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

Table 1. Esophagectomies with intrathoracic anastomosis for esophageal cancer (n = 176): patient characteristics
Hand-sewn Stapler Total
Characteristic P value
126 50 176
Age in years, median [min, max] 62 [42, 88] 61 [34, 84] 61 [34, 84] 0.34
Men/women ratio n (%) 111/15 (88%/12%) 42/8 (84%/16%) 153/23 (86.9%/13.1%) 0.23
Adenocarcinoma of esophagus n (%) 86 (68.3%) 38 (76%) 124 (70.5%) 0.21
Squamous-cell carcinoma of esophagus n (%) 40 (31.7%) 12 (24%) 52 (29.5%) 0.21
COPD n (%) 35 (27.8%) 10 (20%) 45 (25.6%) 0.13
Coronary heart disease n (%) 26 (20.6%) 7 (14%) 33 (18.9%) 0.20
Obesity n (%) 24 (19%) 10 (20%) 34 (19.3%) 0.42
Neoadjuvant therapy n (%) 60 (47.6%) 33 (66%) 93 (52.8%) 0.11

Chi-square and Mann-Whitney U tests were respectively used.

Table 2. Esophagectomies with intrathoracic anastomosis for esophageal cancer (n = 176): operative data and postoperative
outcome
Hand-sewn Stapler Total
Parameters P value
126 50 176
Duration of surgical procedure median [min, max] 280 [128, 532] 261 [160, 376] 269 [128, 532] 0.49
Blood loss in mL median [min, max] 300 [50, 4000] 200 [5, 1500] 300 [5, 4000] 0.12
Number of dissected lymph nodes, median [min, max] 17 [3, 62] 17 [6, 34] 17 [3, 62] 0.59
Minor postoperative complications 13 (10.3%) 10 (20%) 23 (13%) 0.2
Clavien-Dindo Grade I-II, n (%)
Major postoperative complications 25 (19.8%) 4 (8%) 29 (16.5%) 0.12
Clavien-Dindo Grade III-IV, n (%)
Reoperation, n (%) 43 (34.1%) 4 (8%) 47 (26.7%) 0.001***
Respiratory complications, n (%) 35 (27.8%) 12 (24%) 47 (26.3%) 0.36
Anastomotic leak, n (%) 18 (14.3%) 4 (8%) 22 (12.5%) 0.22
Anastomotic stricture, n (%) 17 (13.5%) 3 (6%) 20 (11.4%) 0.1
30-day mortality, n (%) 6 (4.8%) 0 (0%) 6 (4.8%) 0.13
60-day mortality, n (%) 12 (9.6%) 1 (2%) 13 (7.4%) 0.08
90-day mortality, n (%) 17 (13.5%) 1 (2%) 18 (10.2%) 0.02*
Hospital stay in days, median [min, max] 21 [9, 198] 18 [12, 114] 20 [9, 198] 0.26

*P < 0.05, ***P < 0.001; Chi-square and Mann-Whitney U tests were respectively used.

groups (P = 0.26). The rate of anastomotic stricture in the 6-month follow-up did not significantly differ
between the groups (Group 1: 13.5% vs. Group 2: 6%, P = 0.1), although it was more than 50% reduced in
the stapler group. The 30-, 60- and 90-day mortality was 4.8% (n = 6), 7.4% (n = 13) and 10.2% (n = 18),
respectively. The 90-day mortality was significantly lower in Group 2 (Group 1: 13.5% vs. Group 2: 2%, P =
0.02). The most apparent differences of surgical outcome when comparing the anastomotic methods were
the rate of reoperation and consequently the 90-day mortality [Table 2].

Management of anastomotic leak
In the stapler anastomosis group, anastomotic leaks were treated with endoscopic stent insertion: 4 out of 50
(8%) patients after stapler anastomosis suffered from anastomotic leak, of whom only one was subjected to
new surgical procedure and 3 were successfully treated with endoscopic stent insertion. In contrast, in the
hand-sewn anastomosis group, anastomotic leaks were predominantly treated with reoperation: 18 patients
after hand-sewn anastomosis suffered from anastomotic leak, of whom 14 underwent new surgical
procedure and 4 were treated with endoscopic stent insertion. Consequently, 90-day mortality (Clavien-