Impact of thoracic inlet anatomy and reconstruction route selection based on computed tomography three-dimensional reconstruction on cervical anastomotic leakage after esophagectomy.

BACKGROUND

Cervical anastomotic leakage is a serious complication following esophagectomy. The selection of the reconstruction route [posterior mediastinal (PM) vs. retrosternal (RS)] is often subjective, and the role of a narrow thoracic inlet as an independent risk factor remains underexplored. This study aimed to investigate the impact of thoracic inlet anatomy and reconstruction route selection based on computed tomography three‑dimensional reconstruction on cervical anastomotic leakage after esophagectomy.

METHODS

We conducted a retrospective analysis of 100 patients who underwent McKeown esophagectomy between October 2019 and October 2025. After propensity score matching, 33 patients were matched in both the PM and RS groups. Preoperative computed tomography (CT) images were used for three-dimensional reconstruction to measure reconstruction route length and thoracic inlet parameters, including thickness of the clavicle (TC), thickness of the sternum (TS), interclavicular distance (ICD), sternum-trachea distance (STD), sternum-vertebra distance (SVD), and thoracic diameters.

RESULTS

The RS route was significantly shorter than the PM route (336±39.3 vs. 356±32.1 mm, P<0.05). Multivariate regression analysis identified STD and thoracic horizontal diameter (HD) as independent risk factors for cervical anastomotic leakage.

CONCLUSIONS

The RS route is shorter than the PM route. A narrow thoracic inlet, characterized by a smaller STD and a larger HD, is a key risk factor for anastomotic leakage. Preoperative CT assessment of the thoracic inlet provides significant predictive value for surgical planning.