Impact of Upper Mediastinal Anatomy and Anastomotic Position on Anastomotic Leakage After Transcervical–Hiatal Subtotal Esophagectomy With Posterior Mediastinal Reconstruction

Abstract

Introduction

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.

Materials and Methods

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.

Results

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.

Conclusions

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.