Gastroesophageal Reflux after Mckeown Esophagectomy with Embedded or Non- Embedded Anastomosis: a Propensity Score Matched Cohort Study

Backgrounds: Gastroesophageal reflux lowers the quality of life (QoL) in patients with esophageal cancer after esophagectomy with gastric conduits. This study aimed to investigate the incidence of gastroesophageal reflux, dysphagia, and QoL among patients with esophageal cancer undergoing embedded and non-embedded anastomosis during Mckeown esophagectomy. Materials and methods: Data from patients who underwent Mckeown esophagectomy for esophageal cancer from March 2022 to December 2022 were retrospectively analyzed. The incidence of gastroesophageal reflux, dysphagia, and QoL were measured. We included 218 patients, including 155 patients undergoing non-embedded anastomosis (NA group) and 63 patients undergoing embedded anastomosis (EA group). Propensity score matching was used to provide a balanced cohort consisting of 63 paired cases. Patients’ demographics and clinical data were compared between the two arms. Results: Before propensity score matching, there were no significant differences between the two arms in terms of sex, age, body mass index, or comorbidities. Neoadjuvant therapy was the only unbalanced variable. After propensity matching, baseline characteristics were all comparable between the two arms. Anastomotic leakage occurred in 1 (1.6%) patient in the embedded anastomosis arm and in 2 patients (3.2%) in the non-embedded anastomosis arm (P = 1.000). Forty-one (65.1%) patients in the non-embedded anastomosis arm and fifty-one (81%) patients in the embedded anastomosis arm slept in the supine position without reflux (P = 0.045). Multivariable logistic regression analysis in the matched cohorts [OR (95% CI): 2.539 (1.084, 5.949), P = 0.032] showed that embedded anastomosis was the only protective factor against gastroesophageal reflux. Evaluation of quality of life showed embedded anastomosis was superior to non-embedded anastomosis in the pain domain (P = 0.036) of EORTC QLQ-OES18. No significant difference was observed in dysphagia severity, measured by Mellow-Pinkas Scale, or dysphagia subscale of QoL. Conclusion: Embedded anastomosis achieved sufficient control of gastroesophageal reflux without causing dysphagia. It also improved QoL compared with non-embedded anastomosis.