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Page 6 of 11 Kolokotronis et al. Mini-invasive Surg 2021;5:19 https://dx.doi.org/10.20517/2574-1225.2021.07

Dindo Grade V complications) and overall survival were statistically significantly different between the
groups of patients.

Risk factors for major and lethal postoperative complications (Clavien-Dindo Grades III-V) after
abdominothoracic esophageal resection
The type of anastomosis (P = 0.004) and duration of surgery (P = 0.002) significantly influenced the
incidence of major and lethal postoperative complications (Clavien-Dindo Grades III-V) in the multivariate
analysis (binary logistic regression, Table 3).

Survival
Overall median patient survival was 18 months (0-121 months). In Group 1, the median survival was 16
months [minimum: 0; maximum: 119; mean: 31; Standard Deviation (SD): 32], whereas, in Group 2, the
median survival was 22 months (minimum: 1; maximum: 121; mean: 20; SD: 18). Patients subjected to
hand-sewn anastomosis experienced worse overall survival, as did patients with advanced UICC tumor
stage (P = 0.001 and P = 0.002, respectively, log rank test), as shown in Table 4 and Figure 1. No significant
differences were observed between UICC tumor staging and anastomotic technique (P = 0.355) or between
histological type and anastomotic technique (P = 0.175).

In the multivariate analysis, the type of anastomosis and advanced UICC tumor stage were independent
factors that significantly influenced overall survival [Table 5 and Figure 2].

DISCUSSION
In the present study, we focused on the impact of anastomotic method (intrathoracic stapler vs. hand-sewn
esophagogastric anastomosis) on surgical outcome after abdominothoracic esophagectomy for cancer. Our
data suggest that the management of anastomotic leak (endoscopic stent insertion vs. reoperation),
combined with the use of stapler to perform intrathoracic esophagogastric anastomosis, positively
influences postoperative morbidity, mortality and overall survival.

Regarding anastomotic leak rates after abdominothoracic esophageal resection, our incidence of 12.5% is
similar to other reported rates. Major/lethal postoperative complications (Clavien-Dindo Grades III-V)
were significantly lower in the stapler anastomosis group, obviously due to the lower reoperation rate. It is
important to note that, in the hand-sewn anastomosis group, anastomotic leaks were treated with new
surgical procedure (14 out of 18 patients with anastomotic leak), contrary to the stapler anastomosis group,
thus leading to higher mortality (34.1% reoperation and 13.5% Clavien-Dindo Grade V complications in the
hand-sewn anastomosis group, compared to 8% and 2% in the stapler group, respectively). In the same line
of evidence, no patient died from anastomotic leak in the stapler anastomosis group due to successful
treatment with endoscopic stent insertion. This fact implies that the aggressive management of anastomotic
leaks with redo surgery in the hand-sewn anastomosis group significantly worsened the postoperative
outcome. In addition, we cannot exclude that the change of the intrathoracic anastomosis method (end-to-
end vs. end-to-side) may have influenced the postoperative outcome, as the end of the gastric conduit is the
most ischemic part. However, the intrathoracic esophagogastric anastomosis was performed in the height of
azygos vein; the tension of the anastomosis is not so high; and the risk of gastric conduit ischemia is lower
compared to, for example, in a cervical esophagogastric anastomosis. Therefore, it remains unclear whether
the manner of anastomosis substantially influenced the incidence of anastomotic leaks. Moreover, the
esophagogastric anastomosis was sewn from 2001 to 2012, and stapled anastomosis predominated
thereafter; the era effect cannot be estimated in the significant improvement in outcomes. Both
intraoperative blood loss and duration of surgery were comparable between the groups, but lower in the
stapler group, in accordance with the results of other observational studies claiming that stapler anastomosis