Minimally Invasive Ivor Lewis Esophagectomy with Linear Stapled Anastomosis Associated with Low Leak and Stricture Rates

Anterior gastric wall anastomosis may lead to lower rate of delayed gastric emptying after minimally invasive Ivor Lewis esophagectomy: a retrospective cohort study

INTRODUCTION

In minimally invasive esophagectomy, a circular stapled anastomosis is common, but no evidence exists investigating the role of the specific localization of the anastomosis. The aim of this study is to evaluate the impact of an esophagogastrostomy on the anterior or posterior wall of the gastric conduit on the postoperative outcomes.

MATERIAL AND METHODS

All oncologic minimally invasive Ivor Lewis procedures, performed between 2017 and 2022, were included in this study. The cohort was divided in two groups: a) intrathoracic esophagogastrostomy on the anterior gastric wall of the conduit (ANT, n = 285, 65%) and b) on the posterior gastric wall (POST, n = 154, 35%). Clinicopathological parameters and short-term outcomes were compared between both groups by retrieving data from the prospective database.

RESULTS

Overall, 439 patients were included, baseline characteristics were similar in both groups, there was a higher proportion of squamous cell carcinoma in ANT (22.8% vs. 16.2%, P = 0.043). A higher rate of robotic-assisted procedures was observed in ANT (71.2% vs. 49.4%). Anastomotic leakage rate was similar in both groups (ANT 10.4% vs. POST 9.8%, P = 0.851). Overall complication rate and Clavien-Dindo > 3 complication rates were higher in POST compared to ANT: 53.2% vs. 40% (P = 0.008) and 36.9% vs. 25.7% (P = 0.014), respectively. The rate of delayed gastric emptying (20.1% vs. 7.4%, P < 0.001) and nosocomial pneumonia (22.1% vs. 14.8%, P = 0.05) was significantly higher in POST.

CONCLUSION

Patients undergoing minimally invasive Ivor Lewis esophagectomy with an intrathoracic circular stapled anastomosis may benefit from esophagogastrostomy on the anterior wall of the gastric conduit, in terms of lower rate of delayed gastric emptying.

Application of overlap anastomosis in digestive tract reconstruction during minimally invasive Ivor-Lewis esophagectomy

This study aims to assess the feasibility of the Overlap anastomosis technique in minimally invasive Ivor-Lewis esophagectomy. An accompanying video presentation elucidates our surgical procedures. A retrospective review of 46 patients diagnosed with middle and lower esophageal cancer was conducted. These patients underwent minimally invasive Ivor-Lewis esophagectomy with Overlap anastomosis between January 2019 and December 2020. A consistent team of surgeons performed all procedures. The initial phase involved laparoscopic stomach mobilization, intra-abdominal lymphadenectomies, and preparation of the tubular stomach. Subsequently, with the patient in the left decubitus position, thoracoscopy was used to dissect the esophagus, excise the diseased segment, and conduct mediastinal lymph node dissection. The final stage encompassed the intrathoracic gastroesophageal anastomosis using the Overlap method. All surgeries were completed without converting to an open approach, achieving complete resection. There were no operative fatalities, with an average surgery duration of 259.4 min. Average statistics included intraoperative blood loss of 92.3 ml, 16.2 lymph nodes dissected, and a postoperative hospital stay of 10.3 days. Postoperative complications comprised three instances of hoarseness due to recurrent laryngeal nerve palsy, two cases of aspiration pneumonia, one occurrence of chylothorax, and one gastric emptying disorder. Anastomotic technique-related complications were minimal, with only one patient experiencing an anastomotic leak that resolved spontaneously and two patients facing anastomotic stenosis, which was subsequently alleviated. Our findings posit that the Overlap anastomosis method is safe and efficient for minimally invasive Ivor-Lewis esophagectomy, marked by a notably low rate of anastomosis-related complications. Further evaluation of its long-term implications remains necessary.

Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging and machine learning in an experimental model for minimally invasive esophagectomy

INTRODUCTION

Esophagectomy is the mainstay of esophageal cancer treatment, but anastomotic insufficiency related morbidity and mortality remain challenging for patient outcome. Therefore, the objective of this work was to optimize anastomotic technique and gastric conduit perfusion with hyperspectral imaging (HSI) for total minimally invasive esophagectomy (MIE) with linear stapled anastomosis.

MATERIAL AND METHODS

A live porcine model (n = 58) for MIE was used with gastric conduit formation and simulation of linear stapled side-to-side esophagogastrostomy. Four main experimental groups differed in stapling length (3 vs. 6 cm) and simulation of anastomotic position on the conduit (cranial vs. caudal). Tissue oxygenation around the anastomotic simulation site was evaluated using HSI and was validated with histopathology.

RESULTS

The tissue oxygenation (ΔStO₂) after the anastomotic simulation remained constant only for the short stapler in caudal position (-0.4 ± 4.4%, n.s.) while it was impaired markedly in the other groups (short-cranial: -15.6 ± 11.5%, p = 0.0002; long-cranial: -20.4 ± 7.6%, p = 0.0126; long-caudal: -16.1 ± 9.4%, p < 0.0001). Tissue samples from avascular stomach as measured by HSI showed correspondent eosinophilic pre-necrotic changes in 35.7 ± 9.7% of the surface area.

CONCLUSION

Tissue oxygenation at the site of anastomotic simulation of the gastric conduit during MIE is influenced by stapling technique. Optimal oxygenation was achieved with a short stapler (3 cm) and sufficient distance of the simulated anastomosis to the cranial end of the gastric conduit. HSI tissue deoxygenation corresponded to histopathologic necrotic tissue changes. The experimental model with HSI and ML allow for systematic optimization of gastric conduit perfusion and anastomotic technique while clinical translation will have to be proven.

Robotic versus thoraco-laparoscopic minimally invasive Ivor Lewis esophagectomy, a matched-pair single-center cohort analysis

Minimally invasive esophagectomy (MIE) is becoming more widespread with a documented improvement in postoperative morbidity based on level I evidence. However, there is a lack of consensus regarding the optimal MIE approach, conventional thoracoscopy/laparoscopy vs robotics as well as the ideal anastomotic technique. All patients who underwent MIE via an Ivor Lewis approach with a side-to-side stapled anastomosis were included. The thoracoscopy-laparoscopy (TL) group was compared to the robotic group with respect to perioperative outcomes using the entire cohorts and after 1:1 propensity score matching. Comparisons were made using the Mann-Whitney U and Fisher's exact tests. Between July 2013 and November 2020, 72 TL and 67 robotic Ivor Lewis MIE were performed. After comparing the two unadjusted cohorts and 51 propensity matched pairs, there was a decrease in Clavien-Dindo Grade 2 or above complications in the robotic vs TL group (59.7% vs 41.8% [P = 0.042], (62.7% vs 39.2% [P = 0.029]), respectively. In both analyses, there was a reduction in hospital length of stay (median of 8 vs 7 days, P < 0.001) and a trend toward less anastomotic leaks in the robotic group (Unadjusted: 12.5 vs 3% [P = 0.057], Propensity-matched analysis: 13.7% vs 3.9% [P = 0.16]), respectively. A clinically significant decrease in overall morbidity, cardiac complications and hospital length of stay was observed in the robotic Ivor Lewis cohort when compared with the TL group at a high volume MIE program. Side-to-side stapled thoracic anastomoses utilizing a robotic platform provides the best outcomes in this single institution experience.

Acute gastric conduit dilation after minimally invasive esophagectomy: a 10-year experience

Despite decreasing overall morbidity with minimally invasive esophagectomy (MIE), conduit functional outcomes related to delayed emptying remain challenging, especially in the immediate postoperative setting. Yet, this problem has not been described well in the literature. Utilizing a single institutional prospective database, 254 patients who underwent MIEs between 2012 and 2020 were identified. Gastric conduit dilation was defined as a conduit occupying >40% of the hemithorax on the postoperative chest X-ray. Sixty-seven patients (26.4%) demonstrated acute conduit dilation. There was a higher incidence of conduit dilation in the patients who underwent Ivor Lewis esophagectomy compared to those with a neck anastomosis (67.2% vs. 47.1%; P = 0.03). Patients with dilated conduits required more esophagogastroduodenoscopies (EGD) (P < 0.001), conduit-related reoperations within 180 days (P < 0.001), and 90-day readmissions (P = 0.01). Furthermore, in 37 patients (25.5%) undergoing Ivor Lewis esophagectomy, we returned to the abdomen after intrathoracic anastomosis to reduce redundant conduit and pexy the conduit to the crura. While conduit dilation rates were similar, those who had intraabdominal gastropexy required EGD significantly less and trended toward a lower incidence of conduit-related reoperations (5.6% vs. 2.7%). Multivariable analysis also demonstrated that conduit dilation was an independent predictor for delayed gastric conduit emptying symptoms, EGD within 90 days, conduit-related reoperation within 180 days, and 30-day as well as 90-day readmission. Patients undergoing MIE with acute gastric conduit dilation require more endoscopic interventions and reoperations.

Transthoracic Esophagectomy: Hand-sewn Versus Side-to-side Linear-stapled Versus Circular-stapled Anastomosis: A Systematic Review and Meta-analysis

BACKGROUND

Three anastomotic techniques are mostly used to create an esophagogastric anastomosis in a transthoracic esophagectomy: hand-sewn (HS), side-to-side linear-stapled (SSLS), and circular-stapled (CS). The aim of this study was to compare surgical outcomes after HS, SSLS, and CS intrathoracic esophagogastric anastomosis.

MATERIALS AND METHODS

A systematic review using the MEDLINE database was performed to identify original articles analyzing outcomes after HS, SSLS, and CS esophagogastric anastomosis. The main outcome was an anastomotic leakage rate. Secondary outcomes included overall morbidity, major morbidity, and mortality. A meta-analysis of proportions and linear regression models were used to assess the effect of each anastomotic technique on the different outcomes.

RESULTS

A total of 101 studies comprising 12,595 patients were included; 8835 (70.1%) with CS, 2532 (20.1%) with HS, and 1228 (9.8%) with SSLS anastomosis. Anastomotic leak occurred in 10% [95% confidence interval (CI), 6%-15%], 9% (95% CI, 6%-13%), and 6% (95% CI, 5%-7%) of patients after HS, SSLS, and CS anastomosis, respectively. Risk of anastomotic leakage was significantly higher with HS anastomosis (odds ratio=1.73, 95% CI: 1.47-2.03, P<0.0001) and SSLS (odds ratio=1.68, 95% CI: 1.36-2.08, P<0.0001), as compared with CS. Overall morbidity (HS: 52% vs. SLSS: 39% vs. CS: 35%) and major morbidity (HS: 33% vs. CS: 19%) rates were significantly lower with CS anastomosis. Mortality rate was 4% (95% CI, 3%-6%), 2% (95% CI, 2%-3%), and 3% (95% CI, 3%-4%) after HS, SSLS, and CS anastomosis, respectively.

CONCLUSION

HS and SSLS intrathoracic esophagogastric anastomoses are associated with significantly higher rates of an anastomotic leak than CS anastomosis.

Indocyanine green (ICG) fluorescence imaging for prevention of anastomotic leak in totally minimally invasive Ivor Lewis esophagectomy: a systematic review and meta-analysis

BACKGROUND

Indocyanine green (ICG) fluorescence imaging is an emerging technology that might help decreasing anastomotic leakage (AL) rates. The aim of this study was to determine the usefulness of ICG fluorescence imaging for the prevention of AL after minimally invasive esophagectomy with intrathoracic anastomosis.

METHODS

A systematic literature review of the MEDLINE and Cochrane databases was performed to identify all articles on totally minimally invasive Ivor Lewis esophagectomy. Studies were then divided into two groups based on the use or not of ICG for perfusion assessment. Primary outcome was anastomotic leak. Secondary outcomes included operative time, ICG-related adverse reactions, and mortality rate. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for main outcomes.

RESULTS

A total of 3,171 patients were included for analysis: 381 (12%) with intraoperative ICG fluorescence imaging and 2,790 (88%) without ICG. Mean patients' age and proportion of males were similar between groups. Mean operative time was also similar between both groups (ICG: 354.8 vs. No-ICG: 354.1 minutes, P = 0.52). Mean ICG dose was 12 mg (5-21 mg). No ICG-related adverse reactions were reported. AL rate was 9% (95% CI, 5-17%) and 9% (95% CI, 7-12%) in the ICG and No-ICG groups, respectively. The risk of AL was similar between groups (odds ratio 0.85, 95% CI 0.53-1.28, P = 0.45). Mortality was 3% (95% CI, 1-9%) in patients with ICG and 2% (95% CI, 2-3%) in those without ICG. Median length of hospital stay was also similar between groups (ICG: 13.6 vs. No-ICG: 11.2 days, P = 0.29).

CONCLUSION

The use of ICG fluorescence imaging for perfusion assessment does not seem to reduce AL rates in patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis.

Comparison of Two Circular-Stapled Techniques for Esophageal Cancer: A Propensity-Matched Analysis

OBJECTIVE

The optimal technique for the thoracoscopic construction of an intrathoracic esophagogastric anastomosis continues to be a subject of controversy. The aim of this study was to compare the perioperative outcomes of circular-stapled anastomosis using a transorally inserted anvil (Orvil™) with those of circular-stapled anastomosis using a transthoracically placed anvil (non-Orvil™) in totally minimally invasive Ivor Lewis esophagectomy (Ivor Lewis TMIE).

METHODS

The data of 272 patients who underwent Ivor Lewis TMIE for esophageal cancer at multiple centers were collected from January 1, 2014 to December 31, 2017. After propensity score matching (1:1) for patient baseline characteristics, 65 paired cases were selected for statistical analysis. Logistic regression analysis was performed to investigate the significant factors of anastomotic leakage.

RESULTS

In the propensity score-matched analysis, compared with the non-Orvil™ group, the Orvil™ group was associated with a significantly shorter operation time (p=0.031), less intraoperative hemorrhage (p<0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p<0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p<0.001) and a lower postoperative anastomotic leakage rate (p=0.033). Multivariate logistic regression analysis showed that anastomotic technique and pulmonary infection were independent factors for the development of postoperative anastomotic leakage (p< 0.05).

CONCLUSIONS

Orvil™ anastomosis exhibited better perioperative effects than non-Orvil™ anastomosis after the propensity score-matched analysis. Remarkably, the Orvil™ technique contributed to a lower postoperative anastomotic leakage rate than the non-Orvil™ technique.

Surgical outcomes after totally minimally invasive Ivor Lewis esophagectomy. A systematic review and meta-analysis

BACKGROUND

A transthoracic esophagectomy is associated with high rates of morbidity. Minimally invasive esophagectomy has emerged to decrease such morbidity. The aim of this study was to accurately determine surgical outcomes after totally minimally invasive Ivor-Lewis Esophagectomy (TMIE).

METHODS

A systematic literature search was performed to identify original articles analyzing patients who underwent TMIE. Main outcomes included overall morbidity, major morbidity, pneumonia, arrhythmia, anastomotic leak, chyle leak, and mortality. A meta-analysis was conducted to estimate the overall weighted proportion and its 95% confidence interval (CI) for each analyzed outcome.

RESULTS

A total of 5619 patients were included for analysis; 4781 (85.1%) underwent a laparoscopic/thoracoscopic esophagectomy and 838 (14.9%) a robotic-assisted esophagectomy. Mean age of patients was 63.5 (55-67) years and 75.8% were male. Overall morbidity and major morbidity rates were 39% (95% CI, 33%-45%) and 20% (95% CI, 13%-28%), respectively. Postoperative pneumonia and arrhythmia rates were 10% (95% CI, 8%-13%) and 12% (95% CI, 8%-17%), respectively. Anastomotic leak rate across studies was 8% (95% CI, 6%-10%). Chyle leak rate was 3% (95% CI, 2%-5%). Mortality rate was 2% (95% CI, 2%-2%). Median ICU stay and length of hospital stay were 2 (1-4) and 11.2 (7-20) days, respectively.

CONCLUSIONS

Totally minimally invasive Ivor-Lewis esophagectomy is a challenging procedure with high morbidity rates. Strategies to enhance postoperative outcomes after this operation are still needed.

A safe and effective anastomotic technique for robot-assisted minimally invasive oesophagectomy: Reverse-puncture anastomosis

Background

Oesophagogastric anastomosis is mainly complicated by its tediousness. We hope to modify an oesophagogastric anastomotic technique that simplifies anastomosis.

Methods

We conducted a retrospective analysis of 57 cases executed using reverse‐puncture anastomotic (RPA) technique and 64 cases of manual purse anastomosis (MPA) technique for robot‐assisted minimally invasive oesophagectomy (RAMIE). Baseline characteristics and perioperative outcomes were analysed.

Results

There were no significant differences between the 2 groups with regards to demographic data and clinical features. All patients had R0 resection. Relative to MPA, RPA group experienced significantly shorter operation times (232.5 ± 33.84 min vs. 262.3 ± 83.94 min, p = 0.038).RPA group patients had shorter anastomotic times relative to MPA group patients (10.5 ± 3.4 min vs. 18.3 ± 4.1 min, p = 0.014). No adverse events were observed.

Conclusions

Reverse‐puncture anastomosis is safe, feasible in RAMIE. This approach has the potential to efficiently shorten the anastomotic time and ensure safe operation.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy

Background

Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique.

Methods

From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines.

Results

The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum.

Conclusion

Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-021-08715-4.

Minimally invasive Ivor Lewis esophagectomy: Robot-assisted versus laparoscopic-thoracoscopic technique. Systematic review and meta-analysis

BACKGROUND

Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis.

METHODS

A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes.

RESULTS

A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P < .0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P < .0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P < .001).

CONCLUSION

Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

Robotic-assisted Ivor Lewis esophagectomy, a review of the technique

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.

Side-to-side esophagogastric anastomosis for minimally invasive Ivor-Lewis esophagectomy: operative technique and short-term outcomes

Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50–1000 ml). The median overall length of stay was 13 (7–64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.

A long-term follow-up study of minimally invasive Ivor Lewis esophagectomy with linear stapled anastomosis

BACKGROUND

Minimally invasive esophagectomy (MIE) is increasingly performed to expect lower complication rate compared to open esophagectomy. Studies of minimally invasive Ivor Lewis esophagectomy (MIILE) with circular staplers have reported better outcomes compared to MIE with cervical anastomosis, but frequent anastomotic complications have also been reported. MIILE with linear staplers is a promising alternative, but the long-term functional and oncological outcomes are uncertain.

METHODS

To evaluate the functional and oncological outcomes of MIILE with linear stapled anastomosis, a retrospective cohort study was performed in 104 patients who underwent MIILE with linear stapled anastomosis for esophageal malignant tumors. The primary endpoints were the overall complication and anastomotic leak rates. The secondary endpoints were late complications, overall and disease-free survival, and nutritional status at 6 and 12 months after MIILE.

RESULTS

Anastomotic leak occurred in 4 patients (3.8%). The short-term complication rate of grade IIIb or higher was 6.7%. During a median 57-month follow-up period, anastomotic stricture occurred in one patient, 7 required hiatal hernia repair, and 2 underwent conduit revision surgery. The 5-year overall survival and disease-free survival rates were 69.3% and 59.5%, respectively. Status of reflux esophagitis at the time of most recent evaluation was grade N/A/B/C/D in 52/10/10/13/8 among 93 patients who had follow-up endoscopy. The mean body weight loss at 6 and 12 months after MIILE was 11.3 and 11.8% with maintenance of the serum albumin level.

CONCLUSIONS

MIILE with linear stapled anastomosis is a safe procedure with a low anastomotic complication rate and favorable long-term functional and survival outcomes.

The Circular Stapled Esophagogastric Anastomosis in Esophagectomy: No Differences in Anastomotic Insufficiency and Stricture Rates Between the 25 mm and 28 mm Circular Stapler

BACKGROUND

For patients undergoing an Ivor Lewis esophagectomy with a circular stapled anastomosis, the optimal diameter of the used circular stapler to restore continuity is unknown. The aim of this study was to compare the 25 mm stapled versus the 28 mm stapled esophagogastric anastomosis after Ivor Lewis esophagectomy, focusing on anastomotic insufficiency and postoperative anastomotic strictures.

METHODS

Between February 2008 and June 2019, 349 consecutive patients underwent Ivor Lewis esophagectomy with gastric conduit reconstruction and circular stapled anastomosis. Patient characteristics and postoperative results, such as anastomotic insufficiency rates, postoperative anastomotic stricture rates, time to anastomotic stricture rate, and the number of dilatations, were recorded in a prospective database and analyzed.

RESULTS

In 222 patients (64%), the 25 mm circular stapler was used and in 127 patients (36%) the 28 mm circular stapler was used. There were no differences in baseline characteristics. Anastomotic insufficiency rates were comparable between the 25 mm (12%) and the 28 mm groups (11%) (p = 0.751). There were no differences between postoperative anastomotic strictures in the 25 mm (14%) and the 28 mm groups (14%) (p = 0.863). Within patients with postoperative anastomotic strictures, a median number of 2 dilatations were observed in each group (p = 0.573) without differences in the time to first diagnosis (p = 0.412).

CONCLUSION

There were no differences in anastomotic insufficiency and postoperative anastomotic stricture rates between the 25 mm and the 28 mm circular stapled esophagogastric anastomosis after Ivor Lewis esophagectomy. Both the 25 mm and 28 mm stapler can be safely used to create a circular stapled esophagogastric anastomosis to restore continuity after esophagectomy.

Technique for Robotic Transhiatal Esophagectomy

Minimally invasive esophagectomy is increasing performed for cancers of the esophagus and gastroesophageal junction. This video demonstrates the setup and key steps for a robotic transhiatal esophagectomy with a cervical anastomosis.

Effectiveness and safety of bovine pericardium patch repair for cervical anastomotic leakage after oesophagectomy for cancer

Background

The objective of this study is to evaluate the effectiveness and safety of bovine pericardium patch (BPP) repair for cervical anastomotic leakage after esophageal squamous cancer.

Methods

Intractable cervical anastomotic leakage developed in 7 patients of esophageal squamous cell carcinoma undergoing cervical anastomosis. These patients received the BPP repair. The necrotic tissue around the cervical anastomosis was removed during the operation, and the defect was repaired with BPP according to the size of the leakage.

Results

The operative duration was 60-90 min (median, 75 min). There were no signs of recurrent anastomotic leakage in each patient undergoing BPP repair. Oral intake was initiated 5-8 days (median, 6 days) after the BPP repair operation without any discomfort.

Conclusions

The BPP repair is a safe and effective processing scheme for patients with cervical anastomotic fistula after resection of esophageal squamous cell carcinoma. This method may be recommended for appropriate patients with intractable cervical anastomotic fistula.