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Page 12 of 14 Parthasarathi et al. Mini-invasive Surg 2019;3:20 I http://dx.doi.org/10.20517/2574-1225.2019.10

we performed the circular anastomosis. Till the level of the azygous arch, we have completed hand sewn or
linear staple anastomosis. Presently Our preferred technique of anastomosis is circular stapler technique
if the level of the anastomosis is above the level of azygous arch and at the level of azygous or below the
azygous arch hand-sewn technique because of better ergonomics. In robotic cases because of ease of
suturing, we prefer hand-sewn anastomosis in all the circumstances.

[9]
Initial reports of totally endoscopic ILE was by Watson et al. who described, the technique of hand-
assisted laparoscopy for gastric mobilization and a right thoracoscopy for esophageal dissection and
anastomosis in two patients.

One of the potential advantages of the minimally invasive trans-thoracic approach is better exposure and
improved lymph node dissection in the mediastinum, associated with low morbidity and mortality. The
reported rate of peri-operative complications, including anastomotic leak, pneumonia, and recurrent nerve
[10]
injury, was quite low .

[11]
Baranov et al. in their study of 446 patients of minimally invasive ILE, 357 patients were younger than
75 years (younger group) and 89 patients were aged 75 years and older (elderly group) found that regarding
severe complications there was no significant difference between the younger and the elderly group (35.9%
in the younger group versus 43.8% in the elderly group, P = 0.421) and the 30 days mortality was 30-day
mortality was 2.8% in the younger group versus 2.2% in the elderly group (P = 0.889). They have concluded
that minimally invasive ILE can be safely performed in selected patients aged ≥ 75 years, without
increasing severe complications or decreasing survival.

In a recent systemic review and meta-analysis by Deng et al. in 2018 Comparing short-term outcomes
[12]
between minimally invasive McKeown esophagectomy (MIME) and minimally Ivor Lewis esophagectomy
(MILE) for esophageal or junctional cancer found that MIME was associated with more blood loss, longer
operating time, and longer hospital stay than MILE. Pulmonary complications (OR = 1.96, 95%CI: 1.28-
3.00) as well as total anastomotic leak (OR = 2.55, 95%CI: 1.40-4.63), stricture (OR = 2.07, 95%CI: 1.05-4.07),
and vocal cord injury/palsy (OR = 5.62, 95%CI: 3.46-9.14) were significantly higher in MIME compared
[12]
to MILE . In TIME trial, long term results, after three years follow-up, found no differences in disease-
free (37.3% vs. 42.9%, P = 0.602) and overall (41.2% vs. 42.9%, P = 0.633) 3-year survival between open
[13]
esophagectomy and minimally invasive esophagectomy . In their study they also found that minimally
invasive esophagectomy in post neoadjuvant therapy compare to upfront surgery showed no difference
in resection rates and concluded that minimally invasive surgery might be safely attempted in post
[14]
neoadjuvant cases which were considered as a contraindication due to radiation fibrosis .
In our study, the anastomotic leak is 2.09% compared to 4.7 % shown in the meta-analysis of various
[15]
studies . The overall pulmonary complications in our study are 8.39% in comparison to 17.1% in
[16]
minimally invasive esophagectomies, in a meta-analysis of 57 studies . The lymph node retrieval rate
is 22.68 ± 9.49 in comparison to 22 ± 10 in a propensity score-matched study comparing open and
[17]
laparoscopic group by Rinieri et al. . The length of ICU stay in our study is 4.68 ± 3.95 days, and length
of hospital stay is 13.48 ± 7.43 days, in comparison to 3.6 days and 12 days in a similar stud of minimally
[18]
invasive ILE by Zonča et al. . The 30 day mortality rate is 0.69% in comparison to 1 % shown in a
systematic review by Deng et al. .
[12]
In conclusion, thoracolaparoscopic esophagectomy with intrathoracic Ivor Lewis anastomosis is an
excellent option for selected patients, in experienced hands.