Ivor- Lewis Esophagectomy with circular stapled anastomosis (EEA): Single centre experience

Saurabh Singhal, MBBS, MS, Aparna Kailasam, Shunsuke Akimoto, MD, Carrie Bertellotti, RN, Sumeet K Mittal, MBBS. Creighton University

Introduction: Anastomotic leaks continue to be the Achilles heel of esophago-gastric anastomosis. Advent of minimally invasive esophagectomy necessitated the incorporation of stapled anastomotic techniques especially for intra-thoracic anastomosis. Aim of this study is to review a single centre experience of circular stapled anastomosis during Ivor-Lewis esophagectomy.

Methodology: After IRB approval, patient data was retrieved from prospectively maintained database to identify patients who underwent Ivor- Lewis esophagectomy with circular stapled (EEA) anastomosis. The entire group was divided in three equal sequential cohorts (A, B and C) and compared for patient centred variables. Patients with either cervical anastomosis or hand sewn intra-thoracic anastomosis were excluded.

Results: Seventy five patients (divided into sequential cohorts of 25 patients each) underwent Ivor-Lewis esophagectomy with circular stapled (EEA – 25/28) anastomosis from 2007-2015. Mean age and BMI did not differ significantly between the three groups (Age: 63.7 years vs. 66.7 years vs. 64.4 years; BMI: 31.4 Kg/m2 vs. 29.1 Kg/m2 vs. 28.9 Kg/m2). Group A had significantly longer mean hospital stay as compared with Group B and C (23.7 days vs. 15.9 days vs 14.1 days, p<0.05). There were no significant differences between three groups with respect to mean post-operative ICU stay (8 days vs. 6 days vs. 5.6 days, p=NS) or mean operative time (382.9 vs. 374.7 vs. 355.8 min, p=NS). Ten patients (13%) had anastomotic leak; of these, one patient required redo-anastomosis while rest 9 patients underwent endoscopic interventions. Four patients underwent endoscopic stenting, three patients received endoscopic washes and two received trans-nasal wound VAC therapy. There was significant decrease in rate of anastomotic leak with time (8 vs. 1 vs. 1, p=0.004). Procedure was converted to open in 5, 4 and 2 patients in group A, B and C respectively while 1, 4 and 3 patients respectively were electively operated by open approach. One patient in group A had to be converted to open due to intra-operative stapler malfunction necessitating conversion to hand-sewn anastomosis. There were two in-hospital deaths, one each in group A and C, including one death due to anastomotic leak (group A).

Conclusion: There is a decrease in rate of anastomotic leaks with experience following Ivor-Lewis Esophagectomy using EEA stapled anastomosis.

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