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de Pascale et al. Mini-invasive Surg 2019;3:18 I http://dx.doi.org/10.20517/2574-1225.2019.04 Page 7 of 10

Tumors Working Group, has been published: data obtained demonstrated a significant lower rate of PCs after
HIL compared to OIL, particularly for major respiratory complications (18% vs. 30%, respectively, in the two
groups); no differences in terms of long-term oncological outcomes were observed . The logical evolution
[14]
was to decrease invasiveness of IL, introducing thoracoscopy to obtain an even lower rate of postoperative
complications without negatively affecting the rate of anastomotic leaks and mortality. A literature review
of the last 7 years [Table 4] reports the results of retrospective comparisons between TMIIL and OIL. The
principal limits of these studies are represented by their retrospective nature, the fact that sometimes they
derived from subgroup analysis, and that the techniques to perform the intrathoracic anastomosis are
different: the Orvil technique, the technique with a circular stapler but with hand sewn purse string, a side-
to-side anastomosis with linear stapler, or a hand sewn anastomosis. Significant differences in terms of LOS,
blood loss, and PCs in favor of TMIIL were reported. The rate of anastomotic leaks does not seem to be
significantly different in the two groups, whereas operative time is generally longer for TMIIL.

The longer duration for TMIIL seems to be caused by the technical difficulty of performing the anastomosis ;
[19]
a similar result was found in our experience, where duration of surgery was longer for TMIIL even if the
difference was not significant. The new anastomotic technique implies a longer time but the results in terms
of anastomotic leaks do not seem to be different: in our experience, with the use of a thoracoscopic side-
to-side technique, the incidence of leaks was 7%, lower, even if not significantly, than the results of the
standardized anastomotic technique used in the HIL group.

As evidenced by Van Workum , anastomotic leaks and operative time represent the key elements in
[24]
the assessment achieving the learning curve plateau. In his multicenter retrospective analysis, the rate of
anastomotic leaks at the end of the learning curve was 4.4%, starting from an incidence of 18.8%; operative
time also decreased from 344 to 270 min.

The difficulties of thoracoscopic anastomosis are demonstrated by the change in technique reported in some
series during the learning curve: in Mungo’s small series, they moved from a circular transoral anastomosis
to a linear side-to-side anastomosis and ended again with the Orvil technique .
[25]

In our experience, these elements were the principal issues considered as limiting factors for the application
of TMIIL during stage 1 and 2a IDEAL recommendations.

Although the two groups are similar in terms of baseline characteristics, it is important to highlight that in
the HIL group more patients were submitted to neaodjuvant treatment than in the TMIIL group. Considering
the small size of our samples, it is difficult to evaluate how this might have influenced postoperative
complications. This topic has been widely evaluated in the current literature and controversial results have
been reported. In our experience, a direct correlation never emerged as reported by Woodard in the analysis
of this element in a comparison of two groups of patients submitted to HIL .
[26]
A low rate of PCs, associated with better QoL after surgery, with possible better long-term outcomes represents
the benchmark for which surgeons face the hard learning curve of TMIIL. As reported in Table 4, Tapias
and Wang obtained a significant reduction of respiratory complications after TMIIL; these data positively
influence the postoperative course in terms of LOS as well. The principal limit of these analyses is represented
by the fact that they are obtained from comparison between TMIIL and OIL, and it is widely demonstrated
that laparoscopic gastrolysis has a positive impact on this type of complication.

In our analysis, no differences were observed for respiratory complications in the two groups. Data obtained
from the analysis of the QoL questionnaire evidenced lower postoperative pain for patients submitted to
TMIIL and a faster recovery of health global status.