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Page 2 of 11 Kolokotronis et al. Mini-invasive Surg 2021;5:19 https://dx.doi.org/10.20517/2574-1225.2021.07

Keywords: Esophagogastric anastomosis, circular stapler, Clavien-Dindo classification, anastomotic leak, gastric
tube, esophagectomy, esophageal resection, Ivor-Lewis esophagectomy

INTRODUCTION
Esophageal cancer is a severe disease with poor prognosis. The reconstruction of alimentary tract after
esophageal resection remains a challenge, with anastomotic leak being a main reason for major
postoperative morbidity after abdominothoracic esophagectomy. The incidence of anastomotic leak varies
[5]
[1-4]
from 0% to 24% , leading to higher rates of postoperative morbidity and mortality . Various factors have
been suggested to promote anastomotic leak, including patient-related characteristics , perioperative
[6,7]
[8]
factors and surgical technique (undo tension on the anastomosis, technical failures, adequacy of blood
supply of both organs at the connection site and location of the esophagogastric anastomosis ).
[10]
[9]
Controversy remains about the optimal location of esophagogastric anastomosis (intrathoracic vs. cervical).
Intrathoracic esophagogastric anastomosis has been associated with lower anastomotic leak rate, lower rate
of recurrent nerve paresis and shorter hospital stay than a cervical anastomosis [6,10,11] . However, three
randomized controlled trials could not show statistical difference in anastomotic leak rate between
intrathoracic and cervical location [12-14] . Advantages of cervical anastomosis include wider oncologic
resection margin and less devastating complications compared with intrathoracic anastomosis (risk of
mediastinitis and esophagobronchial fistula). A potential solution to manage the challenge of intrathoracic
esophagogastric anastomosis could be the use of a stapler device to perform the anastomosis; therefore, we
focused on this topic of paramount importance in the present study. Since the first use of stapler
anastomosis in 1979 , there have been several reports supporting its use in order to reduce the rate of
[15]
anastomotic leak [16,17] . Further technical variations, including the use of linear stapler to perform semi-
mechanical intrathoracic anastomosis, have also been suggested to reduce postoperative anastomotic leak
rate . We investigated the impact of anastomotic method (hand-sewn vs. circular stapler) on anastomotic
[18]
leak rate in patients with esophageal carcinoma submitted to intrathoracic esophagogastric anastomosis in
the University Clinic of Saarland during a 14-year period.

METHODS
We performed a retrospective, non-randomized study to investigate which anastomotic method rendered
better results. Our study population consisted of 176 patients with esophageal carcinoma, with intrathoracic
anastomosis after abdominothoracic resection. We performed an Ivor-Lewis abdominothoracic esophageal
resection, consisting of a median laparotomy, mobilization of the stomach and preparation of a
conventional gastric tube. Simultaneous cholecystectomy was routinely performed . The gastric conduits
[19]
were performed conventionally (three patients submitted to fundus rotation gastroplasty to achieve
[20]
longer gastric conduit and better blood supply were excluded). For conventional tube formation, the lesser
[9]
[21]
curvature with the vessel arcade was resected with linear stapler . The right gastric and gastroepiploic
vessels provide the blood supply of the gastric conduit. A right anterolateral thoracotomy was performed,
and the esophageal resection was performed in the level of azygos vein. D2 lymphadenectomy was routinely
performed. Patients were divided into two groups: Group 1 received hand-sewn, double row, end-to-end
anastomosis using 4-0 PDS and 5-0 PDS stitches and Group 2 received single row end-to-side, stapler
anastomosis using a 25-mm circular stapler. The type of anastomosis was selected upon surgeon’s
preference. Anastomosis was mainly performed as hand-sewn from 2001 to 2012 and changed to a stapler
anastomosis routinely using the 25-mm circular intraluminal stapler (Covidien, EEA, DST Series).
Operations were only performed by chief or experienced senior surgeons.