A Phase II Randomised Controlled Trial Comparing Pulmonary Complications in Retrosternal vs. Posterior Mediastinal Gastric Conduit Placement in Patients Undergoing McKeown Minimally Invasive Esophagectomy.

Abstract

Introduction: Pulmonary complications are the commonest morbidity after esophageal resection for malignancy. Gastric conduit is commonly used for restoration of the continuity, and can be placed through either posterior mediastinal(PM) or retrosternal route(RS). The choice of the route can have significant effect on the incidence of post operative complication. The current study is a randomised controlled trial comparing post operative pulmonary complications(PPC) in patients undergoing conduit placement among these two routes.

Material and methods: Phase II RCT conducted in a tertiary care canter from August 2023 to January 2025. Thirty patients were included and randomised in two groups of 15 patients each, based upon the placement of the conduit i.e. either posterior mediastinal or retrosternal. Post-operative complications were studied and compared.

Result: Minor complications, classified as Clavien-Dindo grade I-II, were similar in both groups. Pulmonary complications were significantly more frequent in PM (p = 0.021), Anastomotic leaks did not differ among two groups (p = 0.465).FEV₁ and FVC values at 1 and 6 months were significantly reduced among patients with complications; however, the magnitude of decline was less pronounced in the RS group (p = 0.01,0.03). Subgroup analysis showed that patients with anastomotic leaks had longer conduit lengths than those without leaks, (p = 0.020). Univariate and multivariate analyses were performed and among the evaluated parameters, only the route of gastric conduit reconstruction showed a significant association, with complications occurring more frequently in the PM group than in the RS group (77.8% vs. 38.1%; p = 0.014). On multivariate logistic regression, the PM route emerged as an independent determinant of pulmonary complications (adjusted odds ratio 2.40; 95% CI, 1.05-5.80; p = 0.038).

Conclusion: RS gastric conduit reconstruction offers a safe and effective alternative to the PM route, reducing PPCs without significantly increasing anastomotic leak risk. Persistent pulmonary function decline remains linked to PPCs. Although limited by a small, single-centre cohort, these findings support RS reconstruction for patients at higher risk of pulmonary morbidity, warranting validation in larger multicentre studies.

Supplementary information: The online version contains supplementary material available at https://doi.org/10.1007/s13193-026-02555-1.