OGC SO45 - Effect of anastomotic technique on leak rates in two-stage robotic-assisted subtotal oesophagectomy

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Abstract Background Introduction of new surgical techniques requires constant monitoring and real time audit. In our unit the introduction of the thoracic component of our robotic oesophagectomy program resulted in an increase in the anastomotic leak rate which was recognised in real time. This prompted a decision to change from a circular to a linear stapled technique. The aim of this study was to evaluate the impact of this change in technique on the anastomotic leak rate. Method A database was used to identify all cases of patients undergoing two stage subtotal oesophagectomy where the thoracic phase was performed robotically-assisted. Demographic, operative, pathological and complications data were extracted. An anastomotic leak was defined as radiological or endoscopic disruption of the oesophagogastric anastomosis or where a clinician had documented the presence of a leak in the clinical notes. Leaks were then graded by severity according to the classification by Low et al into type 1: localised defect treated with medical therapy or observation; Type 2: localised defect requiring intervention but not surgery, and; Type 3: localised defects requiring surgery. Results Fifty-seven patients were identified. The first 25 cases were reconstructed with a circular-stapled and the subsequent 32 with a linear-stapled anastomosis. There were no differences in baseline demographics. There were no differences in thoracic operating time nor blood loss, intraoperative complications and pathological variables such as lymph node yield. Overall, 11/57 patients (19%) had an anastomotic leak, of which 7 (28%) had a circular stapled anastomosis and 4 (12%) had a linear stapled anastomosis. This difference was not statistically significant (p=0.2384). However, CUSUM analysis after the change in anastomotic technique showed an ongoing and diminished anastomotic leak rate. Conclusion In our unit changing from a circular to a linear stapled anastomotic technique resulted in a reduction in the anastomotic leak rate from 24% to 12%. While this was not statistically significant, this is a clinically appreciable result and this benefit was confirmed on CUSUM analysis.