Redefining Esophagectomy: The Manual Layered Insertion Method That May Reduce Anastomotic Leakage.

INTRODUCTION: Anastomotic leakage post-esophagectomy remains a significant challenge. Despite the use of both mechanical and manual anastomosis, leakage rates remain high. This study evaluated the effectiveness of the manual layered insertion anastomosis technique in addressing this issue. METHODS: A retrospective analysis was conducted on patients who underwent this technique from September 2020 to December 2021. The process involved thoracoscopic release of the esophagus, mediastinal lymph node dissection, laparoscopic stomach release, and its transformation into a tube. The latter was then guided to the neck for anastomosis. The posterior anastomotic wall was reshaped in the neck first for optimal insertion, followed by layered suturing with the gastric conduit. The anterior wall was subsequently sutured and repositioned into the chest. RESULTS: The study included 56 patients (51 men, five women, mean age 65.4 y), with nine having undergone neoadjuvant therapy. All received minimally invasive esophagectomy. Average intraoperative blood loss was 79.8 mL, operation time averaged 331 min, and feeding resumed after an average of 6.3 d. No anastomotic leakages were reported, with reduced incidences of anastomotic stenosis and gastric acid reflux compared to previous studies. CONCLUSIONS: The manual layered insertion anastomosis technique may reduce anastomotic leakage and associated complications, improving the efficacy of esophagectomy, which may improve postoperative results and patient quality of life, suggesting the method's potential suitability for wider clinical application.

Placing vacuum sponges in esophageal anastomotic leaks - how we do it.

PURPOSE: Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult. METHODS: We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits. RESULTS: Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation. CONCLUSION: We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.

Optimizing ischemic preconditioning for esophagogastric anastomosis: A standardized rat model to evaluate histological changes.

INTRODUCTION: A reproducible and simple model is essential for verifying gastric conduit vitality before esophagectomy. Ischemia is a major cause of esophagogastric anastomotic dehiscence and leakage. Ischemic conditioning of the stomach prior to esophageal surgery has been shown to lower the incidence of postoperative complications, including anastomotic leakage. However, the optimal timing and technique of ischemization remain uncertain. METHODS: Male Sprague-Dawley rats (n=24) were randomly divided into four groups: ischemic group - samples collected 1 hour after ischemia (I1H), ischemic group - samples collected 1 day after ischemia (I1D), ischemic group - samples collected 7 days after ischemia (I7D), and control group (C). Ischemia was induced by ligation of the left gastric (LGA) and short gastric arteries (SGA). The samples were verified using histological and macroscopic analysis, and the number and percentage of immunocompetent cells were determined. RESULTS: One hour after ischemization (I1H), ischemic denudation with mucosal erosion was observed, and the total number of eosinophils was significantly higher (p.

Advances in conduits and anastomotic techniques employed in esophageal cancer resections: A review.

Esophageal surgery has evolved significantly since the first esophagectomy, with advancements in diagnosis allowing medicine to keep pace with the disease's increasing incidence. Multimodal treatment improves outcomes, but surgical resection remains imperative for local control, with various techniques in existence but none demonstrating clear superiority. More recently, minimally invasive and robotic surgery have further reduced perioperative morbidity. This review discusses techniques for esophageal resection, with attention to the options available for anastomosis and reconstructive conduits.

Totally mechanical Collard versus circular stapled cervical esophagogastric anastomosis for minimally invasive esophagectomy.

BACKGROUND: Previous studies have proposed that the totally mechanical Collard (TMC) method may reduce anastomotic leakage and stricture. This study aimed to compare the TMC method and the circular stapled (CS) method for cervical anastomosis after minimally invasive esophagectomy (MIE) for esophageal cancer. METHODS: From May 2017 to September 2020, 308 patients (165 in the CS group and 143 in the TMC group) were included in this study. The primary endpoints were anastomotic leakage and anastomotic stricture within 12 months. Propensity score matching was used to control potential selection bias. RESULTS: Anastomotic leak, anastomotic stricture, and refractory stricture (≥ 3 dilations) occurred in 30 (9.7%), 28 (9.1%), and 18 (5.8%) patients, respectively. The rate of anastomotic leak was similar in the CS and TMC methods (9.7 vs. 9.8%; P = 0.978), but anastomotic stricture (3.5 vs. 13.9%; P = 0.001) and refractory stricture (2.8 vs. 9.1%, P = 0.022) occurred less frequently in the TMC method. Propensity score matching yielded 128 patient pairs and confirmed these results. Multivariable analyses found that CS method, anastomotic leakage, and diabetes were independent predictors for both anastomotic stricture and refractory stricture. Subgroup analysis revealed that for patients with anastomotic leakage, the postoperative hospital stay in the TMC group was significantly longer than that in the CS group. CONCLUSION: In cervical anastomosis after MIE, the TMC method is superior to the CS method regarding anastomotic stricture and refractory stricture formation. However, compared to the CS method, the TMC method cannot lower the probability of anastomotic leakage, and anastomotic leakage with the TMC method requires a longer healing time.

Circular-stapled esophagogastrostomy using the keyhole procedure after radical esophagectomy for esophageal cancer.

BACKGROUND: Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS). METHODS: We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery. RESULTS: Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001). CONCLUSIONS: The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

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.

Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis.

BACKGROUND: Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circular-stapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy. METHODS: PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. RESULTS: Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD -0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42). CONCLUSIONS: LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.

Association between bacterial growth in chest tube and anastomotic leakage after esophageal resection: prospective cohort study.

PURPOSE: The aim of this study was to examine whether collagenase producing bacteria could be detected, in fluid collected from chest tubes, before clinical presentation of anastomotic leakage after esophageal resection. METHODS: We conducted a prospective single-center study of patients who underwent resection of the gastroesophageal junction. All patients had a chest tube placed in the pleural cavity perioperatively. Drain fluid was collected and cultured from the first post-operative day and at time of routine removal of the drain (days 3-5). RESULTS: From January 2018 to July 2019, a total of 84 patients were included in the study. Twenty (36%) patients experienced severe complications with a Clavien-Dindo score of 3b-5. Eleven (13%) patients were diagnosed with anastomotic leakage which occurred after 8 days (mean, range 2-13). Twenty patients (24%) had drain samples with significant growth of microbes. Among the 11 patients with anastomotic leakage, we found 2 with microbe growth at POD 2 and POD 4, the remaining 9 samples were negative (p = 0.638). Thirty-day mortality rate was zero. CONCLUSION: Cultured fluid from the pleural cavity of asymptomatic patients following esophageal resection did not indicate a significant association with anastomotic leakage.

Chest drainage after oesophageal resection: A systematic review.

BACKGROUND: Modern enhanced recovery protocols discourage drain use due to negative impacts on patient comfort, mobility, and recovery, and lack of proven clinical benefit. After oesophagectomy, however, drains are still routinely placed. This review aimed to assess the evidence for, and how best to use chest drains after oesophageal surgery. METHODS: A systematic literature search was performed in Medline, Embase and Cochrane collaboration databases. Studies reporting outcomes for different types or uses of thoracic drainage, or outcomes related to drains after trans-thoracic oesophagectomy were included. Studies were collated into domains based on variations in number, position, type, removal criteria, diagnostic use and complications of drains. Methodological quality was assessed with Newcastle-Ottawa and Jadad scores. RESULTS: Among 434 potentially relevant studies, 27 studies met the inclusion criteria and these included 2564 patients. Studies that examined the number of drains showed pain reduction with a single drain compared to multiple drains (3 studies, n = 103), and transhiatal placement compared to intercostal (6 studies, n = 425). Amylase levels may aid diagnosis of anastomotic leak (9 studies, n = 888). Narrow calibre Blake drains may effectively drain both air and fluid (2 studies, n = 163). Drain removal criteria by daily drainage volumes of up to 300 mL did not impact subsequent effusion rates (2 studies, n = 130). Complications related directly to drains were reported by 3 studies (n = 59). CONCLUSION: Available evidence on the impact of thoracic drainage after oesophagectomy is limited, but has the potential to negatively affect outcomes. Further research is required to determine optimum drainage strategies.

Improved anastomotic leakage rates after the "flap and wrap" reconstruction in Ivor Lewis esophagectomy for cancer.

Anastomotic leakage after esophagectomy has serious consequences. In Ivor Lewis esophagectomy, a shorter and possibly better vascularized gastric conduit is created than in McKeown esophagectomy. Intrathoracic anastomoses can additionally be wrapped in omentum and concealed behind the pleura ("flap and wrap" reconstruction). Aims of this observational study were to assess the anastomotic leakage incidence after transhiatal esophagectomy (THE), McKeown esophagectomy (McKeown), Ivor Lewis esophagectomy (IL) without "flap and wrap" reconstruction, and IL with "flap and wrap" reconstruction. Consecutive patients undergoing esophagectomy at a tertiary referral center between January 2013 and April 2019 were included. Primary outcome was the anastomotic leakage rate. Secondary outcomes were postoperative outcomes, mortality, and 3-year overall survival. A total of 463 patients were included. The anastomotic leakage incidence after THE (n = 37), McKeown (n = 97), IL without "flap and wrap" reconstruction (n = 39), and IL with "flap and wrap" reconstruction (n = 290) were 24.3, 32.0, 28.2, and 7.2% (P < 0.001). THE and IL with "flap and wrap" reconstruction required fewer reoperations for anastomotic leakage (0 and 1.4%) than McKeown and IL without "flap and wrap" reconstruction (6.2 and 17.9%, P < 0.001). Fewer anastomotic leakages are observed after Ivor Lewis esophagectomy with "flap and wrap" reconstruction compared to transhiatal, McKeown and Ivor Lewis esophagectomy without "flap and wrap" reconstruction. The "flap and wrap" reconstruction seems a promising technique to further reduce anastomotic leakages and its severity in esophageal cancer patients who have an indication for Ivor Lewis esophagectomy.

Circular stapling anastomosis with indocyanine green fluorescence imaging for cervical esophagogastric anastomosis after thoracoscopic esophagectomy: a propensity score-matched analysis.

BACKGROUND: Thoracoscopic esophagectomy has been extensively used worldwide as a curative surgery for patients with esophageal cancer; however, complications such as anastomotic leakage and stenosis remain a major concern. Therefore, the objective of this study was to evaluate the efficacy of circular stapling anastomosis with indocyanine green (ICG) fluorescence imaging, which was standardized for cervical esophagogastric anastomosis after thoracoscopic esophagectomy. METHODS: Altogether, 121 patients with esophageal cancer who underwent thoracoscopic esophagectomy with radical lymph node dissection and cervical esophagogastric anastomosis from November 2009 to December 2020 at Tottori University Hospital were enrolled in this study. Patients who underwent surgery before the anastomotic method was standardized were included in the classical group (n = 82) and patients who underwent surgery after the anastomotic method was standardized were included in the ICG circular group (n = 39). The short-term postoperative outcomes, including anastomotic complications, were compared between the two groups using propensity-matched analysis and the risk factors for anastomotic leakage were evaluated using logistic regression analyses. RESULTS: Of the 121 patients, 33 were included in each group after propensity score matching. The clinicopathological characteristics of patients did not differ between the two groups after propensity score matching. In terms of perioperative outcomes, a significantly higher proportion of patients who underwent surgery using the laparoscopic approach (P < 0.001) and narrow gastric tube (P = 0.003), as well as those who had a lower volume of blood loss (P = 0.009) in the ICG circular group were observed after matching. Moreover, the ICG circular group had a significantly lower incidence of anastomotic leakage (39% vs. 9%, P = 0.004) and anastomotic stenosis (46% vs. 21%, P = 0.037) and a shorter postoperative hospital stay (30 vs. 20 days, P < 0.001) than the classical group. According to the multivariate analysis, the anastomotic method was an independent risk factor for anastomotic leakage after thoracoscopic esophagectomy (P = 0.013). CONCLUSIONS: Circular stapling anastomosis with ICG fluorescence imaging is effective in reducing complications such as anastomotic leakage and stenosis.

Intrathoracic hand-sewn esophagogastric anastomosis in prone position during totally minimally invasive two-stage esophagectomy for esophageal cancer.

Utilization of totally minimally invasive esophagectomy for cancer is on the rise. Esophagogastric anastomosis is mechanically or robotically performed routinely; little report exists of hand-sewn esophagogastric anastomosis. This is the largest so far study with thoracoscopic hand-sewn esophagogastric anastomosis during fully minimally invasive two-stage esophagectomy for esophageal cancer in prone position. Consecutive two-stage totally minimally invasive esophagectomies for cancer were performed by one surgical team, from September 2016 to March 2019. All operations were technically identical in terms of patient positioning, surgical approach, extend of lymphadenectomy and type of anastomosis formed. Primary end points were anastomotic leak and anastomotic stricture rate, while secondary end points were 30-day and 90-day mortality rates. From the overall n = 80 patients, n = 67 were males, while n = 13 were females. Mean age was 64.6 years. Mean length of stay was n = 14 days. There were no conversions to open. Mean operating time was 420 minutes with no blood loss over 200 mL noted. Pulmonary and cardiac complication rate was 23.75% and 2.5%, respectively. Anastomotic leak rate was 2.5%. Anastomotic strictures were seen in 12.5% of cases. 30-day and 90-day mortality rate was 2.5% and 5%, respectively, with none accounted for ischemic conduit complications. Intrathoracic anastomosis in totally minimally invasive esophagectomy is challenging and accountable for most of the mortality associated with the procedure. In thoracoscopic two-stage esophagectomy, a mechanical anastomosis is usually preferred; this is believed to be due to the complexity of manual anastomosis associated with the thoracoscopic approach. We aim to present our series of completely hand-sewn intrathoracic anastomosis utilizing a totally minimally invasive approach with favorable outcomes. With this study, reproducibility of the anastomosis is shown that can potentially favor a change in the practice of esophageal surgeons worldwide.

Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study.

BACKGROUND: Controversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients. METHODS: This retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year's worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation. RESULTS: Hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02). CONCLUSION: Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.

Variation in esophageal anastomosis technique-the role of collaborative learning.

Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one's own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

Autologous Activated Fibrin Sealant for the Esophageal Anastomosis: A Feasibility Study.

BACKGROUND: Esophageal cancer is surgically treated by means of an esophagectomy. However, esophagectomies are associated with high morbidity rates with dehiscence of the anastomosis occurring in 19% of these procedures in the Netherlands. Application of a fibrin sealant may improve mechanical strength of the anastomosis. The aim of this study was to determine the technical feasibility of the application of an autologous fibrin sealant by aerosolized spraying on esophageal anastomoses. METHODS: This study was designed as a single-center feasibility study. Patients undergoing elective minimal invasive esophageal surgery with the creation of a thoracic or a cervical anastomosis were eligible. Fibrin sealant (Vivostat) was applied to the anastomosis intraoperatively. Feasibility was measured using a nine-item checklist, designed for intraoperative application. RESULTS: In total, fifteen patients, between the ages of 43-79 y, were included in this study. One procedure scored eight out of nine points on the feasibility checklist, so application was considered as unsuccessful. The other fourteen procedures obtained a 100% score and were documented as successful procedures. Together, this led to a success rate of 93%. Grade III anastomotic leakage occurred in one of the fifteen patients (6.7%). CONCLUSIONS: This study showed that application of fibrin sealant on esophageal anastomoses is technically feasible and safe. Future studies may investigate the possible protective effects of fibrin sealant application on the development of anastomotic leakage. NCT03251040.

Triple-stapled quadrilateral anastomosis: a new technique for creation of an esophagogastric anastomosis.

BACKGROUND: Esophagogastric anastomosis performed after esophagectomy is technically complex and often the source of postoperative complications. The best technique for this anastomosis remains a matter of debate. We describe a new all-stapled side-to-side anastomosis, which we refer to as triple-stapled quadrilateral anastomosis (TRIQ), that can be performed after minimally invasive surgery, and we report results of a retrospective evaluation of postoperative outcomes among the 60 patients in whom this anastomosis has been performed thus far. METHODS: The anastomosis is created by apposition of the posterior walls of the esophagus and stomach. A linear stapler is applied to create a V-shaped posterior anastomotic wall. The anterior wall is closed in a gentle chevron-like shape with the use of 2 separate linear staplers, resulting in a wide quadrilateral anastomosis. The anastomosis is then wrapped with a greater omentum flap. RESULTS: The patient group comprised 48 men and 12 women with a mean age of 67.8 years. Neoadjuvant chemotherapy was performed in 43 of these patients. Neither the thoracoscopic or laparoscopic procedure was converted to open surgery in any patient. The median operation time was 474 min (range 680-320 min). The intraoperative blood loss volume was 104.4 mL (range 240-30 mL). There were no anastomosis-related complications above Clavien-Dindo grade II. CONCLUSIONS: TRIQ can be performed easily and safely, and good short-term outcome can be expected.

Modified anastomotic technique for thoracolaparoscopic Ivor Lewis esophagectomy: early outcomes and technical details.

Thoracoscopic intrathoracic esophagogastrostomy is a technically demanding operation; these technical requirements restrict the extensive application of minimally invasive Ivor Lewis esophagectomy. In an attempt to reduce the difficulty of this surgical procedure, we developed a modified anastomotic technique for thoracolaparoscopic Ivor Lewis esophagectomy. During the entirety of this modified approach, neither technically challenging operations such as intrathoracic suturing, or knotting, nor special instruments such as an OrVil system or a reverse-puncture head are required. Between Octomber 2015 and January 2016, 15 consecutive patients with cancer in the distal third of the esophagus or the gastric cardia underwent this modified surgical procedure. The good short-term outcomes that were achieved suggest that the modified anastomotic technique is safe and feasible for thoracolaparoscopic Ivor Lewis esophagectomy.

Modified anastomotic technique for thoracolaparoscopic Ivor-Lewis esophagectomy: early outcomes and technical details.

Thoracoscopic intrathoracic esophagogastrostomy is a technically demanding operation; these technical requirements restrict the extensive application of minimally invasive Ivor-Lewis esophagectomy. In an attempt to reduce the difficulty of this surgical procedure, this study developed a modified anastomotic technique for thoracolaparoscopic Ivor-Lewis esophagectomy. During the entirety of this modified approach, neither technically challenging operations such as intrathoracic suturing or knotting, nor special instruments such as an OrVil system or a reverse-puncture head are required. Between October 2015 and January 2016, 15 consecutive patients with cancer in the distal third of the esophagus or the gastric cardia underwent this modified surgical procedure. The good short-term outcomes that were achieved suggest that the modified anastomotic technique is safe and feasible for thoracolaparoscopic Ivor-Lewis esophagectomy.

A comparison of cervical delta-shaped anastomosis and circular stapled anastomosis after esophagectomy.

BACKGROUND: The delta-shaped anastomosis has been reported to reduce anastomotic complications for a decade. However, little has been written comparing this technique with the circular stapler technique. The objective of this retrospective study was to assess the safety and efficacy of cervical delta-shaped anastomosis after esophagectomy. METHODS: Medical records of patients with esophageal squamous cell carcinoma who underwent McKeown (three-incision) esophagectomy between September 2013 and June 2015 were reviewed. Either circular stapled anastomosis (CSA) or delta-shaped anastomosis (DSA) was performed at the cervical stage. The clinical characteristics and short-term outcome were retrospectively assessed to identify the differences between the two groups. RESULTS: A total of 81 patients were included in this study. The clinical characteristics were similar between the two groups. Cervical anastomotic leakage occurred in 3 (7.7%) of 39 patients in the DSA group and in 8 (19%) of 42 patients in the CSA group (P = 0.197). The average anastomotic orifice width was 16.1 ± 4.9 mm and 11.7 ± 2.2 mm, respectively (P < 0.001). The incidence of anastomotic stenosis was 2.6% (1/39) and 23.5% (10/42) in the DSA and CSA groups, respectively (P = 0.007). There was no significant difference in surgical duration, blood loss, pulmonary complication, postoperative mortality, time of hospitalisation and time of ICU stay between the two groups. CONCLUSIONS: Delta-shaped anastomosis may be an effective alternative method for gastroesophageal anastomosis after esophagectomy, with lower incidence of leakage and stenosis.