# Survival outcomes of intrathoracic vs. cervical anastomosis post-esophagectomy in middle and lower thoracic esophageal squamous cell carcinoma: a retrospective propensity score matching analysis

## TL;DR

This study compares long-term survival outcomes of two surgical techniques for esophageal cancer and finds that initial survival benefits of one technique disappear after adjusting for other factors.

## Contribution

The novel contribution is the use of propensity score matching to assess the true impact of anastomotic technique on survival in esophageal cancer patients.

## Key findings

- Cervical anastomosis initially showed better survival outcomes compared to intrathoracic anastomosis.
- After adjusting for confounding factors, the survival advantage of cervical anastomosis disappeared.
- Tumor stage and lymphovascular invasion were stronger predictors of survival than anastomotic technique.

## Abstract

This study aimed to compare long-term survival outcomes between cervical anastomosis (CA) and intrathoracic anastomosis (IA) in patients with middle and lower thoracic esophageal squamous cell carcinoma (ESCC).

A retrospective cohort analysis was conducted on 571 patients who underwent esophagectomy at a single institution. Patients were stratified into CA and IA groups based on anastomotic technique. Propensity score matching (PSM, 1:1) was applied to balance baseline covariates. Overall survival (OS) and disease-free survival (DFS) were evaluated using Kaplan-Meier analysis and Cox regression. Secondary outcomes included postoperative complications.

In the unmatched cohort, CA demonstrated superior OS (median: 51.17 vs. 34.50 months; HR: 1.368, 95% CI: 1.062–1.763; p=0.015) and DFS (median: 45.07 vs. 28.87 months; HR: 1.289, 95% CI: 1.013–1.641; p=0.039) compared to IA. However, after PSM, the survival advantage attenuated (OS: HR = 1.303, 95% CI: 0.953–1.780, p=0.097; DFS: HR = 1.295, 95% CI: 0.962–1.744, p=0.089). Multivariate analysis identified pathological T3/T4 stages (OS: p=0.002–0.009; DFS: p<0.001) and lymphovascular invasion (DFS: p=0.023) as dominant prognostic factors, overshadowing anastomotic technique. The CA group exhibited more extensive lymph node dissection (>7 stations, p<0.001), but short-term mortality (30-/90-day) did not differ between groups (p≥0.382).

In conclusion, our study suggests that there may be a potential survival advantage of CA over IA in patients undergoing esophagectomy for ESCC. However, the initial survival benefits associated with CA diminished after adjusting for confounding factors.