hemostatic devices used, such as the ultrasonic scalpel [ 16 ] or LigaSure [ 17 , 18 ] , may also have influenced bleeding control. Variability in the management of intraoperative bleeding may have been another contributing factor. Whereas some bleeding sites were managed with compression using hemostatic materials, others were treated with direct suturing. Importantly, in the two patients who later underwent unplanned reoperation for postoperative bleeding, the initial intraoperative bleeding had been controlled mainly by compression with hemostatic materials. In one of these patients, slight splenic oozing remained visible at the time of abdominal closure. Both patients also received low-dose low-molecular-weight heparin postoperatively, which may have further increased the risk of delayed bleeding. These observations suggest that, when bleeding control is uncertain during surgery, more definitive hemostatic measures may be warranted rather than compression alone, and the postoperative use of low-molecular-weight heparin (LMWH) for anticoagulation should be avoided whenever possible. Although the hemorrhagic risk in our cohort appeared somewhat higher than that reported in comparable series, the overall reoperation rate remained 5.6%, with no perioperative mortality, which is still within an acceptable range [ 18 ] . Greater standardization of hemostatic techniques and careful balancing of thromboprophylaxis against bleeding risk may help reduce such complications in future practice. Our deliberate omission of routine cervical lymphadenectomy was guided by current Chinese guidelines recommending selective three-field dissection for upper thoracic tumors or suspicious nodes [ 19 ] . Only 23.1% of recurrences were isolated cervical nodal metastases, suggesting that routine neck dissection may be safely omitted in most patients with mid/lower thoracic tumors, thereby reducing recurrent laryngeal nerve injury and operative time without compromising survival. The strong independent protective effect of adjuvant therapy (adjusted HR 0.08) reinforces the importance of multimodal treatment, in line with long-term data from landmark trials [ 20 ] . Nevertheless, existing evidence has demonstrated that three-field lymph node dissection (3FLD), compared with two-field lymph node dissection (2FLD), can significantly improve long-term survival in selected patients, which merits further exploration in well-designed prospective studies [ 21 ] . In our cohort, 3 (23.1%) of all recurrences were anastomotic or perianastomotic in origin. For T-shaped anastomosis, surgical protocols mandate a minimum proximal tumor margin of 19.5 cm (45 mm stapler) or 21 cm (60 mm stapler) from the incisors [ 11 ] . Anastomotic and perianastomotic recurrence after surgery for middle and lower esophageal cancer may be explained by inadequate resection margins [ 22 ] or the advanced stage of the tumor [ 23 ] , while cervical OrVil anastomosis for upper esophageal cancer can achieve proximal shift of the anastomosis to improve R0 resection rates [ 18 , 24 ] . Our study has several limitations. First, the retrospective design, modest sample size, and relatively short follow-up period limit the strength and generalizability of the conclusions. Second, because some patients were lost to follow-up or were not evaluated face-to-face, BMI data beyond 3 months were unavailable for part of the cohort. Third, 2 patients who received neoadjuvant therapy were included within the 17 patients who received adjuvant therapy and were not analyzed separately. In addition, adjuvant therapy was not always initiated within the guideline-recommended time frame; in most cases, it began only after the detection of local recurrence or distant metastasis. Owing to the limited sample size, neither the timing nor the specific regimens of adjuvant therapy could be analyzed independently. Nevertheless, the standardized surgical protocol and repeated HRQoL assessments enhance the internal consistency and validity of our findings. Conclusion Left cervical T-type esophagogastric anastomosis with a tubular gastric conduit represents a safe and viable reconstructive option for the treatment of esophageal cancer, with a low rate of severe complications and favorable functional recovery. Continued nutritional support after discharge remains essential for postoperative recovery. Adjuvant therapy was independently associated with improved overall survival. Omission of routine cervical lymphadenectomy appears acceptable in most patients with middle or distal thoracic tumors, although careful surveillance for cervical recurrence remains necessary, further underscoring the critical role of adjuvant systemic therapy. This standardized approach represents a valuable option for esophageal reconstruction. Larger multicenter prospective studies are warranted to further refine patient selection for selective cervical lymphadenectomy and to confirm long-term oncologic safety. Abbreviations MIE: minimally invasive esophagectomy; TMC: totally mechanical Collard; CS: circular stapled; HRQoL: health-related quality of life; LVI: lymphovascular invasion; PNI: perineural invasion; OS: overall survival; RFS: recurrence-free survival; EORTC: European Organisation for Research and Treatment of Cancer. Declarations Ethics approval and consent to participate: Approved by the Institutional Review Board of Nanjing Lishui People’s Hospital (2025-KY-0424-01). Informed consent was waived due to the retrospective nature of the study. Consent for publication: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors’ contributions: Study conception: YS, YQ, SY, FL; data acquisition: YS, YQ, ZZ, KW, CZ, WD; analysis and interpretation: YS, YQ, SY, FL, SZ; drafting: YS, YQ, SY; critical revision: all authors; final approval: all authors. Acknowledgements: The authors thank the surgical team and patients at Nanjing Lishui People’s Hospital and Yijishan Hospital. Language polishing and statistical analysis of this manuscript were assisted by artificial intelligence tools. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9129760","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Method Article","associatedPublications":[],"authors":[{"id":606491318,"identity":"53a6cfd0-6bb8-4112-ace8-c54dacc58319","order_by":0,"name":"Yayun Sheng","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Yayun","middleName":"","lastName":"Sheng","suffix":""},{"id":606491319,"identity":"b842d647-5910-454e-a05e-12036d7d6ad3","order_by":1,"name":"Yonghui Quan","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Yonghui","middleName":"","lastName":"Quan","suffix":""},{"id":606491320,"identity":"4818da14-c434-49e0-9595-155da9fe71f8","order_by":2,"name":"Shouqiang Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYJACZhDBBiI+GNjYkaaFcUZBWjLxWsAMng+HGBsIKTe4kcD8uaDisGwf+9nDr20MDjAzsB8+uoGAFjbpGWcOG7fx5KVZ5xjc4WPgSUu7QUgLM2/b4cQ2hhwz4xyDZ8wMEjxmhLQwfwZr4X9jZmxhcJixgQgtDNJgLRI5xo8ZiNEieeZhmzTPmXTjNok3Zow9BmnJbIT8wnc8+fBnngpr2fn9OcYffvyxseNnP3wMrxaFA5CIAJFsEiAWGz7lICDfAKFBWpg/EFI9CkbBKBgFIxMAAA2uSZN86IUpAAAAAElFTkSuQmCC","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":true,"prefix":"","firstName":"Shouqiang","middleName":"","lastName":"Yu","suffix":""},{"id":606491321,"identity":"2fb28191-5556-4a80-925c-bf51c3c2310c","order_by":3,"name":"Zhiliang Zhou","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Zhiliang","middleName":"","lastName":"Zhou","suffix":""},{"id":606491322,"identity":"874e31d5-4230-4262-a0ae-15d6f13c6f9a","order_by":4,"name":"Kunpeng Wu","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Kunpeng","middleName":"","lastName":"Wu","suffix":""},{"id":606491323,"identity":"6b7c0383-a345-4f0c-9a82-0e0d63b1bccd","order_by":5,"name":"Chen Zhang","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Chen","middleName":"","lastName":"Zhang","suffix":""},{"id":606491324,"identity":"3f7cfc26-c355-4a7c-9970-c31d190bba27","order_by":6,"name":"Wen Du","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Wen","middleName":"","lastName":"Du","suffix":""},{"id":606491325,"identity":"015f5f4f-f840-4f99-9e03-53b6d0f6782c","order_by":7,"name":"Feng Liu","email":"","orcid":"","institution":"Nanjing Lishui People’s Hospital, Lishui Branch of Zhongda Hospital Affiliated to Southeast University","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Liu","suffix":""},{"id":606491326,"identity":"5d7b06ee-7470-4af8-80ec-f296e908c563","order_by":8,"name":"Shaojin Zhu","email":"","orcid":"","institution":"The First Affiliated Hospital of Wannan Medical University (Yijishan Hospital)","correspondingAuthor":false,"prefix":"","firstName":"Shaojin","middleName":"","lastName":"Zhu","suffix":""}],"badges":[],"createdAt":"2026-03-15 15:38:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9129760/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9129760/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104877288,"identity":"132df91c-44e4-4393-a613-d68efcdb3ed4","added_by":"auto","created_at":"2026-03-18 08:48:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":97384,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eKaplan Meier survival curves. (A) Overall survival, (B) Recurrence-free survival.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9129760/v1/44bf23a34a9e77e03a10fe47.png"},{"id":104877290,"identity":"173b3d15-edbc-4110-9212-c746f224d063","added_by":"auto","created_at":"2026-03-18 08:48:14","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":347424,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eHRQoL trajectories. (A) Physical functioning, (B) Global health status, (C) Dysphagia, (D) Eating difficulties.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9129760/v1/c2905b90c3519ef33bc507ad.png"},{"id":107567960,"identity":"d33d3711-e319-47f7-8b14-8de164841544","added_by":"auto","created_at":"2026-04-22 17:25:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":725537,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9129760/v1/74ff9d66-380c-40a1-9e33-80e30f053238.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eOutcomes of Radical Esophagectomy with Left Cervical Tubular Gastric T-Type Anastomosis for Esophageal Cancer: A Single-Center Retrospective Cohort Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEsophageal cancer continues to be a major clinical challenge, with high morbidity and mortality despite therapeutic advances \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In China, esophageal squamous cell carcinoma (ESCC) predominates, often presenting at locally advanced stages requiring multimodal treatment \u003csup\u003e[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Surgical resection via esophagectomy is the cornerstone of curative therapy, but outcomes are heavily influenced by anastomotic technique, conduit geometry, and extent of lymphadenectomy \u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Cervical esophagogastric anastomosis offers a more proximal resection margin and easier management of anastomotic leaks; however, it has historically been associated with higher leakage rates compared with intrathoracic anastomoses \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eRecent refinements, such as linear-stapled \u0026ldquo;T-type\u0026rdquo; side-to-side techniques and narrow tubular gastric conduits (3\u0026ndash;4 cm width), have emerged to reduce stricture formation and reflux while preserving conduit perfusion \u003csup\u003e[\u003cspan additionalcitationids=\"CR9 CR10 CR11 CR12\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. The totally mechanical Collard (TMC) method, a linear-stapled side-to-side anastomosis with stapled closure of the common enterotomy, has been shown to lower stricture rates compared with circular stapling \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. At our center, we have standardized a left cervical approach using a tubular gastric conduit and T-type linear-stapled anastomosis through a small oblique incision \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e, combined with two-field lymphadenectomy without routine cervical node dissection \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. This technique aims to balance oncological radicality with reduced morbidity and improved quality of life.\u003c/p\u003e \u003cp\u003eOur primary objective was to assess the short- and long-term outcomes of this standardized approach in a consecutive cohort of patients with esophageal cancer. We report perioperative complications graded by the Clavien\u0026ndash;Dindo classification, survival and recurrence patterns, and longitudinal HRQoL using validated EORTC instruments.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and patients\u003c/h2\u003e \u003cp\u003e We performed a retrospective review of patients treated at Nanjing Lishui People\u0026rsquo;s Hospital and included all 36 consecutive patients with histologically confirmed esophageal cancer who underwent elective radical esophagectomy between January 2021 and June 2025. Inclusion criteria required complete clinicopathological data and a minimum follow-up of three months. Patients with incomplete records were excluded. The study protocol was approved by the Institutional Ethics Committee of Nanjing Lishui People\u0026rsquo;s Hospital (Approval #2025-KY-0424-01); the requirement for individual informed consent was waived because of the retrospective nature.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique (T-type anastomosis)\u003c/h3\u003e\n\u003cp\u003eAll patients underwent minimally invasive Ivor-Lewis esophagectomy and left cervical tubular gastric T-type anastomosis. The stomach was mobilized and tubularized along the greater curvature to a width of 3\u0026ndash;4 cm, ensuring preservation of the right gastroepiploic arcade. The esophagogastric anastomosis was uniformly performed in the left neck through a 4\u0026ndash;5 cm oblique incision. A linear stapler was used to create a T-shaped, side-to-side, functional end-to-end anastomosis based on the totally mechanical Collard (TMC) principle (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e in reference \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e). Briefly, the tip of the gastric conduit (the most ischemic portion) was resected 3\u0026ndash;5 cm from the top. The posterior wall of the gastric conduit and the remnant esophagus were aligned side by side. A 45-mm or 60-mm linear stapler was inserted through separate gastrotomy and esophagotomy to create a V-shaped posterior wall anastomosis. After placing a nasogastric tube, the anterior wall was closed using a 60-mm linear stapler in an everted fashion, thereby creating a T-shaped configuration (two perpendicular staple lines). The staple lines were routinely reinforced with interrupted 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Vicryl sutures. A standard two-field lymphadenectomy (mediastinal and abdominal) was performed in all cases; cervical lymph nodes were not routinely dissected. R0 resection was defined as absence of tumor cells at all microscopic margins.\u003c/p\u003e\n\u003ch3\u003eData collection and outcomes\u003c/h3\u003e\n\u003cp\u003eWe collected baseline demographics, comorbidities, neoadjuvant/adjuvant therapy, operative details, and pathological data (8th-edition TNM, lymphovascular invasion [LVI], perineural invasion [PNI], lymph node yield). Postoperative complications were documented and graded according to the Clavien\u0026ndash;Dindo classification. Primary endpoints were overall survival (OS) and recurrence-free survival (RFS). Recurrence sites were confirmed by imaging or biopsy. HRQoL was prospectively assessed at baseline, 3, 6, and 12 months postoperatively using the EORTC QLQ-C30 and QLQ-OES18 in a subset of 23 patients who completed all time points. Body mass index (BMI) was recorded at the same intervals in the subset of patients with complete longitudinal data (n\u0026thinsp;=\u0026thinsp;9).\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were described as median (interquartile range, IQR) or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD; categorical variables as frequencies. OS and RFS curves were generated using the Kaplan\u0026ndash;Meier method, and differences were assessed by log-rank test. Univariable and multivariable Cox proportional hazards models were used to identify independent prognostic factors for OS and RFS. Variables with P\u0026thinsp;\u0026lt;\u0026thinsp;0.10 on univariable analysis were entered into multivariable models. For HRQoL, overall changes across time points were evaluated by Friedman test, and linear mixed-effects models with Sidak correction for pairwise comparisons. BMI changes were analyzed by repeated-measures ANOVA. A two-sided P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant. Analyses were performed using Stata/MP 16.0 and SPSS 22.0.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient characteristics and perioperative outcomes\u003c/h2\u003e \u003cp\u003eThirty-six patients were included. Patient demographics and clinical features are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Median age was 70.5 years (IQR 65.5\u0026ndash;75.5); 88.9% were male and 88.9% had squamous cell carcinoma. Median operative time was 235 min (IQR 190\u0026ndash;305), estimated blood loss 100 mL (IQR 100\u0026ndash;200). R0 resection was achieved in 33 patients (91.7%). Median lymph node yield was 23 (IQR 16\u0026ndash;30); 18 patients (50.0%) were pN0.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline and perioperative characteristics (N\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eValue\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (IQR), years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.5 (65.5\u0026ndash;75.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (88.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI, median (IQR), kg/m\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.2 (20.3\u0026ndash;24.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCOPD, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHistology: SCC, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (88.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor length, median (IQR), cm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (3\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor location (cervical/upper/mid/lower), n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/10/18/6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epT1/2/3/4a, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3/5/24/4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epN0/1/2/3, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/10/6/2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVI, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePNI, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (33.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeoadjuvant therapy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (5.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAdjuvant therapy, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (47.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR0 resection, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (91.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperative time, median (IQR), min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e235 (190\u0026ndash;305)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss, median (IQR), mL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (100\u0026ndash;200)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLymph node yield, median (IQR)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (16\u0026ndash;30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eICU stay, median (IQR), h\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17.5 (13.3\u0026ndash;19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative stay, median (IQR), days\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (15\u0026ndash;24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReadmission, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eBMI, body mass index; COPD, chronic obstructive pulmonary disease; SCC, squamous cell carcinoma; LVI, lymphovascular invasion; PNI, perineural invasion; IQR, interquartile range; ICU, intensive care unit.\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostoperative complications\u003c/h3\u003e\n\u003cp\u003eAny complication occurred in 15 patients (41.7%); severe (Clavien\u0026ndash;Dindo\u0026thinsp;\u0026ge;\u0026thinsp;III) in seven (19.4%). Pulmonary infection was most frequent (11 patients, 30.6%). Anastomotic leak occurred in three patients (8.3%); all were managed conservatively (endoscopic stenting or drainage), none required reoperation for leak. One patient developed intraoperative shock secondary to hemorrhage from the short gastric vessels. Management included intraoperative transfusion of 4 units of packed red blood cells, compression hemostasis, and postoperative blood transfusion. Another two patients (5.6%) underwent unplanned reoperation for bleeding (one thoracotomy on postoperative day 9 for aortoesophageal branch hemorrhage, one laparotomy on postoperative day 10 for short gastric vessel bleeding). No 30-day or in-hospital mortality occurred.\u003c/p\u003e\n\u003ch3\u003eSurvival and recurrence\u003c/h3\u003e\n\u003cp\u003eMedian follow-up was 18.5 months (range 3\u0026ndash;55). During follow-up, nine patients (25.0%) died and 13 (36.1%) developed recurrence at a median of 13.0 months. Patterns of initial recurrence: locoregional (n\u0026thinsp;=\u0026thinsp;6), distant (n\u0026thinsp;=\u0026thinsp;6), both (n\u0026thinsp;=\u0026thinsp;1). Notably, among 13 recurrences, three (23.1%) were isolated cervical lymph node metastases (undissected field) and three (23.1%) were anastomotic/perianastomotic. OS and RFS curves are illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePrognostic factor analysis\u003c/h2\u003e \u003cp\u003eFor RFS, univariable analysis showed tumor length (HR 1.87 per cm; 95% CI 1.05\u0026ndash;3.32; P\u0026thinsp;=\u0026thinsp;0.032), LVI (HR 7.44; 95% CI 2.16\u0026ndash;25.65; P\u0026thinsp;=\u0026thinsp;0.001), and nodal positivity (HR 6.99; 95% CI 1.55\u0026ndash;31.59; P\u0026thinsp;=\u0026thinsp;0.012) as predictors. In the multivariable model including tumor length, LVI, and N stage (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), tumor length (adjusted HR 2.07; 95% CI 1.06\u0026ndash;4.01; P\u0026thinsp;=\u0026thinsp;0.032) and LVI (adjusted HR 6.10; 95% CI 1.42\u0026ndash;26.18; P\u0026thinsp;=\u0026thinsp;0.015) remained independent; N stage yielded HR 2.63 (95% CI 0.46\u0026ndash;15.15; P\u0026thinsp;=\u0026thinsp;0.279).\u003c/p\u003e \u003cp\u003eUnivariable Cox regression for OS identified LVI (HR 5.85; 95% CI 1.50\u0026ndash;22.78; P\u0026thinsp;=\u0026thinsp;0.011) and adjuvant therapy (HR 0.08; 95% CI 0.01\u0026ndash;0.67; P\u0026thinsp;=\u0026thinsp;0.003) as significant. In multivariable analysis adjusting for LVI and adjuvant therapy, both remained independent: LVI (adjusted HR 5.74; 95% CI 1.27\u0026ndash;25.92; P\u0026thinsp;=\u0026thinsp;0.023) and adjuvant therapy (adjusted HR 0.08; 95% CI 0.01\u0026ndash;0.71; P\u0026thinsp;=\u0026thinsp;0.023).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariable Cox analysis for recurrence-free survival\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdjusted HR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTumor length (per cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.07 (1.06\u0026ndash;4.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.032\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLVI (present vs absent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.10 (1.42\u0026ndash;26.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eN stage (positive vs negative)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.63 (0.46\u0026ndash;15.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eModel likelihood ratio χ\u0026sup2;=19.56, P\u0026thinsp;=\u0026thinsp;0.0002. Proportional hazards assumption satisfied (global P\u0026thinsp;=\u0026thinsp;0.84).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eHealth-related quality of life\u003c/h2\u003e \u003cp\u003eLongitudinal HRQoL data (23 patients) showed significant improvement in global health status (mean 65.6 baseline to 82.6 at 12 months, Friedman P\u0026thinsp;=\u0026thinsp;0.026). Dysphagia and eating difficulties scores decreased markedly (both P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with improvements sustained from three months onward (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eBMI trajectory\u003c/h2\u003e \u003cp\u003eIn patients with complete data (n\u0026thinsp;=\u0026thinsp;9), BMI decreased from preoperative 22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 kg/m\u0026sup2; to 20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 at three months (P\u0026thinsp;=\u0026thinsp;0.003) and stabilized thereafter.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis single-center series of 36 patients undergoing radical esophagectomy with a standardized left cervical T-type linear-stapled anastomosis with two-field lymphadenectomy without routine cervical node dissection demonstrates that this technique yields an acceptably low anastomotic leak rate (8.3%), no in-hospital mortality, and significant improvement in HRQoL by 12 months. The T-type (modified Collard) anastomosis, by creating a wider, compliant orifice, likely contributes to the low stricture rates and excellent functional recovery observed, consistent with prior reports comparing linear-stapled to circular stapled techniques \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. All leaks were managed non-operatively, underscoring the reliability of this configuration.\u003c/p\u003e \u003cp\u003eThree patients experienced massive intraoperative or postoperative hemorrhage, and two required reoperation. These findings emphasize the critical role of meticulous hemostasis, particularly in high-risk patients undergoing neoadjuvant therapy or extensive mediastinal dissection. The relatively higher hemorrhagic rate in our cohort may, at least in part, be associated with heterogeneity in surgeons\u0026rsquo; intraoperative hemostatic preferences. At critical anatomical sites, some surgeons tend to perform preventive ligation or suture ligation, whereas others may rely primarily on energy-based devices without further reinforcement. In addition, differences in the hemostatic devices used, such as the ultrasonic scalpel \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e or LigaSure \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, may also have influenced bleeding control.\u003c/p\u003e \u003cp\u003eVariability in the management of intraoperative bleeding may have been another contributing factor. Whereas some bleeding sites were managed with compression using hemostatic materials, others were treated with direct suturing. Importantly, in the two patients who later underwent unplanned reoperation for postoperative bleeding, the initial intraoperative bleeding had been controlled mainly by compression with hemostatic materials. In one of these patients, slight splenic oozing remained visible at the time of abdominal closure. Both patients also received low-dose low-molecular-weight heparin postoperatively, which may have further increased the risk of delayed bleeding. These observations suggest that, when bleeding control is uncertain during surgery, more definitive hemostatic measures may be warranted rather than compression alone, and the postoperative use of low-molecular-weight heparin (LMWH) for anticoagulation should be avoided whenever possible.\u003c/p\u003e \u003cp\u003eAlthough the hemorrhagic risk in our cohort appeared somewhat higher than that reported in comparable series, the overall reoperation rate remained 5.6%, with no perioperative mortality, which is still within an acceptable range \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Greater standardization of hemostatic techniques and careful balancing of thromboprophylaxis against bleeding risk may help reduce such complications in future practice.\u003c/p\u003e \u003cp\u003eOur deliberate omission of routine cervical lymphadenectomy was guided by current Chinese guidelines recommending selective three-field dissection for upper thoracic tumors or suspicious nodes \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. Only 23.1% of recurrences were isolated cervical nodal metastases, suggesting that routine neck dissection may be safely omitted in most patients with mid/lower thoracic tumors, thereby reducing recurrent laryngeal nerve injury and operative time without compromising survival. The strong independent protective effect of adjuvant therapy (adjusted HR 0.08) reinforces the importance of multimodal treatment, in line with long-term data from landmark trials \u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. Nevertheless, existing evidence has demonstrated that three-field lymph node dissection (3FLD), compared with two-field lymph node dissection (2FLD), can significantly improve long-term survival in selected patients, which merits further exploration in well-designed prospective studies \u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn our cohort, 3 (23.1%) of all recurrences were anastomotic or perianastomotic in origin. For T-shaped anastomosis, surgical protocols mandate a minimum proximal tumor margin of 19.5 cm (45 mm stapler) or 21 cm (60 mm stapler) from the incisors \u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Anastomotic and perianastomotic recurrence after surgery for middle and lower esophageal cancer may be explained by inadequate resection margins \u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e or the advanced stage of the tumor \u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e, while cervical OrVil anastomosis for upper esophageal cancer can achieve proximal shift of the anastomosis to improve R0 resection rates \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur study has several limitations. First, the retrospective design, modest sample size, and relatively short follow-up period limit the strength and generalizability of the conclusions. Second, because some patients were lost to follow-up or were not evaluated face-to-face, BMI data beyond 3 months were unavailable for part of the cohort. Third, 2 patients who received neoadjuvant therapy were included within the 17 patients who received adjuvant therapy and were not analyzed separately. In addition, adjuvant therapy was not always initiated within the guideline-recommended time frame; in most cases, it began only after the detection of local recurrence or distant metastasis. Owing to the limited sample size, neither the timing nor the specific regimens of adjuvant therapy could be analyzed independently. Nevertheless, the standardized surgical protocol and repeated HRQoL assessments enhance the internal consistency and validity of our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eLeft cervical T-type esophagogastric anastomosis with a tubular gastric conduit represents a safe and viable reconstructive option for the treatment of esophageal cancer, with a low rate of severe complications and favorable functional recovery. Continued nutritional support after discharge remains essential for postoperative recovery. Adjuvant therapy was independently associated with improved overall survival. Omission of routine cervical lymphadenectomy appears acceptable in most patients with middle or distal thoracic tumors, although careful surveillance for cervical recurrence remains necessary, further underscoring the critical role of adjuvant systemic therapy. This standardized approach represents a valuable option for esophageal reconstruction. Larger multicenter prospective studies are warranted to further refine patient selection for selective cervical lymphadenectomy and to confirm long-term oncologic safety.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eMIE: minimally invasive esophagectomy; TMC: totally mechanical Collard; CS: circular stapled; HRQoL: health-related quality of life; LVI: lymphovascular invasion; PNI: perineural invasion; OS: overall survival; RFS: recurrence-free survival; EORTC: European Organisation for Research and Treatment of Cancer.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eApproved by the Institutional Review Board of Nanjing Lishui People\u0026rsquo;s Hospital (2025-KY-0424-01). Informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eStudy conception: YS, YQ, SY, FL; data acquisition: YS, YQ, ZZ, KW, CZ, WD; analysis and interpretation: YS, YQ, SY, FL, SZ; drafting: YS, YQ, SY; critical revision: all authors; final approval: all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eThe authors thank the surgical team and patients at Nanjing Lishui People\u0026rsquo;s Hospital and Yijishan Hospital. Language polishing and statistical analysis of this manuscript were assisted by artificial intelligence tools.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHooks O, Childers LT, Childers JT, et al. Role of anti-tumorigenic cytokines in gastrointestinal cancers. Cytokine Growth Factor Rev. 2026;87:54\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Wang W, Wang K, et al. Interleukin 13 participates in terminal differentiation of esophageal squamous cell carcinoma cells. J Gastrointest Oncol. 2022;13(4):1571\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZeng H, Zhang F, Sun Y, et al. Treatment options for neoadjuvant strategies of esophageal squamous cell carcinoma (Review). Mol Clin Oncol. 2024;20(1):4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWei Z, Wang L, Wang R, et al. Safety and effectiveness of induction chemoimmunotherapy followed by definitive radiotherapy or concurrent chemoradiotherapy in esophageal squamous cell carcinoma. World J Clin Oncol. 2025;16(3):101251.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Hagen P, Hulshof MCCM, van Lanschot JJB, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med. 2012;366(22):2074\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEyck BM, van Lanschot JJB, Hulshof MCCM, et al. Ten-Year Outcome of Neoadjuvant Chemoradiotherapy Plus Surgery for Esophageal Cancer: The Randomized Controlled CROSS Trial. J Clin Oncol. 2021;39(18):1995\u0026ndash;2004.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSabra MJ, Alwatari YA, Wolfe LG, et al. Ivor Lewis vs Mckeown esophagectomy: analysis of operative outcomes from the ACS NSQIP database. 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[in Chinese].\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Esophageal Cancer, Esophagectomy, Cervical Anastomosis, T-type Anastomosis, Complications, Quality of Life, Recurrence","lastPublishedDoi":"10.21203/rs.3.rs-9129760/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9129760/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEsophageal cancer, predominantly squamous cell carcinoma, remains a major health burden in China. Cervical anastomosis after esophagectomy offers a wider proximal margin but has historically been linked with higher leakage rates. We sought to evaluate the short- and long-term outcomes of a standardized left cervical T-type linear-stapled esophagogastric anastomosis using a narrow tubular gastric conduit through a small oblique incision, combined with two-field lymphadenectomy without routine cervical node dissection.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe retrospectively reviewed data from 36 consecutive patients with esophageal cancer who underwent radical esophagectomy with left cervical T-type anastomosis between January 2021 and June 2025. Perioperative complications (Clavien\u0026ndash;Dindo), overall survival (OS), recurrence-free survival (RFS), and health-related quality of life (HRQoL; EORTC QLQ-C30 and QLQ-OES18) were analyzed. Cox proportional hazards models were used to identify independent prognostic factors.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eMedian age was 70.5 years; 88.9% were male and had squamous cell carcinoma. R0 resection was achieved in 91.7%, with a median lymph node yield of 23. Any complication occurred in 15 patients (41.7%); anastomotic leak occurred in three (8.3%), all managed conservatively without reoperation. One patient developed intraoperative shock secondary to hemorrhage from the short gastric vessels, and another two patients (5.6%) required reoperation for bleeding. No 30-day or in-hospital mortality occurred. At a median follow-up of 18.5 months, nine patients (25.0%) died and 13 (36.1%) developed recurrence. In our multivariable models, lymphovascular invasion (LVI) and tumor length independently predicted worse RFS (HR 6.10, P\u0026thinsp;=\u0026thinsp;0.015; HR 2.07, P\u0026thinsp;=\u0026thinsp;0.032), while LVI (HR 5.74, P\u0026thinsp;=\u0026thinsp;0.023) and adjuvant therapy (HR 0.08, P\u0026thinsp;=\u0026thinsp;0.023) were independent predictors for OS. HRQoL global health status improved significantly from baseline to 12 months (mean 65.6 to 82.6, P\u0026thinsp;=\u0026thinsp;0.026). In patients with complete data (n\u0026thinsp;=\u0026thinsp;9), BMI trajectory showed a significant decrease from preoperative 22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0 kg/m\u0026sup2; to 20.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7 kg/m\u0026sup2; at 3 months postoperatively (P\u0026thinsp;=\u0026thinsp;0.003), with subsequent stabilization.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eLeft cervical T-type esophagogastric anastomosis with a tubular gastric conduit without routine cervical node dissection is safe, associated with a low rate of severe complications, and yields meaningful improvements in quality of life. A significant 3-month postoperative BMI decline (despite later stabilization) underscores the importance of standardized postoperative nutritional support. Adjuvant therapy independently improves overall survival. Omitting routine cervical lymphadenectomy is acceptable for most mid/distal tumors, though surveillance for cervical recurrence is warranted.\u003c/p\u003e","manuscriptTitle":"Outcomes of Radical Esophagectomy with Left Cervical Tubular Gastric T-Type Anastomosis for Esophageal Cancer: A Single-Center Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:48:08","doi":"10.21203/rs.3.rs-9129760/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"576207cc-0007-44fc-8c52-160103fdc369","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-22T17:24:35+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:48:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9129760","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9129760","identity":"rs-9129760","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}