Endoscopy vs esophagram for routine anastomotic evaluation following McKeown esophagectomy: a retrospective cohort study

Background: The diagnostic value of esophagram (EP) for anastomotic evaluation after esophagectomy is limited. Endoscopy (ES) is a promising alternative to EP. Whether ES is superior to EP requires further investigation. Methods and materials: This retrospective cohort study enrolled 246 patients with esophageal cancer who underwent McKeown esophagectomy at Sun Yat-sen University Cancer Center between 2022 and 2023. On postoperative day (POD) 7, 107 patients who underwent routine ES for anastomotic evaluation were included in the ES group, while 139 patients who underwent routine EP were included in the EP group. The cutoff date was 1 July 2023. The primary endpoint was the diagnostic efficacy, including sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the two examinations for detecting anastomotic leakage (AL) during routine POD 7. Results: During follow-up, 25 cases (10.2%) of AL were confirmed, including 8 (7.5%) cases in the ES group and 17 (12.2%) cases in the EP group ( P = 0.22). Compared to EP, ES had significantly better sensitivity (ES vs. EP: 87.5% vs. 41.2%, P = 0.04) and NPV (99.0% vs. 92.4%, P = 0.03), while comparable specificity (100% vs. 99.2%, P = 1.00) and PPV (100% vs. 87.5%, P = 1.00) were observed. The overall diagnostic accuracy was significantly greater in the ES group (99.1% vs. 92.1%, P = 0.01). Among patients without AL at the first examination, the ES group had a significantly lower rate of post-intake AL than the EP group [1.0% (1/100) vs. 7.6% (10/131), P = 0.03]. Furthermore, the ES group also showed significantly earlier AL diagnosis [median (IQR): 7 (7–10) vs. 11 (9–12) days, P = 0.04] and shorter AL healing time [median (IQR): 14.5 (7.0–31.8) vs. 34 (27.5–41.5) days, P = 0.02] than the EP group. Conclusion: ES might be superior to EP for the routine evaluation of anastomosis after McKeown esophagectomy. Further studies are warranted.