Technique Of Esophagectomy Research Articles

Surgical Technique and Implementation of Total Minimally Invasive (Laparo-Thoracoscopic) Ivor Lewis Esophagectomy for Cancer.

Esophagectomy represents a major oncological operation due to the surgical involvement of both the abdominal and thoracic cavities. The minimally invasive technique has been developed to minimize the operative impact on patients undergoing esophageal resections, often presenting with nutritional deterioration and poor functional reserves. The present article provides an illustrative description of the total minimally invasive (laparo-thoracoscopic) Ivor Lewis esophagectomy for cancer integrated with complementary components of perioperative clinical management. This standardized surgical technique of two-field esophagectomy (i.e., laparoscopy and thoracoscopy) was depicted based on the experience of a tertiary center for esophageal cancer care with more than 1500 cases operated on, and in accordance with the SUPER reporting guidelines. The accomplishment of the following descriptive and illustrative content allowed the development of remarks on the strengths and possible flaws of this specific procedure, providing a measurable opportunity to absorb technical details of the most widespread surgical resection for esophageal cancer worldwide.

Robot-assisted cervical esophagectomy with simultaneous transhiatal abdominal procedure for thoracic esophageal carcinoma

BackgroundMinimally invasive robot-assisted cervical esophagectomy has been sporadically reported as a novel thoracic esophagectomy technique for patients with thoracic esophageal carcinoma. Most reports indicate that the abdominal component of robot-assisted cervical esophagectomy is performed sequentially after the cervical phase. However, if the cervical and abdominal phases are performed simultaneously using a nerve integrity monitoring system with no administration of muscle relaxants, there are two major advantages: a reduced risk of recurrent nerve palsy and a shorter operative time. We herein report our experience performing novel robot-assisted transcervical esophagectomy with a simultaneous transhiatal abdominal approach using a nerve integrity monitoring system.MethodsThirty cases of robot-assisted cervical esophagectomy performed from 2023 to April 2024 were reviewed. The operative and short-term surgical outcomes of this procedure were compared with those of robot-assisted cervical esophagectomy using a sequential abdominal approach, and the feasibility and efficacy of the simultaneous procedure were analyzed.ResultsAll patients successfully underwent robot-assisted cervical esophagectomy with no intraoperative adverse events. There were no differences in the patients’ demographic or operative data between the two groups. There was no difference in the mean operation time for the cervical procedure (p = 0.23). However, there was a significant difference in the total time for the whole procedure (sequential group: 453.8 ± 26.8 min, simultaneous group: 291.2 ± 36.1 min; p < 0.01). There were no differences in postoperative surgical complications between the groups. There was also no difference in the total number of surgically harvested mediastinal lymph nodes (p = 0.33).ConclusionsRobot-assisted transcervical esophagectomy, a new technique for thoracic esophageal cancer, was safe and feasible under intraoperative management using nerve integrity monitoring without muscle relaxants. This procedure facilitates intraoperative monitoring of recurrent laryngeal nerve activity, significantly shortening the total operative time.

370. LOWER MEDIASTINUM DISSECTION IN THORACOSCOPIC ESOPHAGECTOMY

Abstract Background Thoracic esophagectomy is currently the preferred technique for the thoracic phase of transthoracic esophagectomy for esophageal cancer. Randomized controlled trials comparing this minimally invasive approach to the open one, demonstrated a lower rate of pulmonary complications rate, without worst long-term outcomes. Video-based learning of minimally invasive surgery is essential, especially in such a complex procedure like esophagectomy. However, resources are lacking. Therefore, we aim to conduct a video demonstration of lower mediastinum dissection of our standardized right thoracoscopy esophagectomy, in the prone position. Methods Surgery de-construction through video assessment is routinely performed in our upper gastrointestinal unit. It is fundamental for surgical training, as well as for technical skills improvement of experienced surgeons. Here we present a step-by-step approach of one of the key parts of our standardized thoracoscopic esophagectomy technique – the lower mediastinum dissection. Results Thoracoscopic esophagectomy is systematically performed in a prone position, using a bronchial blocker, 4 working ports and a pressure of 6 mmHg for pneumomediastinum. The first stage of thoracoscopic esophagectomy is the lower mediastinum dissection. Three main steps compose this procedure - posterior dissection, anterior dissection and main bronchus and carina dissection. This video offers a comprehensive overview of the key anatomical landmarks that require identification during the procedure, the sequential steps involved and the critical pitfalls. Conclusion Thoracoscopic esophagectomy for esophageal cancer should be performed in high-volume centers, in a standardized and systematic way. Video revision and procedure debriefing is essential not only for surgery learning and coaching, but also for outcome improvement. Sharing knowledge and experience through video-based presentations can contribute to development of this complex area of minimally invasive esophagectomy. https://drive.google.com/file/d/1vWJOTCey8wI6HQi0jAR8C_t3tUKVbrW1/view?usp=drive_link

Hybrid minimal invasive esophagectomy for esophageal cancer: a single center experience with 14 cases

AIM: To perform a retrospective evaluation of morbidity, early postoperative mortality rates, and the safety of the procedure in patients who underwent hybrid minimally invasive esophagectomy in our clinic. MATERIAL AND METHOD: The records of 14 patients with esophageal cancer operated using the minimally invasive esophagectomy technique in the general surgery clinic of the XXX Hospital between November 2015 and November 2022 were analyzed retrospectively. RESULTS: The mean age of the 14 cases was 55 ± 11.96 years (32-71). Ten patients (71%) were men and four (29%) were women. The tumor was located in the lower esophagus in 12 cases, in the middle esophagus in one, and in the upper esophagus in one. Near total esophagectomy – cervical anastomosis was performed in 13 cases. Pharyngogastric anastomosis was performed after total esophagectomy, bilateral total thyroidectomy, and laryngectomy in one patient with upper esophageal tumor. The mean operative time was 319.64 ± 76.28 (188-452) min. Mean intraoperative bleeding was 109.64 ± 58.58 (40-220) ml, and the mean length of hospital stay was 13.71 ± 3.72 (7-21) days. No early postoperative mortality was observed in any case. CONCLUSION: Our early postoperative results in cases in which we performed hybrid minimally invasive esophagectomy are consistent with the previous literature.

395. SURGICAL PROCEDURE AND PERIOPERATIVE OUTCOME OF TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

Abstract Background We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 548 patients had undergone our method during various esophageal surgical procedures, including esophagogastric junction cancer (EGJC). Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal esophagectomy (TME) without thoracic approach (435 cases). Seventy five patients with EGJC were treated by TME. Methods Left single-port mediastinoscopic cervical approach was performed with pneumomediastinum. Mainly for advanced SCC, upper mediastinal lymph node dissection including recurrent laryngeal nerve LNs was performed with intraoperative monitoring using NIM system. Next, LTHA was performed for en bloc mediastinal lymph node dissection. The esophageal hiatus was opened, and working space was secured by Long Retractors. The posterior plane of the pericardium was extended. The posterior side of LNs was then separated. Finally, while lifting LNs like a membrane, they were resected from bilateral mediastinal pleura. Reconstruction with narrow gastric conduit was performed through substernal tract. Results Patients with EGJC performed TME were analyzed (n = 75, SCC/Adeno/Others = 37/35/3). Upper mediastinal lymph node metastasis was found in 13 cases (SCC/Adeno = 6/7), middle mediastinal lymph node metastasis was found in 10 cases (SCC/Adeno = 3/7), and all of them had advanced tumors. Their perioperative outcome was compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TME. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in TME group were not inferior to the right thoracotomy group. In 93.3% of patients treated by TME, extubation was performed at 0 POD. Postoperative respiratory complication was decreased by TME (TME:6.7%, thoracotomy:17.1%). Conclusions This procedure, TME, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.

340. LONG-TERM ONCOLOGIC OUTCOMES OF ESOPHAGEAL CANCER AFTER NEOADJUVANT CHEMORADIATION AND SINGLE-INCISION MINIMALLY INVASIVE ESOPHAGECTOMY

Abstract Purpose For locally advanced esophageal cancer, neoadjuvant chemoradiation therapy followed by esophagectomy is a widely accepted standard treatment. However, the preferable techniques for esophagectomy are still debatable. Multi-incision minimally invasive esophagectomy (MIE) had shown similar long-term oncologic outcomes with open esophagectomy, while it provided shorter hospital stay and less surgical pain due to its decreased wound size. Following the trend to minimize wounds, we developed single-incision MIE, with uniport thoracoscopy and single-incision laparoscopy. In this study, we presented the long-term oncologic outcomes of esophageal cancer after neoadjuvant chemoradiation and single-incision MIE and identified the risk factors for poor oncological outcomes. Materials and Methods: From 2008 to 2022, 573 patients with locally advanced esophageal cancer who received neoadjuvant chemoradiation followed by MIE at our institute were included. 254 of them underwent single-incision MIE. Kaplan–Meier analysis was used to calculate overall survival (OS) and progression free survival (PFS). Univariate and multivariate analyses were applied by Cox proportional hazard regression model. Results The 5-year OS of esophageal cancer with neoadjuvant chemoradiation and single-incision MIE was 62.5% (stage 0–1), 34.5% (stage 2), 31.1% (stage 3) and 13.1% (stage 4), while its 5-year PFS was 47.7% (stage 0–1), 33.2% (stage 2), 26.5% (stage 3) and 19.6% (stage 4) (Figure 1). For esophageal cancer treated with neoadjuvant chemoradiation and MIE, factors such as age ≤ 65, female, FEV1 &amp;gt; 80%, Single-incision MIE, operation time ≤ 500 min, lymph nodes retrieved&amp;gt;40, pathological cancer staging ≤2, clinical cancer staging ≤2 and negative resection margin were significantly predictive of improved overall survival (OS). After multivariate analysis, only age, FEV1, cancer staging (both pathological and clinical) and resection margin were independent risk factors for OS. Conclusion For patients with advanced esophageal cancer, single-incision MIE after neoadjuvant chemoradiation is a feasible procedure with fair long-term oncological outcomes. Risk factors, such as age &amp;gt; 65, FEV1 ≤ 80%, pathological cancer staging &amp;gt;2, clinical cancer staging &amp;gt;2 and positive resection margin were independently predictive of poor OS.

P-158 The algorithm of esophagectomy technique selection in surgical treatment of squamous cell carcinoma and adenocarcinoma of esophagus

P-158 The algorithm of esophagectomy technique selection in surgical treatment of squamous cell carcinoma and adenocarcinoma of esophagus

Minimally invasive laparo-thoracoscopic Ivor-Lewis esophagectomy with semi-mechanical triangular anastomosis: Short-term outcomes of 114 consecutive patients.

Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy. This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis. Mean patient age was 62.8years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8-116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality. The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.

Depth Analysis of Open Transhiatal Esophagectomy Outcomes (Orringer Technique) in Patients with Esophageal Cancer from 1990 to 2015: A 25-Year Experience Single-center Study

Background: Esophageal cancer is an invasive tumor with rapid growth and a poor prognosis. The annual incidence of esophageal cancer in the United States is 6 per 100 000 men and 1.6 per 100 000 women. This is different in the case of Iran, and the number of patients in the country is higher than in other countries. In this evaluation, the researchers present the experience with open Transhiatal Esophagectomy (Orringer) technique outcomes. Objectives: This study aimed at evaluating the Orringer technique and its complications in patients with esophageal cancer for 25 years at the Cancer Research Center of Shahid Beheshti University of Medical Sciences. Methods: This is a descriptive study conducted from the beginning of 1988 to 2016. In this study, 114 patients with a mean age of 55 years and a gender classification of 60% male and 40% female were evaluated. Results: After resection, more than 98% of patients were in the T3 N1 - N3 stage. There were 4 mortalities: 2 were due to descending aorta tearing, 1 was due to tracheobronchial tearing, and 1 was pneumonia From 40 cases of pleural effusion, only 5 cases (12.5%) needed a thoracotomy tube. Only 2 patients needed intervention from 30 patients with dysphagia; 1 case was relieved by balloon dilatation and the other needed a free jejunal flap. Five-year survivals were 30% and 20% versus 48% and 23% in the neoadjuvant and non-neoadjuvant groups, respectively. conclusions: The present study and other experiences showed that non-radical surgery such as the Orringer technique is acceptable and compassable compared to radical surgery in 3 fields.

Hybrid or Full-Robotic? Comparing the efficacy of robot-assisted esophagectomy (RAMIE) techniques

Hybrid or Full-Robotic? Comparing the efficacy of robot-assisted esophagectomy (RAMIE) techniques

Hybrid Minimally Invasive Esophagectomy for Carcinoma Oesophagus: Experience at Tertiary Care Centre in North Karnataka.

Surgery remains the mainstay for curative treatment of carcinoma of midthoracic and lower thoracic oesophagus. In the twentieth century, open esophagectomy was the standard of care. In the twenty-first century, treatment for carcinoma oesophagus has revolutionized with incorporation of neoadjuvant treatment and application of various minimally invasive techniques for esophagectomy. At present, there is no consensus about the optimum position to perform minimally invasive esophagectomy (MIE). We share our experience of MIE with modification in the port position in this article.

Minimally invasive surgery is associated with decreased postoperative complications after esophagectomy

BackgroundAlthough some studies have compared esophagectomy outcomes by technique or approach, there is opportunity to strengthen our knowledge surrounding these outcomes. We aimed to perform a comprehensive comparison of esophagectomy postoperative complications. MethodsWe retrospectively reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2007-2018). Esophagectomies were identified using Current Procedural Terminology codes and grouped by operative technique (Ivor Lewis, transhiatal, McKeown) and surgical approach (minimally invasive vs open esophagectomy). Twelve postoperative complications were compared. Significant complications underwent risk adjustment using multivariate logistic regression. ResultsAnalysis was performed on 13,457 esophagectomies: 11,202 (83.2%) open and 2255 (16.8%) minimally invasive. There were 7611 (56.6%) Ivor Lewis, 3348 (24.9%) transhiatal, and 2498 (18.6%) McKeown procedures. There were significant differences among the surgical techniques in 6 of 12 risk-adjusted complications. When comparing the outcomes of minimally invasive techniques, there were only significant differences in 2 of 12 complications: overall morbidity (minimally invasive Ivor Lewis 30.5%, minimally invasive transhiatal 43.4%, minimally invasive McKeown 40.3%, P = .0009) and infections (minimally invasive Ivor Lewis 15.4%, minimally invasive transhiatal 26.0%, minimally invasive McKeown 25.3%, P = .0003). Patients who underwent minimally invasive surgery were less likely to have overall morbidity (odds ratio, 0.68; 95% confidence interval, 0.62-0.75), respiratory complications (odds ratio, 0.77; 95% confidence interval, 0.68-0.87), urinary tract infection (odds ratio, 0.61; 95% confidence interval, 0.43-0.88), renal complications (odds ratio, 0.52; 95% confidence interval, 0.34-0.81), bleeding complications (odds ratio, 0.36; 95% confidence interval, 0.30-0.43), and nonhome discharge (odds ratio, 0.54; 95% confidence interval, 0.45-0.64), and had shorter length of stay (9.7 vs 13.2 days, P < .0001). ConclusionsPatients undergoing minimally invasive esophagectomy have lower rates of postoperative complications regardless of esophagectomy techniques. The minimally invasive approach was associated with reduced complication variance among 3 common esophagectomy techniques.

240. PERIOPERATIVE OUTCOME AND SURGICAL TECHNIQUE OF TRANSMEDIASTINAL ESOPHAGECTOMY FOR ESOPHAGOGASTRIC JUNCTION CANCER

Abstract We started performing mediastinal lymph node dissection by a laparoscopic transhiatal approach (LTHA) in 2009. To date, 463 patients had undergone our method during various esophageal surgical procedures, including esophagogastric junction cancer (EGJC). Furthermore, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a simple technique for transmediastinal esophagectomy (TME) without thoracic approach (350 cases). Fifty four patients with EGJC were treated by TME. Left single-port mediastinoscopic cervical approach was performed with pneumomediastinum. Mainly for advanced SCC, upper mediastinal lymph node dissection including recurrent laryngeal nerve LNs was performed with intraoperative monitoring using NIM system. Next, LTHA was performed for en bloc mediastinal lymph node dissection. The esophageal hiatus was opened, and working space was secured by Long Retractors. The posterior plane of the pericardium was extended. The posterior side of LNs was then separated. Finally, while lifting LNs like a membrane, they were resected from bilateral mediastinal pleura. Reconstruction with narrow gastric conduit was performed through substernal tract. Patients with EGJC performed TME were analyzed (n = 54, SCC/Adeno/Others = 29/23/2). Upper mediastinal lymph node metastasis was found in 9 cases (SCC/Adeno = 5/4), middle mediastinal lymph node metastasis was found in 5 cases (SCC/Adeno = 3/2), and all of them had advanced tumors. Their perioperative outcome were compared with those performed the right thoracotomy (n = 41). The operative time and bleeding were decreased by TME. The number of resected mediastinal lymph nodes, pR0 rate, and mediastinal recurrence in the two groups were not different. In 92.6% of patients treated by TME, extubation was performed at 0 POD. Postoperative respiratory complications was decreased by TME (TME:7.4%, thoracotomy:17.1%). This procedure, TME, resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications in patients with EGJC.

Intraoperative fluorescence imaging in esophagectomy and its application to the robotic platform: a narrative review.

Background and ObjectiveRobotic-assisted esophagectomy is an approach to minimally invasive esophagectomy (MIE) that has demonstrated equivalent or improved outcomes relative to open and other minimally invasive techniques. The robotic approach also allows unique opportunities to improve complications following esophagectomy through use of enhanced visualization tools, including intraoperative fluorescence imaging. In this review, we summarize the specific uses of intraoperative fluorescence imaging as an adjunct tool during esophagectomy and discuss its application to the robotic platform.MethodsA literature search was conducted via PubMed in February 2022 with the following keywords: esophagectomy, esophageal cancer, infrared, near-infrared (NIR) and fluorescence. Peer-reviewed academic journal articles published in English between 2000 and 2021 were included.Key Content and FindingsThere is a growing body of literature evaluating the use of intraoperative fluorescence imaging in robotic-assisted esophagectomy. This includes assessment of gastric conduit perfusion, including feasibility, creation of the gastroesophageal anastomosis, and qualification of perfusion, along with lymphatic mapping and identification of critical anatomy. These tools are uniquely leveraged using the robotic platform to standardize and quantify key technical aspects of the operation.ConclusionsIntraoperative fluorescence imaging provides the opportunity to assess perfusion and identify anatomy for more precise and patient-specific dissection and reconstruction. Among all the operative techniques for esophagectomy, robotic-assisted esophagectomy is uniquely suited to utilize these imaging modalities to optimize outcomes and minimize risk associated with esophagectomy.

Indocyanine green fluorescent lymphography: Surgical procedure.

Several surgical teams have developed so-called minimally invasive esophagectomy techniques with the intention of decreasing post-operative complications. The goal of this report is to determine the feasibility, reproducibility, morbidity and mortality of esophagectomy and intrathoracic anastomosis via thoracoscopy.This retrospective series included 114 consecutive non-selected patients who underwent Lewis Santy type esophagectomy between 2016 and 2020. The procedure was performed via abdominal laparoscopy, thoracoscopy with the patient in a supine position, without selective intubation, with intra-thoracic semi-mechanical triangular esophagogastric anastomosis.Mean patient age was 62.8 years. Conversion from laparoscopy to laparotomy was required in three patients (2.6%); no patient required conversion from thoracoscopy to thoracotomy. A semi-mechanical triangular esophagogastric anastomosis was successfully performed in all patients. Median duration of hospital stay was 16 (8–116) days. Mortality was 2.6%; 34 patients (29.8%) had major complications, 55 (48%) had a respiratory complication. The leakage rate was 12.3%; most were type I. Only 5.2% required an additional procedure. There was no mortality.The analysis of this consecutive series found that this operative technique was reproducible and reliable. These results need to be confirmed by other studies. Pulmonary morbidity was high and remains the main challenge in this type of surgery.

Esophagectomy-prevention of complications-tips and tricks for the preoperative, intraoperative and postoperative stage.

Esophagectomy still remains the mainstay of treatment for localized esophageal cancer. Many progresses have been made in the technique of esophagectomy in the last decades but the overall morbidity for this operation remains formidable. Postoperative complication and mortality rate after esophagectomy are significant; anastomotic leak has an incidence of 11,4%. The occurrence of a complication is a significant negative prognostic factor for long term survivaland is also linked to longer postoperative stay, a lower quality of life, increased hospital costs. Preventing the occurrence of postoperative morbidity and reducing associated postoperative mortality rate is a major goal for surgeons experienced in resective esophageal surgery. Many details of pre, intra and postoperative care for patients undergoing esophagectomy need to be shared among the professionals taking care of these patients (oncologists, dieticians, physiotherapists, surgeons, nurses, anesthesiologists, gastroenterologists) in order to improve the short and long term clinical results.

Minimally invasive Ivor-Lewis esophagectomy for esophageal cancer.

Background In this study, we present our minimally invasive Ivor-Lewis esophagectomy technique and survival rates of this technique. Methods Between September 2013 and December 2020, a total of 140 patients (56 males, 84 females; mean age: 55.5±10.3 years; range, 32 to 76 years) who underwent minimally invasive Ivor- Lewis esophagectomy for esophageal cancer were retrospectively analyzed. Preoperative patient data, oncological and surgical outcomes, pathological results, and complications were recorded. Results Primary diagnosis was esophageal cancer in all cases. Minimally invasive Ivor-Lewis esophagectomy was carried out in all of the cases included in the study. Neoadjuvant chemoradiotherapy was administrated in 97 (69.3%) of the cases. The mean duration of surgery was 261.7±30.6 (range, 195 to 330) min. The mean amount of intraoperative blood loss was 115.1±190.7 (range, 10 to 800) mL. In 60 (42.9%) of the cases, complications occurred in intraoperative and early-late postoperative periods. The anastomotic leak rate was 7.1% and the pulmonary complication rate was 22.1% in postoperative complications. The mean hospital stay length was 10.6±8.4 (range, 5-59) days and hospital mortality rate was 2.1%. The median follow-up duration was 37 (range, 2-74) months and the three- and five-year overall survival rates were 61.8% and 54.6%, respectively. Conclusion Minimally invasive Ivor-Lewis esophagectomy can be used safely with low mortality and long-time survival rates in esophageal cancer.

Technique of robotic esophagectomy.

Robotic surgery continues to grow in thoracic surgery, and currently plays an evolving role in esophagectomy. Robotic assisted minimally invasive esophagectomy (RAMIE) has continued to expand, with many institutions adapting the technique. As the overall experience continues to grow, new data is emerging in its support. We present our approach to this operation.

130 SEVERITY OF ANASTOMOTIC LEAKAGE AFTER DIFFERENT TYPES OF ESOPHAGECTOMY: A NATIONWIDE COHORT STUDY

Abstract Orringer, McKeown and Ivor Lewis esophagectomy are the most commonly performed procedures for esophageal and gastro-esophageal junction cancer. Anastomotic leakage remains a major problem after all types of esophagectomy and it is currently unknown whether anastomotic leakage severity is different between the types of esophagectomy. The aim of this study was to investigate the relationship between surgical techniques and the severity of anastomotic leakage in patients after Orringer esophagectomy, McKeown esophagectomy or Ivor Lewis esophagectomy. Methods All esophageal and gastro-esophageal junction cancer patients with anastomotic leakage after Orringer, McKeown or Ivor Lewis esophagectomy between 2011 and 2019 were selected from the Dutch Upper Gastrointestinal Cancer Audit (DUCA). The primary outcome parameter was a composite endpoint of reoperation, intensive care unit (ICU) readmission and 30-day/in-hospital mortality. Secondary outcome parameters included postoperative complications, re-intervention rate, ICU and hospital length of stay. Results Data from 1034 patients with anastomotic leakage after Orringer (n = 287), McKeown (n = 397) and Ivor Lewis esophagectomy (n = 346) were evaluated. The primary endpoint occurred in 36.3% of patients with anastomotic leakage after Orringer esophagectomy, in 55.4% of patients with anastomotic leakage after McKeown esophagectomy and in 61.2% of patients with anastomotic leakage after Ivor Lewis esophagectomy (p &amp;lt; 0.001). When adjusting for potential confounding variables, the sequelae of anastomotic leakage after Orringer and McKeown esophagectomy remained less severe compared to anastomotic leakage after Ivor Lewis esophagectomy (OR 0.28, 95% CI 0.20–0.41, p &amp;lt; 0.001 and OR 0.71, 95% CI 0.52–0.97, p = 0.031, respectively). Conclusion Consequences of anastomotic leakage are most severe after Ivor Lewis esophagectomy, moderately severe after McKeown esophagectomy and least severe after Orringer esophagectomy. This study demonstrated that not only the incidence, but also the severity of anastomotic leakage should be considered in current clinical practice and in studies that compare leakage rates between different surgical techniques of esophagectomy.

Anastomotic technique of esophagectomy with gastric reconstruction-Cervical or intrathoracic?

Anastomotic technique of esophagectomy with gastric reconstruction-Cervical or intrathoracic?