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Hambright et al. Mini-invasive Surg 2024;8:19 https://dx.doi.org/10.20517/2574-1225.2024.08 Page 5 of 12

ANASTOMOSIS
One of the most critical aspects of esophagectomy is the esophagogastric anastomosis, which, according to
the most recent meta-analysis, has a 9% incidence of anastomotic leak. This analysis also revealed that high-
volume centers (> 37 esophagectomies per year) had lower esophageal leak rates compared to centers of
lower volume [8.34% (95%CI = 7.54; 9.22) vs. 9.58% (95%CI = 8.76; 10.46), P = 0.043]. Furthermore, thoracic
anastomosis was associated with a lower anastomotic leak rate compared to cervical anastomosis (5.55% vs.
[20]
10.06%, P < 0.001) .
With this in mind, there are numerous approaches to this anastomosis, and understanding common
methods, their advantages, and disadvantages is imperative. The first method to consider is circular stapling;
this technique uses an anvil (either trans-oral or intra-thoracic approach is possible) and a circular stapler.
In the intra-thoracic approach, the anvil is inserted into the distal portion of the transected esophagus and
secured in place using a combination of a so-called “baseball” stitch with an overlying purse-string for
added security . The trans-oral approach differs in the fact that instead of advancing the anvil portion of
[21]
the mechanism into the distal esophagectomy directly, the anvil is guided through the oral cavity with the
use of a plastic guide tube into the distal esophagus. A small linear incision is made on the esophageal staple
line through which the plastic guide tube can be advanced by allowing for proper positioning of the anvil
within the esophagus. Once the anvil is positioned properly for anastomosis, the plastic guide tube can be
removed . In both approaches, the staple spike is then advanced through a proximal gastrotomy, pushed
[22]
through the gastric wall along the greater curvature, and connected to the anvil. After joining the anvil to
the handle, the stapler is fired, the handle is removed, and the open end of the conduit is closed. If an
omental flap was created, it can be wrapped around the staple line to provide an additional layer of
security . A propensity-matched study comparing trans-oral anvil placement to intrathoracic anvil
[21]
placement in patients undergoing MI-ILE found that the trans-oral anvil approach resulted in significantly
lower anastomotic leak rates (1.5% vs. 12.3%, P = 0.033), significantly lowered operating time (259 vs.
288 min, P = 0.031), and significantly lowered intraoperative hemorrhage (150 vs. 250 mL, P ≤ 0.001)
[23]
compared to patients that underwent intrathoracic anvil placement .

Another commonly used anastomotic technique is the linear staple method. This approach allows for the
creation of a wider conduit but necessitates a longer gastric conduit to complete the anastomosis
successfully. In this technique, a gastrotomy is created near the greater curvature of the posterior aspect of
the gastric conduit. The transected end of the esophagus and the gastric conduit are then stapled together
with a linear stapler, whether handheld by the assistant or robotically. The remaining opening can be either
stapled or hand-sewn. Hand-sewn techniques are more time-consuming but may offer advantages by
allowing more precise protection of the vascular supply to the conduit . Anchoring sutures can be placed
[24]
between the conduit and the right parietal pleura, particularly when performing an intrathoracic
anastomosis. These sutures help relieve tension from the anastomosis and have been associated with
reduced rates of anastomotic leakage .
[21]

With the multitude of approaches available for esophagogastric anastomosis, several studies have sought to
discern the most effective techniques in terms of efficiency and outcomes. A randomized controlled trial
conducted in 2007 compared circularly stapled intrathoracic anastomosis to cervical hand-sewn
anastomosis and revealed no significant differences in anastomotic leak, stricture rates, or long-term post-
operative outcomes . Similarly, a 2012 randomized controlled trial comparing hand-sewn anastomosis to
[25]
the linear staple technique for cervical esophagogastric anastomosis found no disparities in anastomotic leak
rates between the groups. However, the linear staple method exhibited a faster average anastomosis time
[26]
and a lower rate of anastomotic stricture at follow-up (20.7% vs. 8.6%, P = 0.045) .