title: Neoadjuvant chemoradiotherapy may increase the risk of severe anastomotic complications after esophagectomy with cervical anastomosis.
abstract: OBJECTIVE
  Neoadjuvant chemoradiotherapy (nCRT) improves long-term survival for patients with esophageal cancer. On the other hand, there are indications that nCRT may increase the risk for postoperative morbidity. The aims of this study were to estimate the radiation exposure to the site of anastomosis on the gastric fundus and to assess whether nCRT affected the incidence or severity of cervical anastomotic complications.
  
  
  METHODS
  A retrospective cohort of patients with cancer of the esophagus or gastroesophageal junction, who were reconstructed with cervical anastomosis. The planned radiation dose to the site of the cervical anastomosis on the gastric fundus was estimated for each patient.
  
  
  RESULTS
  The analysis of the dose plans showed that 20 out of 22 (93 %) available patients received radiotherapy toward the planned site of the anastomosis in the region of the gastric fundus with doses ranging from 6 to 40 Gy. In the nCRT group, 12 out of 28 patients (43 %) had anastomotic complications compared to 16 out of 42 (38 %) in the non-RT group (p = 0.69). In the nCRT group, 39 % had anastomotic complications that led to a Clavien-Dindo grade of IVa or higher compared to 17 % in the non-RT group (p = 0.03). The OR for Clavien-Dindo grade IVa or worse was 6.0 (95 % CI 1.52-23.50).
  
  
  CONCLUSIONS
  This small retrospective study suggests that nCRT exposes the future anastomotic site to doses of radiation that may impair healing of the subsequent cervical anastomosis. Our data further suggest that nCRT may increase the severity of cervical anastomotic complications, and this hypothesis needs to be tested in a large prospective study.
authors.affiliation: Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden. fredrik.klevebro@ki.se.|Centre for Digestive Diseases, Karolinska University Hospital, K53 14186, Stockholm, Sweden. fredrik.klevebro@ki.se.
authors.forename: Fredrik
authors.identifier: http://orcid.org/0000-0002-1695-4103
authors.initials: F
authors.lastname: Klevebro
authors.affiliation: Department of Oncology, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Signe
authors.initials: S
authors.lastname: Friesland
authors.affiliation: Department of Oncology, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Mattias
authors.initials: M
authors.lastname: Hedman
authors.affiliation: Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Jon A
authors.initials: JA
authors.lastname: Tsai
authors.affiliation: Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Mats
authors.initials: M
authors.lastname: Lindblad
authors.affiliation: Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Rouvelas
authors.affiliation: Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Lundell
authors.affiliation: Division of Surgery, Department of Clinical Science Intervention and Technology, Karolinska Institutet, and Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.
authors.forename: Magnus
authors.initials: M
authors.lastname: Nilsson
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical / Q000009:adverse effects; D002277:Carcinoma / Q000628:therapy*; D059186:Chemoradiotherapy, Adjuvant / Q000009:adverse effects*; D004938:Esophageal Neoplasms / Q000628:therapy*; D016629:Esophagectomy / Q000009:adverse effects*; D004943:Esophagogastric Junction; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009333:Neck; D020360:Neoadjuvant Therapy / Q000009:adverse effects*; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies
keywords: Anastomotic complications; Esophageal cancer; Neoadjuvant chemoradiotherapy