Although mortality and morbidity from esophageal cancer surgery is decreasing, complications of the esophagogastric anastomosis are a source of significant concern 3, 15-17
. We have found that constructing a circular stapled anastomosis with the transoral anvil allows for a standardized esophagogastric anastomosis. It is a straightforward and reproducible technique that is particularly suited to the minimally invasive thoracoscopic approach, and has a low leak and stricture rate.
Anastomotic leaks are a concern with all types of esophagogastric anastomoses. Prior studies have suggested that intrathoracic anastomotic leaks may be associated with greater morbidity and mortality than cervical anastomotic leaks after transhiatial esophagectomy 18
. However, recent reports have shown similar related morbidity rate due to a leak of a neck or intrathoracic anastomosis3
and also similar stricture, leak, mortality, or five year survival rates when comparing a hand sewn cervical versus a stapled intrathoracic anastomosis14
. Unlike the leak rates reported with a hand-sewn technique during a cervical anastomosis, the intrathoracic anastomotic leak rate seem not to differ by type of anastomosis (hand sewn versus stapled) 8, 19
. Factors such as body habitus, peripheral vascular disease, and neoadjuvant therapy may influence the esophagogastric anastomotic leak rate and have not been controlled for in many prior studies.
There are several treatment options for intrathoracic esophageal anastomotic leaks including surgical re-exploration and repair or consevative therapy including external drainage, total parenteral nutrition, and nasogastric decompression 20
. In addition, temporary esophageal stents have been used more frequently to treat anastomotic leaks. Several studies have reported successful treatment of intrathoracic anastomotic leaks using temporary esophageal stents placed endoscopically 20-21
. We had one patient with an anastomotic leak (2.7%) using the transoral circular stapled intrathoracic anastomosis that was successfully treated with re-operation, drainage, pleural flap, and endoscopic stenting.
Anastomotic strictures are another important technical complication of esophagogastric anastomoses. The stricture rate using different intrathoracic anastomotic techniques can be difficult to determine because there is no standardized reporting system for strictures. Therefore, the results of studies comparing the stricture rate between hand sewn and stapled intrathoracic esophagogastric anastomosis vary; there is no consistent trend favoring one technique over the other. In general, authors have reported a spectrum ranging from postoperative dysphagia (22% to 73%) to radiologically or endoscopically noted narrowings not needing intervention, to strictures necessitating multiple dilations (13% to 40%) when using a traditional circular stapling technique 22
. We report a 13.8% stricture rate with two patients requiring three endoscopic dilatations with the last endoscopy showing a patent anastomosis. At the time of final endoscopy all patients were eating and drinking without difficulty.
There is concern that there may be an association between anvil size and the risk of stricture 23
. However, two recent studies compared different anvil sizes (25, 29, and 33mm) and found no correlation between anvil size and dysphagia or stricture 14, 19
. We use a 25 mm transoral anvil and have a low stricture rate. We suspect that stricture formation is multifactorial including patient characteristics and operative factors such as blood supply to the conduit and tension at the anastomosis.
Complications specific to the trans-oral passage of the OrVil™ 25 mm device have been reported and are rare13
. They consist of premature dislodging of the anvil from the delivery tube necessitating manual or endoscopic removal of the anvil or hypopharyngeal or esophageal mucosal injuries. These complications can usually be prevented by gentle and appropriate handling during the trans-oral passage of the anvil.
To decrease morbidity, minimally invasive techniques have been applied to esophagectomies. Recently, several series have described the feasibility and safety of minimally invasive Ivor-Lewis Esophagectomy24
. The extent of minimally invasive techniques has ranged from a laparoscopic abdominal component with a thoracotomy or mini-thoracotomy, to a thoracoscopic thoracic component and an open abdominal procedure. We used a minimally invasive abdominal component in the majority of our patients and a thoracoscopic technique in one-third of the patients. Long-term oncologic outcomes using minimally invasive techniques are still being investigated, but in our series, lymph node retrieval seems similar to retrieval when using standard open techniques. In addition, using a transoral anvil technique seems more efficient and may decrease operative time.
In summary, we report our experience with intrathoracic esophagogastric anastomoses using a transoral anvil during minimally invasive Ivor-Lewis Esophagectomy. We have found that it is a safe technique with preliminary results showing an anastomotic leak rate and stricture formation on the low end of reported ranges. Furthermore, the transoral anvil improves the technical feasibility of the intrathoracic esophagogastric anastomosis during completely minimally invasive esophagectomy.