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Page 6 of 12 Hambright et al. Mini-invasive Surg 2024;8:19 https://dx.doi.org/10.20517/2574-1225.2024.08

In a non-randomized single-center study from 2015, which specifically assessed intrathoracic hand-sewn
and linear staple techniques in 415 patients undergoing open Ivor Lewis esophagectomies, the hand-sewn
technique demonstrated a higher rate of anastomotic leakage (20.9% vs. 10%, P = 0.002) and anastomotic
stricture (20.3% vs. 6.3%, P = 0.002). However, overall morbidity, in-hospital mortality, and length of
hospital stay did not significantly differ between the two groups .
[27]
A systemic review and meta-analysis of anastomotic techniques, published in 2020, reviewed 37 studies and
included over 8,000 patients. The findings indicated that stapling techniques, especially the aforementioned
linear staple method, had lower rates of anastomotic leaks compared to hand-sewn techniques.
Additionally, the meta-analysis revealed that the linear staple technique exhibited lower rates of anastomotic
[28]
stricture compared to both circular stapling and hand-sewn anastomotic techniques .

Other studies examine the results of various anastomotic techniques performed specifically in a minimally
invasive setting. A retrospective study in 2019 by Zhang et al. evaluated 79 patients undergoing robotic Ivor
[29]
Lewis esophagectomy and compared linear-stapled anastomosis to circularly stapled anastomosis . The
findings indicated that the linear staple method exhibited a longer mean anastomosis time (63.0 vs.
44.2 min, P ≤ 0.001), with no significant differences observed in anastomotic leakage and post-operative
dysphagia when compared to the circularly stapled group . Additionally, a separate study, also published
[29]
in 2019, evaluated different anastomotic techniques in the setting of totally minimally invasive transthoracic
esophagectomy. In this study of 996 patients, it was found that the intrathoracic linear staple, circular staple
with purse-string, and cervical linear staple approaches had significantly lower anastomotic leakage rates
when compared to cervical hand-sewn techniques and intrathoracic circular staple using the double staple
technique . This is still a very active area of research within thoracic surgery, and the lack of published
[30]
randomized control trials, specifically in the robotic setting, makes it difficult to declare one specific
technique the best. However, the currently published studies support the notion that the stapled
anastomosis is faster and does not contribute to increased rates of strictures, leakage, or mortality in the
post-operative setting.

Researchers have studied whether the diameter of the circular stapler used affects esophagogastric
anastomosis outcomes. A 2021 study published by Tagkalos et al. evaluated this question, comparing 25 and
28 mm circular staple diameters . In their population of 349 Ivor-lewis patients, they found no differences
[31]
[31]
between the groups in rates of anastomotic insufficiency or strictures . A single-institution retrospective
study by Feingold et al. of 391 patients showed that using the 28 mm diameter circular stapler was
[32]
associated with a decreased need for additional dilations; however, this was not statistically significant .
While the issue of diameter in the context of circular staple technique is still being explored, the current
evidence supports little impact.

Regardless of the chosen technique, the primary objective is to create an anastomotic junction that is free of
tension and adequately perfused. Failing to achieve this goal can lead to conduit necrosis or anastomotic
stricture, with potentially devastating consequences.

PROCEDURE: HOW WE DO IT
Preparation
We use a completely portal technique for the thoracic and abdominal phases of esophagectomy. We
generally prefer an Ivor Lewis approach to resection, unless the tumor extends to 25 cm from the incisors or
above, in which case a McKeown approach is taken. Standard preoperative testing for medical fitness for
esophagectomy includes pulmonary function testing and a myocardial perfusion scan (stress test). Smoking