Comparison of substernal and posterior mediastinal route of reconstruction after minimally invasive esophagectomy for esophageal cancer

Abstract

Background Substernal (ST) and posterior mediastinal (PM) routes are the two most common for reconstruction after esophagectomy with cervical anastomosis. Recent evidence showed similar outcomes between the routes; thus, the superior choice remained controversial. This study aimed to compare the short-term outcomes of the ST to the PM route for reconstruction after esophagectomy for esophageal cancer (EC). Method This retrospective cohort study included 132 patients who underwent McKeown minimally invasive esophagectomy (MIE) with gastric conduit for EC between March 2015 and December 2022. Among these, 89 and 43 patients received the ST route and PM route for reconstruction, respectively. Short-term outcomes including operative characteristics, postoperative morbidity, and mortality were evaluated. Result There was no conversion from ST to PM route. The ST group had longer operating time (375 min vs. 341 min). Oral feeding initiation, postoperative hospital stays, and overall complication rates were comparable in the two groups. The rate and severity of anastomotic leakage were similar between the groups. The ST group had a significantly lower incidence of postoperative ICU admission and pneumonia compared to the PM group (5.6% vs. 16.3% and 19.1% vs. 37.2%, respectively). Azygos vein bleeding, obstruction at feeding jejunostomy site, and conduit–trachea fistula were severe complications that only occurred in PM route. Conclusion ST route was superior to PM route in term of postoperative ICU admission and pneumonia. This route may prevent severe complications that only occur in PM route. ST route can be favorable option for reconstruction after McKeown MIE for EC.