Anastomotic distance from the right gastroepiploic artery terminus is associated with anastomotic leakage after neoadjuvant immunochemotherapy and minimally invasive esophagectomy: a retrospective cohort study

Abstract

Abstract Background Minimally invasive esophagectomy (MIE) after neoadjuvant immunochemotherapy is standard for locally advanced esophageal cancer, but anastomotic leakage (AL) remains common and severe. Perfusion of the gastric conduit via the right gastroepiploic artery (RGEA) is critical. We investigated whether the distance from anastomosis to the distal RGEA terminus (anastomotic distance) is associated with AL. Methods This retrospective cohort study included 134 patients with esophageal squamous cell carcinoma undergoing MIE after neoadjuvant immunochemotherapy. Patients were stratified by anastomotic distance using a receiver operating characteristic (ROC)-derived cut‑off (6.1 cm). The primary outcome was AL. Associations were analyzed by logistic regression, restricted cubic spline (RCS), and piecewise regression with subgroup analyses. Results AL occurred in 21.6% of patients. Each 1‑cm increase in anastomotic distance independently predicted AL in the primary parsimonious model (adjusted OR 1.62, 95% CI 1.03–2.55, p = 0.035). RCS revealed a J-shaped nonlinear association ( p for nonlinearity = 0.031) with an exploratory inflection at 5.5 cm. Piecewise regression identified this exploratory inflection point. In the below-threshold segment (< 5.5 cm), no statistically significant association was detected (OR 0.519, 95% CI 0.192–1.404, p = 0.196); however, this does not establish all distances below 5.5 cm as uniformly safe. Notably, the shortest distances (Q1, < 5.06 cm) also showed elevated risk (adjusted OR 8.5, 95% CI 1.39 ~ 51.98), suggesting potential risk at both extremes. Distances ≥ 5.5 cm were associated with significantly increased AL risk (OR 2.943, 95% CI 1.117–7.752, p = 0.029). This exploratory threshold requires prospective validation. Conclusions Anastomotic distance from the RGEA terminus was independently associated with AL and exhibited a J-shaped association, with a sharp risk increase beyond 5.5 cm. Distances ≥ 5.5 cm were associated with significantly increased AL risk, while the shortest distances also showed elevated risk. The 5.5-cm threshold is exploratory and requires prospective validation.