398. THE HYBRID INTRA-THORACIC OESOPHAGO-GASTRIC ANASTOMOSIS—CONTEMPORARY PERFORMANCE WITH LOW BENIGN ANASTOMOTIC STRICTURE FORMATION

Abstract

Abstract Background The intra-thoracic linear stapled semi-mechanical anastomosis is associated with reduced rates of benign anastomotic stricture when compared with circular stapled and end-to-end hand-sewn methods. The hybrid anastomosis is a modification of this. The hand-sewn posterior wall, extended with a stapler firing provides the theoretical advantage of increased luminal patency. It has been published as a single surgeon experience from our institutions (1993–2011), with low leak rate and stricture rate of ten percent. These patients largely underwent upfront surgery. Methods We assessed the performance of this hybrid anastomotic technique amongst multiple surgeons, in a contemporary setting with high use of neoadjuvant therapy, compared with the end-to-end hand-sewn anastomosis. Patients undergoing open Ivor Lewis oesophagectomy over a 6 year period were identified using the prospective oesophagectomy database across two public hospitals. Chart review was used to compile data on anastomotic technique, reflux symptoms, PPI use and endoscopic dilatations. Results There were 80 patients, with minimum 12 month and mean 24 months follow up. 60 patients underwent hybrid anastomosis and 20 hand-sewn. Four surgeons oversaw more than 10 anastomoses. 70% of patients received neoadjuvant treatment. Four anastomotic leaks required intervention (5%). Benign stricture formation requiring endoscopic dilatation was more common in the hand-sewn group (35%) compared with the hybrid group (12%) (p = 0.0061). All strictures were identified within 12 months. On multi-variate analysis, anastomotic leak, neoadjuvant therapy, smoking, diabetes and vascular comorbidities did not predict stricture formation. Symptomatic reflux approached 50% in both groups, despite 89% long term PPI adherence. Conclusion We demonstrate that the hybrid anastomosis continues to achieve low rates of benign anastomotic stricture amongst multiple surgeons, even in the era of neoadjuvant therapy. Symptomatic reflux remains common after oesophagectomy, so PPI should be used long-term. Outcomes for both anastomoses compare to published standards. These results are relevant to consider when modifying techniques for minimally invasive anastomosis.