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The ideal management of bronchoesophageal fistulas is a debated topic. While open surgical repair remains the most definitive treatment, not all patients are fit for surgery. In this communication, we present a patient who developed a bronchoesophageal fistula 1 year after an Ivor Lewis esophagectomy that involved the native oesophagus and right mainstem bronchus. Endoluminal vacuum therapy was successful at closing this benign bronchoesophageal fistula.

Background The number of elderly patients diagnosed with esophageal cancer rises. Current information about outcomes in elderly patients undergoing thoracoscopic Ivor Lewis esophagectomy is limited. The objective of this study was to evaluate the influence of age on short-and mid-term outcomes after thoracoscopic Ivor Lewis esophagectomy. Methods A retrospective review of 188 patients with esophageal cancer undergoing thoracoscopic Ivor Lewis esophagectomy between August 2014 and July 2019 was performed. Patients were divided into patients aged > 75 years (elderly group (EG), n = 37) and patients ≤ 75 years (younger group (YG), n = 151) and matched using propensity-score matching. Baseline characteristics, length of hospital stay, mortality and major postoperative complications (Clavien-Dindo ≥ grade III) were compared. Results After matching 74 patients remained (n = 37 in each group). Postoperatively, no significant differences in major and overall complications, intra-hospital and 30-day mortality, disease-free or overall survival up to 3 years after surgery were noted. The incidence of pulmonary complications (65% vs. 38%) and pneumonia (54% vs. 30%) was significantly higher and the median hospital length of stay (12 vs. 14 days) significantly longer in the EG versus YG. Conclusion Thoracoscopic Ivor Lewis esophagectomies resulted in acceptable postoperative major morbidity and mortality without compromising 3-years overall and disease-free survival in elderly compared to younger patients with esophageal cancer. However, the incidence of postoperative pulmonary complications was higher in patients aged over 75 years. Supplementary Information The online version contains supplementary material available at 10.1186/s12893-021-01435-5.

Evidence comparing conventional minimally invasive esophagectomy (CMIE) via laparoscopy and thoracoscopy with robot-assisted minimally invasive esophagectomy (RAMIE) is scarce. The aim of this meta-analysis was to compare surgical outcomes after CMIE and RAMIE with an intrathoracic anastomosis.A systematic literature search was performed to identify original articles analyzing outcomes after CMIE and RAMIE. Main surgical outcomes included operative time, intraoperative blood loss, anastomotic leak rates, pneumonia, overall morbidity, length of stay (LOS), and 30-day mortality. Oncologic outcomes included lymph node yield and R0 resections rates. A meta-analysis of proportions and linear regression models were used to assess the effect of each procedure on the different outcomes.A total of 6,249 patients were included for analysis; 5,275 (84%) underwent CMIE and 974 (16%) RAMIE. Robotic esophagectomy had longer operative time and less intraoperative blood loss. Anastomotic leakage rates were similar with both approaches. Patients undergoing RAMIE had significantly lower rates of postoperative pneumonia (OR 0.46, 95% CI 0.35-0.61, P.0001) and overall morbidity (OR 0.67, 95% CI 0.58-0.79, P.0001). Median LOS was similar in both procedures (RAMIE: 12.1 versus CMIE: 11.9 days, P = .64). Similar mortality rates were found after RAMIE and CMIE (OR 0.69, 95% CI 0.34-1.38, P = .29). Lymph node yield was similar in both procedures, but RAMIE was associated with higher rates of R0 resection (OR 2.84, 95% CI 1.53-5.26, P.001).Patients undergoing robotic esophagectomy have less intraoperative blood loss, lower rates of postoperative pneumonia, reduced overall morbidity, and higher rates of R0 resections, as compared with those undergoing a laparoscopic-thoracoscopic esophageal resection.

Background: Early nasogastric tube (NGT) removal is a component of enhanced recovery after surgery (ERAS) protocol for esophagectomy. The aim of this study is to assess a protocol-driven application of UGI contrast study to facilitate early NGT removal and direct a standardized therapeutic response in patients with evidence for delayed gastric conduit emptying (DGCE). Methods: All patients undergoing esophagectomy between January 2017 and October 2019 were prospectively enrolled. Esophageal resections were performed through different surgical approaches involving gastric conduit reconstruction. A standardized clinical protocol (SCP) was systematically applied, which targeted a UGI contrast study on POD 2–3 to allow immediate NGT removal or initiate DGCE protocols. Results: This study enrolled 50 patients undergoing open Ivor Lewis (42%), left thoracoabdominal (46%), and three-field procedure (12%) with gastric conduit reconstruction and either upper thoracic (66%) or cervical (34%) anastomosis. Jejunostomy was routinely placed while pyloric procedures were not performed. Patients achieving targeted contrast study (86%) demonstrated significantly earlier NGT removal (p-value 0.010), oral protocol initiation (0.001), and decreased length of hospital stay (6 vs 10days, 0.024). Four patients (8%) presented with radiology signs of DCGE and underwent protocoled treatment, eventually achieving discharge similar to the overall study population (7 vs 8.5days). Conclusions: Protocol-driven UGI contrast study can effectively provide objective data facilitating early NGT removal and discharge. Patients with DGCE can successfully undergo intervention to improve conduit emptying and adhere to ERAS discharge goals.

OBJECTIVE: This international multicenter study by the Upper GI International Robotic Association aimed to gain insight in current techniques and outcomes of RAMIE worldwide.BACKGROUND: Current evidence for RAMIE originates from single-center studies, which may not be generalizable to the international multicenter experience.METHODS: Twenty centers from Europe, Asia, North-America, and South-America participated from 2016 to 2019. Main endpoints included the surgical techniques, clinical outcomes, and early oncological results of ramie.RESULTS: A total of 856 patients undergoing transthoracic RAMIE were included. Robotic surgery was applied for both the thoracic and abdominal phase (45%), only the thoracic phase (49%), or only the abdominal phase (6%). In most cases, the mediastinal lymphadenectomy included the low paraesophageal nodes (n=815, 95%), subcarinal nodes (n = 774, 90%), and paratracheal nodes (n = 537, 63%). When paratracheal lymphadenectomy was performed during an Ivor Lewis or a McKeown RAMIE procedure, recurrent laryngeal nerve injury occurred in 3% and 11% of patients, respectively. Circular stapled (52%), hand-sewn (30%), and linear stapled (18%) anastomotic techniques were used. In Ivor Lewis RAMIE, robot-assisted hand-sewing showed the highest anastomotic leakage rate (33%), while lower rates were observed with circular stapling (17%) and linear stapling (15%). In McKeown RAMIE, a hand-sewn anastomotic technique showed the highest leakage rate (27%), followed by linear stapling (18%) and circular stapling (6%).CONCLUSION: This study is the first to provide an overview of the current techniques and outcomes of transthoracic RAMIE worldwide. Although these results indicate high quality of the procedure, the optimal approach should be further defined.

OBJECTIVE: The aim of this study is to identify factors influencing reoperations following minimally invasive Ivor Lewis esophagectomy and associated mortality and hospital costs. MATERIALS AND METHODS: Between 2013 and 2018, 125 patients were retrospectively analyzed. Outcomes included reoperations, mortality, and hospital costs. Multivariable logistic regression analyses determined factors associated with reoperations. RESULTS: In-hospital reoperations (n = 10) were associated with inhospital mortality (n = 3, P < 0.01), higher hospital costs (P < 0.01), and longer hospital stay (P < 0.01). Conversely, reoperations after discharge were not associated with mortality. By multivariable analysis, baseline cardiovascular (P = 0.02) and chronic kidney disease (P = 0.01) were associated with reoperations. However, anastomotic leaks were not associated with reoperations nor mortality. CONCLUSION: The majority of reoperations occur within 30 days often during index hospitalization. Reoperations were associated with increased in-hospital mortality and hospital costs. Notably, anastomotic leaks did not influence reoperations nor mortality. Efforts to optimize patient baseline comorbidities should be emphasized to minimize reoperations following minimally invasive Ivor Lewis esophagectomy.

OBJECTIVE Preemptive endoluminal vacuum therapy (pEVT) is a novel concept to reduce postoperative morbidity and has the potential to disrupt current treatment paradigms for patients undergoing esophagectomy. SUMMARY OF BACKGROUND DATA Endoluminal vacuum therapy is an accepted treatment for AL after esophagectomy. METHODS Retrospective analysis of patients undergoing minimally invasive Ivor Lewis esophagectomy with pEVT between 11/2017 and 10/2020. The sponge was removed endoscopically after 4-6 days, and anastomosis and gastric conduit were assessed according to a novel endoscopic grading system. Further management was customized according to endoscopic appearance and clinical course. Endpoints were postoperative morbidity and AL rate, defined according to the Clavien-Dindo (CD) and International Esodata Study Group classifications. RESULTS PEVT was performed in 67 consecutive patients, 57 (85%) were high-risk patients with an ASA score >2, WHO/ECOG score >1, age >65 years, or BMI >29 kg/m2. Thirty patients experienced textbook outcome, and overall minor (≤CD IIIa) and major (≥CD IIIb) morbidity was 40.3% and 14.9% respectively. 30-day-mortality was 0%. Forty-nine patients (73%) had uneventful anastomotic healing after pEVT without further endoscopic treatment. The remaining 18 patients (27%) underwent prolonged EVT with uneventful anastomotic healing in 13 patients (19%), contained AL in 4 patients (6%), and 1 uncontained leakage (1.5%) in a case with proximal gastric conduit necrosis, resulting in an overall AL rate of 7.5%. CONCLUSIONS PEVT is an innovative and safe procedure with a promising potential to reduce postoperative morbidity after minimally invasive Ivor Lewis esophagectomy and may be particularly valuable in highly comorbid cases.

Background/aim Esophagectomy is crucial for achieving long-term survival in patients with esophageal cancer, while being associated with a significant risk of complications. Aiming to reduce invasiveness and morbidity, total minimal-invasive esophagectomy (MIE) has been gradually implemented worldwide. The aim of the study was to compare MIE to open Ivor-Lewis esophagectomy (OE) for esophageal cancer or cancer of the gastroesophageal junction (GEJ), in terms of postoperative and oncological outcomes. Patients and methods Clinicopathological data of patients undergoing oncologic transthoracic esophagectomy (Ivor Lewis procedure) between 2010 and 2019 were assessed. Postoperative outcomes and long-term survival of patients undergoing OE were compared to those after MIE using 1:1 propensity score matching. Results After excluding hybrid and robotic procedures, 90 patients who underwent MIE were compared with a matched cohort of 90 patients who underwent OE. MIE was associated with lower major postoperative morbidity (31% vs. 46%, p=0.046) and lower 90-day mortality (2% vs. 12%, p=0.010) compared to OE. MIE showed non-inferior 3-year overall (65% vs. 52%, p=0.019) and comparable disease-free survival rates (49% vs. 51%, p=0.851) in comparison to OE. Conclusion Our data suggest that MIE should be preferably performed in patients with esophageal cancer or cancer of the GEJ.

Contains fulltext : 237885.pdf (Publisher’s version ) (Closed access) BACKGROUND: Transthoracic minimally invasive esophagectomy (MIE) is increasingly performed as part of curative multimodality treatment. There appears to be no robust evidence on the preferred location of the anastomosis after transthoracic MIE. OBJECTIVE: To compare an intrathoracic with a cervical anastomosis in a randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS: This open, multicenter randomized clinical superiority trial was performed at 9 Dutch high-volume hospitals. Patients with midesophageal to distal esophageal or gastroesophageal junction cancer planned for curative resection were included. Data collection occurred from April 2016 through February 2020. INTERVENTION: Patients were randomly assigned (1:1) to transthoracic MIE with intrathoracic or cervical anastomosis. MAIN OUTCOMES AND MEASURES: The primary end point was anastomotic leakage requiring endoscopic, radiologic, or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality, and quality of life. RESULTS: Two hundred sixty-two patients were randomized, and 245 were eligible for analysis. Anastomotic leakage necessitating reintervention occurred in 15 of 122 patients with intrathoracic anastomosis (12.3%) and in 39 of 123 patients with cervical anastomosis (31.7%; risk difference, -19.4% [95% CI, -29.5% to -9.3%]). Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference, -21.9% [95% CI, -32.1% to -11.6%]). Intensive care unit length of stay, mortality rates, and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with fewer severe complications (risk difference, -11.3% [-20.4% to -2.2%]), lower incidence of recurrent laryngeal nerve palsy (risk difference, -7.3% [95% CI, -12.1% to -2.5%]), and better quality of life in 3 subdomains (mean differences: dysphagia, -12.2 [95% CI, -19.6 to -4.7]; problems of choking when swallowing, -10.3 [95% CI, -16.4 to 4.2]; trouble with talking, -15.3 [95% CI, -22.9 to -7.7]). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, intrathoracic anastomosis resulted in better outcome for patients treated with transthoracic MIE for midesophageal to distal esophageal or gastroesophageal junction cancer. TRIAL REGISTRATION: Trialregister.nl Identifier: NL4183 (NTR4333).

Background: Delayed gastric emptying (DGE) is a common complication after esophagectomy with gastric tube reconstruction. It is still unclear whether a pyloric drainage procedure might reduce the r...

Esophageal resection is a key component of the multidisciplinary management of esophageal cancer. Robotic-assisted minimally invasive esophagectomy is gaining widespread approval amongst few centers with promising early data. There is significant variability in the operative approach utilized by different centers and this review describes, step-by-step, the operative technique at a high-volume tertiary center. The cornerstone of management is individualized surgical approach, based on patient, tumor and technical factors. Although our approach is based on aforementioned factors, our preferred approach is an Ivor Lewis esophagectomy and this review focuses on that. The procedure is broken down into three key parts, starting with an abdominal exploration and creation of the gastric conduit, placement of jejunostomy tube, moving to thoracic mobilization and creation of the side-side 6 cm stapled esophagogastric anastomosis with a final abdominal portion to assure proper positioning of the conduit and reducing redundancy. This approach is fully robotic and a side to side anastomosis facilitates the creation of a widely patent anastomosis therefore minimizing the risk of anastomotic leaks and strictures. Our experience with minimally invasive esophagectomy, as has been previously published, is associated with a 5.1% of anastomotic leak and 7.6% of anastomotic stricture. The robotic platform further optimizes this technique and helps us safely accomplish a side to side stapled anastomosis. Superior instrument dexterity in a restricted thoracic space is facilitated by intracorporeal suturing and robotic stapling. Thus, it obviates the need for a larger thoracotomy incision, which is typically needed for an EEA anastomosis, and that is traditionally associated with higher stricture rate.

The morbidity and mortality remain relatively high for transthoracic esophagectomy with open thoracotomy. We compared a total laparoscopic and thoracoscopic minimally invasive Ivor Lewis esophagectomy (M-ILE) cohort with a propensity score-weighted cohort of open Ivor Lewis esophagectomy (O-ILE) cases.This is a retrospective review of 259 patients diagnosed with esophageal carcinoma who underwent M-ILE (n = 173) or O-ILE (n = 86) from April 2009 to March 2019. The postoperative morbidity and mortality were reported for each group. Inverse probability of treatment weighting (IPTW) adjustment was used to balance the baseline characteristics between study groups. Recurrence-free and overall survival rates were compared on an intention-to-treat basis.The IPTW cohort included 249 patients with esophageal carcinoma who underwent M-ILE (n = 163) or O-ILE (n = 86). The overall rate of postoperative adverse events was significantly higher after IPTW adjustment in the O-ILE group (54.2% vs 39.02%; P = .039). The median hospital length of stay was 8.0 (interquartile range, 7.0-9.0) days for the M-ILE group compared with 10.0 (interquartile range, 8.0-14.0) days for the O-ILE group (P.001). The 3-year overall survival for the M-ILE group was 64.63% (95% confidence interval, 54.7%-72.9%) compared with 54.76% (95% confidence interval, 39.9%-67.4%) for the O-ILE group (P = .447). The 3-year recurrence-free survival rate did not differ significantly between the groups (P = .461).The M-ILE approach demonstrated short-term clinical outcomes that were superior to O-ILE at our institution. The survival rate and recurrence-free survival rate for M-ILE were not significantly different from O-ILE for esophageal carcinoma.

Robotic assistance has gained acceptance in thoracic procedures, including esophagectomy. There is a paucity of data regarding long-term outcomes for robotic esophagectomy. We previously reported our initial series of robot-assisted Ivor Lewis (RAIL) esophagectomy. We report long-term outcomes to assess the efficacy of the procedure. We performed a retrospective review of 112 consecutive patients who underwent a RAIL. Patient demographics, diagnosis, pathology, operative characteristics, post-operative complications, and long-term outcomes were documented. Descriptive statistical analysis was performed for all the variables. Primary endpoints were mortality and disease-free survival. Overall survival (OS) and disease-free survival (DFS) were calculated using the Kaplan-Meier method. Of the 112 patients, 106 had a diagnosis of cancer, with adenocarcinoma the dominant histology (87.5%). Of these 106 patients, 81 (76.4%) received neo-adjuvant chemoradiation. The 30-, 60-, and 90-day mortality was 1 (0.9%), 3 (2.7%), and 4 (3.6%), respectively. There were 9 anastomotic leaks (8%) and 18 (16.1%) patients had a stricture requiring dilation. All-patient OS at 1, 3, and 5 years was 81.4%, 60.5%, and 51.0%, respectively. For cancer patients, the 1-, 3-, and 5-year OS was 81.3%, 59.2%, and 49.4%, respectively, and the DFS was 75.3%, 42.3%, and 44.0%. We have shown that long-term outcomes after RAIL esophagectomy are similar to other non-robotic esophagectomies. Given the potential advantages of robotic assistance, our results are crucial to demonstrate that RAIL does not result in inferior outcomes.

The aim of this study is to determine the financial impact of clinical complications and outcomes after minimally invasive Ivor Lewis esophagectomy (MILE) at a safety-net hospital. This was a single-center retrospective analysis of consecutive patients undergoing MILE from 2013 to 2018. Postoperative complications were classified by Clavien-Dindo grade and associated total and direct recovered costs were assessed. Direct cost and LOS index were defined as the ratio of observed to expected values (>1 denotes above nationwide expectations). Annual outcomes were based on Medicare fiscal years. One hundred twenty-four patients (99 males, mean age 65.7 ± 9.3) were surgically treated for esophageal malignancy (n = 118) and benign disease (n = 6) by MILE between 2014 and 2018. Mean ICU LOS (5.8 ± 6.6 versus 4.3 ± 6.3 days) and LOS index (1.16 versus 0.76) improved from 2014 to 2018. Both direct cost index (1.03 versus 0.99) and indirect costs (43.4% versus 41.4%) decreased over time. However, direct costs recovered (213.6 to 159.0%) and total costs recovered (119.1 to 92.5%) declined during this period. Clinical complications grade was not associated with total costs recovered (p = 0.69). Extent of recovered expenditure was significantly higher from commercial/private payers as compared to government-sponsored payers (p < 0.05). Improvement in clinical outcomes and efficiency of care are not reflected by annual recovered expenditure. Furthermore, clinical complications do not correlate with the ability to recover hospital spending. Financial recovery was primary payer dependent. Enhanced collaboration with hospital administration may be needed in an effort to maximize financial fidelity in the presence of good quality of care after highly complex procedures.

Introduction Elective surgery in the UK came to a halt during the early part of the COVID-19 pandemic. As COVID-19-related infection and mortality rates in Devon and Cornwall were relatively low, however, urgent elective surgery continued in Plymouth, with the necessary precautions in place. This study aimed to assess outcomes following Ivor Lewis oesophagectomy (ILO) during the pandemic. Methods We prospectively analysed details of 20 consecutive patients who underwent ILO for cancer over a 3-month period between 17 March and 12 June 2020. All patients underwent COVID-19 swab testing 24–48 hours before surgery and during admission when clinically indicated. The primary outcome measure was COVID-19-related morbidity. Secondary outcome measures were non-COVID-19-related morbidity, mortality and length of hospital stay. Results Twenty patients underwent ILO during the study period. All patients identified as white British. No patients tested positive for COVID-19 pre- or postoperatively. There was no COVID-19-related morbidity. There was no in-hospital mortality. Seven patients developed pneumonia, which settled with antibiotics. One patient developed an anastomotic leak, which was treated conservatively. One patient returned to theatre for a para-conduit hernia repair. The median length of hospital stay was nine days. One patient required admission to the high dependency unit for inotropic support for two days. Conclusions ILO can be performed safely during the COVID-19 pandemic with the necessary precautions in place.

OBJECTIVE: To describe the pooled learning curves of Ivor Lewis totally minimally invasive esophagectomy (TMIE) in hospitals stratified by predefined hospital- and surgeon-related factors.BACKGROUND: Ivor Lewis (TMIE is known to have a long learning curve which is associated with considerable learning associated morbidity. It is unknown whether hospital and surgeon characteristics are associated with more efficient learning.METHODS: A retrospective analysis of prospectively collected data of consecutive Ivor Lewis TMIE patients in 14 European hospitals was performed. Outcome parameters used as proxy for efficient learning were learning curve length, learning associated morbidity, and the plateau level regarding anastomotic leakage and textbook outcome. Pooled incidences were plotted for the factor-based subgroups using generalized additive models and 2-phase models. Casemix predicted outcomes were plotted and compared with observed outcomes. The investigated factors included annual volume, TMIE experience, clinic visits, courses and fellowships followed, and proctor supervision.RESULTS: This study included 2121 patients. The length of the learning curve was shorter for centers with an annual volume >50 compared to centers with an annual volume CONCLUSIONS: More efficient learning was observed in centers with higher annual volume. Visiting an expert clinic, completing a fellowship, or implementation under a proctor's supervision were not associated with more efficient learning.

Robotische Systeme wurden vor uber 20 Jahren zum ersten Mal in die Viszeralchirurgie eingefuhrt, kurz darauf fuhrte Horgan in Chicago 2003 die erste roboterassistierte Osophagusresektion durch. Ziel dieser Arbeit ist die Darstellung neuer Techniken und Trainingsmethoden fur die roboterassistierte Chirurgie mit Kosten-Nutzen-Bewertung am Beispiel der Ivor-Lewis-Osophagektomie Es erfolgte eine systematische Literaturrecherche zu neuen Technologien im Bereich der roboterassistierten Chirurgie und Kostenanalyse der intraoperativen Verbrauchsmaterialien fur die Hybrid-Ivor-Lewis-Osophagektomie sowie die roboterassistierte Ivor-Lewis-Osophagektomie. Roboterassistierte Osophaguschirurgie ist komplex und erfordert eine aufwendige Lernphase. Diese kann durch moderne Trainingsmethoden deutlich verkurzt werden. Neue Robotersysteme zielen auf den Einsatz bildgestutzter Chirurgie und kunstliche Intelligenz. Roboterassistierte Eingriffe in der Osophagustumorchirurgie sind signifikant teurer als vergleichbare Eingriffe ohne diese Technologie. Onkologische Kurz- und Langzeitvorteile fur den Patienten nach roboterassistierten Eingriffen am oberen Gastrointestinaltrakt mussen weiter evaluiert werden, um den Einsatz robotischer Technologie zu rechtfertigen.

Synopsis Standardization of robotic oesophagectomy can benefit both patients and surgeons by decreasing complications, shortening the learning curve and improving surgical training. Background Thoraco-abdominal oesophagectomy with lymphadenectomy is the cornerstone of curative therapy for oesophageal carcinoma. To reduce post-operative morbidity, minimally invasive technology has become increasingly established. Conventional thoraco-laparoscopic procedures, however, are limited by their technical feasibility. These limitations can be overcome using robot-assisted technology. Methods Robotic Ivor-Lewis oesophageal resection has gradually been implemented in our clinic from 2013. We have performed over 250 robot-assisted minimally invasive oesophagectomies and more than 2000 robotic procedures overall. This experience allowed us to establish a standardized operative technique. Results We identified 11 operative steps as key elements for oesophageal resection, which should help implementation of this technique and allow surgeons to approach this complex procedure with greater confidence. Conclusion Standardization is fundamental to the establishment of a new surgical technique and is a key element in the learning curve of Ivor-Lewis oesophageal resection. Standardization can lead to better reproducibility of results, and thus to improved quality.

Background During esophagectomy for esophageal cancer, a gastric tube is necessary for the perioperative period. However, the gastric tube and anastomotic anvil placement is often extremely difficult and time consuming during surgery. Methods We used the traditional method or improved method to place the gastric tube and anastomotic anvil during thoracoscopic and laparoscopic Ivor Lewis esophagectomy. Thirty-seven patients were in the improved group: the gastric tube and anastomotic anvil were placed using the improved method; 35 patients were in the traditional group: the gastric tube and anastomotic anvil were placed using the traditional method. Retrospectively, we analyze the basic clinical characteristics, perioperative clinical features, and postoperative complications of the two groups of patients. Results The two groups were matched well for baseline characteristics. There was no significant difference between the two groups in blood loss, postoperative hospital stay, postoperative fasting time, drainage volume, and overall complications. But significant between-group differences were observed in time consuming and chest tube indwelling time (P < 0.05), both of which were significantly shorter in the improved group than in the traditional group. Conclusions This improved method can reduce the difficulty of placing anastomotic anvil and gastric tube and prevent damage to the anastomosis during surgery.

Background Anastomotic leak following Ivor Lewis esophagectomy is associated with increased morbidity/mortality and decreased survival. Tissue oxygenation at the anastomotic site may influence anastomotic leak. Methods for establishing tissue oxygenation at the anastomotic site are lacking. Methods Over a 2-year study period, 185 Ivor Lewis esophagectomies were performed. Study participants underwent measurement of gastric conduit tissue oxygenation at the planned anastomotic site using the wireless pulse oximetry device. Associations between anastomotic leaks or strictures and tissue oxygenation levels were analyzed using Wilcoxon rank sum test or Fisher's exact test. Results Among study participants (n=114), median gastric conduit tissue oxygenation level was 92% (range, 62-100%). There were 8 (7.0%) anastomotic leaks and 3 (2.6%) strictures. Analysis of tissue oxygenation as a continuous variable showed no difference in median tissue oxygenation in patients with and without leaks (98% and 92%; P=0.2) and stricture formation (89% and 92%; P=0.6). Analysis of tissue oxygenation as a dichotomous variable found no difference in anastomotic leak rates [7.5% (n=93) in >80% vs. 0% (n=20) in ≤80%; P=0.3]. There were no significant differences in leak rates in concurrent study nonparticipants. Conclusions No significant association was observed between intraoperative tissue oxygenation at the anastomotic site and subsequent anastomotic leak or stricture formation among patients undergoing Ivor Lewis esophagectomy.

Background Anastomosis is one of the important factors affecting anastomotic complications after esophagectomy, and multiple reports have compared anastomotic complications among various techniques. However, there is insufficient evidence in the literature to definitively recommend one anastomotic technique over another. Method We retrospectively evaluated 34 consecutive patients who underwent an improved totally mechanical side-to-side: posterior-to-posterior linear stapled (TM-STS) technique for minimally invasive Ivor Lewis esophagogastric anastomosis, performed by a single surgeon between February 2015 to November 2017. The operative techniques and short-term outcomes are analyzed in this study. Results There were no conversions to an open approach and a complete resection was achieved in all patients undergoing this improved procedure. During the first half of the series, the median operation time was 355 minutes, ranging from 257 to 480 minutes. Over the second half of this series, the median operation time was reduced to 256 minutes. There were no mortalities or serious postoperative complications. Only one patient (2.9%) had an anastomotic leak, which resolved without intervention. Another patient (2.9%) experienced transient, delayed conduit emptying which upper gastrointestinal radiography determined was due to a mechanical obstruction caused by an abnormally long gastric tube in the chest cavity. Conclusions The results of our study suggest that this improved TM-STS technique is safe and effective for minimally invasive Ivor Lewis esophagectomy, and can be considered as one of the alternative procedure for patients with lower esophageal as well as Siewert types I/II gastroesophageal junction carcinoma.

Minimally invasive esophagectomy is an accepted approach to treating esophageal malignancy and is associated with excellent postoperative outcomes. Creation of the intrathoracic anastomosis with a minimally invasive approach remains one of the most critical and challenging steps of the operation. There is currently no consensus regarding the optimal technique for the esophagogastric anastomosis. Here we aimed to review the most commonly used esophagogastric anastomotic techniques for minimally invasive Ivor Lewis operations.

Background Minimally invasive esophagectomy (MIE) is a complex and technically demanding procedure with a long learning curve, which is associated with increased morbidity and mortality. To master MIE, training in essential steps is crucial. Yet, no consensus on essential steps of MIE is available. The aim of this study was to achieve expert consensus on essential steps in Ivor Lewis and McKeown MIE through Delphi methodology. Methods Based on expert opinion and peer-reviewed literature, essential steps were defined for Ivor Lewis (IL) and McKeown (McK) MIE. In a round table discussion, experts finalized the lists of steps and an online Delphi questionnaire was sent to an international expert panel (7 European countries) of minimally invasive upper GI surgeons. Based on replies and comments, steps were adjusted and rephrased and sent in iterative fashion until consensus was achieved. Results Two Delphi rounds were conducted and response rates were 74% (23 out of 31 experts) for the first and 81% (27 out of 33 experts) for the second round. Consensus was achieved on 106 essential steps for both the IL and McK approach. Cronbach’s alpha in the first round was 0.78 (IL) and 0.78 (McK) and in the second round 0.92 (IL) and 0.88 (McK). Conclusions Consensus among European experts was achieved on essential surgical steps for both Ivor Lewis and McKeown minimally invasive esophagectomy.

To compare complications following totally minimally invasive (TMIE), laparoscopically assisted (hybrid) and open Ivor Lewis esophagectomy in patients with esophageal cancer. Three randomized trials have reported benefits for minimally invasive esophagectomy. Two studies compared TMIE versus open esophagectomy and another compared hybrid versus open Ivor Lewis esophagectomy. Only small retrospective studies compared TMIE with hybrid Ivor Lewis esophagectomy. Methods Data were used from the International Esodata Study Group assessing patients undergoing TMIE, hybrid or open Ivor Lewis esophagectomy. Primary outcome was pneumonia, secondary outcomes included incidence and severity of anastomotic leakage, (major) complications, length of stay, escalation of care and 90-day mortality. Data were analyzed using multivariate multilevel models. Results In total, 4733 patients were included in this study (TMIE:1472, hybrid:1364 and open:1897). Patients undergoing TMIE had lower incidence of pneumonia compared to hybrid (10.9% vs 16.3%, Odds Ratio (OR):0.56, 95%CI: 0.40–0.80) and open esophagectomy (10.9% vs 17.4%, OR:0.60, 95%CI: 0.42–0.84) and had shorter length of stay (median 10 days (IQR 8–16)) compared to hybrid (14 (11–19), p = 0.041) and open esophagectomy (11 (9–16), p = 0.027). Patients undergoing TMIE had higher rate of anastomotic leakage compared to hybrid (15.1% vs 10.7%, OR:1.47, 95%CI: 1.01–2.13) and open esophagectomy (7.3%, OR:1.73, 95%CI: 1.26–2.38). No differences were reported between hybrid and open esophagectomy. Conclusion Compared to hybrid and open Ivor Lewis esophagectomy, TMIE resulted in a lower pneumonia rate, a shorter hospital length of stay but a higher anastomotic leakage rate. The impact of these individual complications on survival and long-term quality of life should be further investigated.

Anastomotic leak following Ivor Lewis oesophago-gastrectomy is a major complication with high morbidity and mortality. We report our experience with three such cases where endoscopically deployed double pigtail stents (DPT) were used to help manage the leaks. Methods Three patients from October 1, 2019 to February 29, 2020 experienced leakage from the oesophago-gastric anastomosis following minimally invasive Ivor Lewis oesophago-gastrectomy. These occurred on post-operative day 9, day 29 and day 7 respectively. All cases were managed with endoscopic deployment of double pigtail stents along with other adjunctive measures. Results To date all patients remain alive, with sepsis under control. One of the patients had been able to have his double pigtail stent removed at six weeks and he has been able to commence adjuvant chemotherapy. Another patient had a follow-up contrast study one week after DPT insertion which showed no further contrast extravasation and was able to recommence oral intake. The third patient has a left empyema (managed conservatively with a combination of internal DPT and external pigtail drainage) which is gradually resolving. Conclusion Endoscopically deployed DPTs are a useful tool in the armamentarium for managing oesophago-gastric anastomotic leaks in selected patients following Ivor Lewis oesophago-gastrectomy. They are advantageous in that stent migration does not appear to be an issue, nor is there any problem with leakage around the stent. Patients are mostly able to restart oral intake soon after insertion of DPTs. This reduces the morbidity associated with these anastomotic leaks, and reduces the number of interventions needed.

In early 2000s, cervical anastomosis after esophagectomy was associated with a higher rate of recurrent nerve trauma than thoracic anastomosis. Recently, new technologies have been developed that reduce surgical complications. Mediastinoscopic esophagectomy is reportedly less invasive and allows faster recovery than thoracoscopic esophagectomy. Intraoperative nerve monitoring (IONM) prevents recurrent laryngeal nerve (RNL) palsy. We present the case of minimally invasive mediastinoscopic Ivor-Lewis Esophagectomy (MMIE) under IONM performed on an elderly esophagogastric junction (EGJ) adenocarcinoma patient. Methods An 84-year old man was consulted for adenocarcinoma of GEJ without lymphnode metastasis. Despite his advanced age, he had no comorbidities. We planned to perform MMIE under IONM. The procedure started with a patient lithotomy, and three trocars plus small incision were made in the upper abdomen. Celiac lymphadenectomy was performed. Subsequently, a 35 mm incision was made in the left side of the neck and a monitor was attached to left vagus nerve. Three trocars were placed with single incision surgical devices and pneumomediastinum was noticed. Mediastinoscopic esophagectomy was performed. Gastric tube reconstruction via mediastinum with cervical anastomosis was performed. Results The operation was successful. Total operation time was 393 minutes, with an estimated blood loss of 5 mL. There were no intraoperative and postoperative complications, and no RLN palsy occurred. Conclusion MMIE with cervical anastomosis under IONM is safe and less invasive especially for the respiratory system as a thoracotomy is unnecessary. Video https://www.dropbox.com/s/9yqkzg3pm619pf6/%E7%B8%A6%E9%9A%94%E9%8F%A12%E5%88%8656%E7%A7%92.mp4?dl=0.

One of the most feared complications of the esophagectomy for esophageal cancer is anastomotic leakage (AL). Early diagnosis is vital for timely initiation of therapeutic interventions as well as prompting early feeding in the absence of AL. The aim of this study is to investigate the role of serum C-reactive protein (CRP) and drain amylase levels in the early detection of AL. Methods All 109 patients who underwent a minimally invasive Ivor-Lewis procedure in our hospital between January 2018 and October 2020 were retrospectively included in this study. Data on CRP and drain amylase levels were collected during the first 5 postoperative days (POD) and were available for analyses. Mean CRP and median drain amylase levels between patients with and without AL were compared and ROC curves on POD 3, 4 and 5 were plotted to calculate cut-off values for CRP. Results In 13 of 109 patients (12%) AL was diagnosed with a median time to diagnosis of 8 days. Mean CRP was significantly higher in patients with AL on POD 3, 4 and 5. Cut-off values of 48, 113 and 90 mg/L had a high sensitivity of 100%, 92% and 92% on POD 3, 4 and 5. No difference in median drain amylase levels was observed. Conclusion CRP levels with a cut-off point of 113 mg/L on POD 4 do not improve earlier detection of AL, but has a high sensitivity for excluding AL while the value of drain amylase in the first 5 days after surgery is limited.

Anastomotic leak (AL) and conduit necrosis (CN) are among the most serious surgical complications after esophageal resection. Endoscopic, radiological and surgical methods are used in their treatment. The aim of this paper is to evaluate the results of the treatment of acute anastomotic complications after Ivor-Lewis esophagectomy in a single high-volume center. Methods We performed a retrospective audit of a consecutive cohort of 815 patients undergoing transthoracic esophagectomy with intrathoracic esophago-gastric anastomosis from 2005 to 2019. AL was graded according to Esophagectomy Complications Consensus Group recommendation. Results There were 79 patients with AL and 6 patients with CN (10%). AL type I, II and III was diagnosed in 33 (39%), 25 (29%) and 27 (32%) patients, respectively. Esophageal stent was used in 40 patients. Primary surgical revision (with/without stent insertion) was performed in 14 patients. Reoperation was necessary overall in 25 patients (29%). Seventeen patients (20%) ended-up with esophageal diversion. Treatment with esophageal stent was successful in 28/40 patients (70%). Endoscopic vacuum-therapy was successfully used in three patients for peristent leak after stent extraction. Mortality of severe AL (type II and III) was 10/52 patients (19%). Conclusion Successful management of acute anastomotic complications requires early diagnosis and an individual treatment approach with the use of endoscopic, radiological and surgical methods. The primary attempt for anastomosis preservation using esophageal stent is desirable. Considering the clinical condition and CT finding, we recommend not to hesitate with surgical revision with debridement and drainage of pleural cavity and mediastinum. If primary therapy fails, life-saving procedure is the esophageal diversion.

Background Minimal invasive Ivor-Lewis esophagectomy (MIIVE) with intrathoracic esophago-gastric anastomosis (EGA) is still under exploration and the preferred technique for intrathoracic anastomosis has not been established. Methods We retrospectively reviewed 43 consecutive patients who underwent MIIVE using the series technique called pretreatment-assisted robot intrathoracic layered anastomosis (PRILA), performed by a single surgeon between September 2018 and December 2020. The operative outcomes were analyzed. Results The mean total operation time had been reduced from 446.38±54.775 minutes (range, 354-552) in the first year to 347.70±60.420 minutes (range, 249-450) later. There were no conversions to thoracotomy. All the patients achieved R0 resection. No patient suffered from anastomotic leakage. There was no 30-day mortality. The median length of postoperative stay was 10.0 days. Conclusions PRILA further visualizes and streamlines the process of minimal invasive intrathoracic EGA, thus ensuring the precise anastomosis. It could be considered as a feasible alternative for intrathoracic EGA in MIILE.

Background The side‐to‐side anastomosis was considered a promising approach to create an intrathoracic esophagogastrostomy in the minimally invasive esophagectomy, with advantages over the side‐to‐end anastomosis with aspects of no need for additional mini‐thoracotomy and lower occurrence of stenosis. The hand‐sewing anterior aspect of the anastomosis is technically challenging in the thoracoscopic Ivor Lewis esophagectomy. Here we introduced our initial experience to facilitate this approach by using the surgical robot and barbed suture. Methods A retrospective study of all patients underwent robot‐assisted Ivor Lewis esophagectomy with side‐to‐side esophagogastrostomy from February 2016 to September 2018 was performed. The technical details are described in this paper. Results A total of 37 patients (35 male and 2 female, median age of 62.7 years) were successfully treated with completely robot‐assisted Ivor Lewis esophagectomy. The median total surgical time was 340 minutes including 65 minutes to perform the anastomosis. Median estimated blood loss was 120 mL and the length of hospital stay was 10 days. There was no 90‐day mortality. Three patients suffered anastomotic leakage (8.1%,3/37), who were successfully treated without reoperation. Conclusion Our initial results imply that it is technically feasible to perform intrathoracic gastroesophageal anastomosis by taking advantage of a robotic system and knotless suturing.

Surgical approaches for treating esophageal carcinoma include the transhiatal esophagectomy (THE) and the transthoracic esophagectomy (TTE) with the anastomosis in the thorax or the neck. Compared with THE, TTE can resect more extensive intrathoracic esophageal tumors. Meanwhile, the range of the resected mediastinal lymph nodes with TTE is wider than THE. Performing an intrathoracic esophagogastric anastomosis using MIE techniques can be technically challenging and time-consuming (1,2). Combined laparoscopic with thoracoscopic Ivor-Lewis esophagectomy needs video-assisted mini-thoracotomy and the use of Endo-GIA stapler over and over. Due to the use of OrVil system, the operation of the intrathoracic esophagus anastomosis has become easy, and the operation time has reduced.

A considerable number of reports have been published on the feasibility, techniques, and early postoperative results of robotic-assisted oesophageal surgery. However, these are mostly smaller case series, suggesting that the robot-assisted Ivor Lewis procedure is still in the implementation phase and far from being standardised. Oesophageal surgeons from seven robotic university centres in Germany, experienced in both minimally invasive and robot-assisted minimally invasive surgery, took part in a workshop on robot-assisted surgery. An intensive exchange of opinions and experiences, followed by a step-by-step re-enactment of the operation in a cadaver lab, enabled us to develop a standardised robot-assisted Ivor Lewis surgical workflow, which is presented here. Systematic and objective comparison of experiences and results using a robot-assisted Ivor Lewis procedure has made it possible to develop a standardised surgical workflow that is now clinically applied in our centres. It is hoped that standardisation of this procedure will help to maintain patient safety, prevent medical errors, and facilitate the learning curve, while introducing robotic surgery into a centre.

In the face of an increasingly aged population, surgical management in the elderly will rise. This study assesses the short-term outcomes of esophagectomies in octogenarians.The National Surgical Quality Improvement Program database was queried for esophagectomy cases from 2005 to 2014. Patients aged80 and ≥80 y were compared in univariate and multivariate analysis, controlling for confounding variables.Among 9354 esophagectomies, 4.3% were performed in patients aged ≥80 y. Ivor Lewis was the most common approach, comprising 43% of cases. Octogenarians more frequently had dependent functional status (P 0.0001) and cardiovascular disease (P 0.0001), whereas younger patients were more likely obese (P 0.0001), smokers (P 0.0001), and have excess preoperative weight loss (P = 0.0043). Compared to younger patients, in multivariate analysis, elderly patients were noted to have increased risk of 30-d mortality (odds ratio [OR] 1.67; confidence interval [CI] 1.03-2.67), discharge to facility (OR 3.08; CI 2.36-4.02), myocardial infarction (OR 2.49; CI 1.29-4.82), and pneumonia (OR 1.47; CI 1.12-1.910). However, regardless of age, dependent functional status demonstrated the strongest association with mortality (OR 3.41; CI 2.14-6.61). Within the elderly, each additional year above 80 y old increased the risk of discharge to a facility by 17% (OR 1.17; CI 1.04-1.30). Cases requiring nongastric intestinal conduit were also more likely to suffer from early mortality (OR 2.87; CI 1.87-4.40).Age is independently associated with multiple adverse outcomes, including mortality, discharge to facility, and postoperative cardiopulmonary complications. Functional dependence is even more so associated with poor outcomes. Careful selection of very elderly patients is required to minimize additional risk.

BACKGROUND The main clinical treatment for esophageal cancer is surgery. Since traditional open esophageal cancer resection has the disadvantages of large trauma, long recovery period, and high postoperative complication rate, its clinical application is gradually reduced. The current report of minimally invasive Ivor-Lewis esophagectomy (MIILE) is increasing. However, researchers found that patients with MIILE had a higher incidence of early delayed gastric emptying (DGE). AIM To investigate the influencing factors of postoperative early DGE after MIILE. METHODS A total of 156 patients diagnosed with esophageal cancer at Deyang People's Hospital were enrolled. According to the criteria of DGE, patients were assigned to a DGE group (n = 49) and a control group (n = 107). The differences between the DGE group and the control group were compared. Multivariate logistic regression analysis was used to further determine the influencing factors of postoperative early DGE. The receiver operating characteristic (ROC) curve was used to assess potential factors in predicting postoperative early DGE. RESULTS Age, intraoperative blood loss, chest drainage time, portion of anxiety score ≥ 45 points, analgesia pump use, postoperative to enteral nutrition interval, and postoperative fluid volume in the DGE group were higher than those in the control group. Perioperative albumin level in the DGE group was lower than that in the control group (P < 0.05). Age, anxiety score, perioperative albumin level, and postoperative fluid volume were independent factors influencing postoperative early DGE, and the differences were statistically significant (P < 0.05). The ROC curve analysis revealed that the area under the curve (AUC) for anxiety score was 0.720. The optimum cut-off value was 39, and the sensitivity and specificity were 80.37% and 65.31%, respectively. The AUC for postoperative fluid volume were 0.774. The optimal cut-off value was 1191.86 mL, and the sensitivity and specificity were 65.3% and 77.6%, respectively. The AUC for perioperative albumin level was 0.758. The optimum cut-off value was 26.75 g/L, and the sensitivity and specificity were 97.2% and 46.9%, respectively. CONCLUSION Advanced age, postoperative anxiety, perioperative albumin level, and postoperative fluid volume can increase the incidence of postoperative early DGE.

Oesophageal resection is a challenging procedure, and it is more so in patients who have undergone bariatric procedures, especially after laparoscopic sleeve gastrectomy. We present the case of a patient with a history of an laparoscopic sleeve gastrectomy who underwent a hybrid Ivor-Lewis oesophagectomy in which the sleeve was successfully used to reconstruct the upper gastrointestinal tract.

Objectives: To analyze the impact of the reversal penetrating technique (RPT) for intrathoracic gastroesophageal mechanical anastomosis on the development of anastomotic complications in Ivor Lewis minimally invasive esophagectomy (ILMIE) and further identify the risk factors for the development of anastomotic leakage and stricture.Methods: A retrospective observational study was conducted using clinical data of 316 patients with esophageal carcinoma (EC) who underwent ILMIE from January 2012 to December 2019. The participants were divided into three groups of RPT, transoral Orvil technique (TOT), or purse-string technique (PST) according to the different stapler placenent methods for intrathoracic mechanistic circular stapling. Multivariable analysis was performed to investigate the association of risk factors with anastomotic leakage and stricture.Results: There were 154 patients with RPT, 78 with TOT and 84 with PST intrathoracic gastroesophageal circular stapling in ILMIE. There was no differences in intraoperative anastomosis related conditions inclouding conversion of open operations, ways of esophageal reconstruction, lymph nodes harvested between the three groups. Whereas, The mean total operative time, and gastroesophageal anastomosis time in the RPT group were significantly shorter than those in other groups (both p

Summary This study aimed to demonstrate the learning curve of robot-assisted minimally invasive esophagectomy (RAMIE). A retrospective analysis of the first 124 consecutive patients who underwent RAMIE with intrathoracic anastomosis (Ivor Lewis) by a single surgeon between May 2015 and August 2020 was performed. An risk-adjusted cumulative sum (RA-CUSUM) analysis was applied to generate a learning curve of RAMIE considering the major complication rate, which reflected the technical proficiency. The overall 30-day morbidity rate was 38.7%, while the major complication rate was 25.8%. The learning curve was divided into two phases based on the RA-CUSUM analysis: phase I, the initial learning phase (cases 1–51) and phase II, the proficiency phase (cases 52–124). As we compared the proficiency phase with the initial learning phase, significantly decreased trends were observed in relation to the major complication rate (37.3% vs. 18.7%, P = 0.017), total operation time (330.9 ± 55.6 vs. 267.3 ± 39.1 minutes, P

Objective We introduced robotic-assisted Ivor Lewis esophagectomies (rob-E) using the da Vinci Xi in Oct. 2015. Prior to that, esophagectomies were performed as open Ivor Lewis (open-E) procedures. Aim of this study is to evaluate the safety of rob-E in comparison to open-E procedures regarding perioperative outcomes. Methods Retrospective analysis of prospectively collected data between Feb. 1999 and Dec. 2020. A case-matched analysis, matching open-E to rob-E in a 1:1 manner, was conducted. Cases were matched regarding age, gender, American Society of Anesthesiologists (ASA) score, histological type of tumor, tumor location and stage. Results In the study period 321 patients underwent an esophagectomy. 76 received rob-E and 245 open-E. After matching the cases the comparison of preoperative patient and tumor characteristics revealed no differences between the rob-E and open-E group regarding age at time of operation with a median of 69.5 (35-83) respectively 70 (46-88) years (p = 0.900), gender with 84.2% male in both groups (p = 1.000), ASA score with 68.4% ASA 3 or 4 in both groups (p = 1.000), percentage of tumor stage III of 53.9% respectively 57.9% (p = 0.707), and rate of neoadjuvant treatment of 82.9% in rob-E and 81.6% in open-E (p = 1.000). Conversion from rob-E to open-E was never necessary. For rob-E versus open-E no difference was found regarding overall morbidity with 69.7% versus 60.5% (p = 0.307), major morbidity (Clavien-Dindo > = 3b) with 11.8% versus 14.5% (p = 0.811), incidence of anastomotic insufficiency with 7.9% versus 5.3% (p = 0.745), rate of surgical reintervention with 5.3% versus 7.9% (p = 0.745), and mortality with 2.6% versus 3.9% (p = 1.000). Postoperative details showed no difference including a similar duration of hospitalization with a median of 20 (13-62) respectively 18.5 (13-52) days (p = 0.368) and number of harvested lymph nodes with a median of 24.5 (7-59) in rob-E and 23 (2-64) in open-E (p = 0.203). Conclusion The introduction of rob-E in our institution was safe, as perioperative morbidity and mortality did not differ from the previously performed open-E. Overall, the incidence of major morbidity and anastomotic insufficiency in rob-E and open-E show a satisfactory rate compared to previous reports in literature. Further studies with a larger cohort of rob-E are planned in order to draw more decisive conclusions.

Objective We introduced robotic-assisted Ivor Lewis esophagectomies (rob-E) using the da Vinci Xi in Oct. 2015. Two anastomotic techniques have been performed – continuously sutured (COSU) and linear-stapled (LIST). Aim of this study is to evaluate the two anastomotic techniques regarding perioperative outcomes in our experience. Methods Retrospective analysis of prospectively collected data between Oct. 2015 and Dec. 2020 including 76 patients. 45 underwent COSU and 31 LIST. Techniques are demonstrated with video material. Minor (Clavien-Dindo = 3b) morbidity, rate of anastomotic insufficiency, mortality, and duration of hospitalization were compared. Results Patient characteristics were as follows: median age of 69 (35-83) years in COSU and 70 (36-83) years in LIST (p = 0.575), male gender in 84.4% of COSU and 83.9% of LIST (p = 1.000), and physical status with American Society of Anesthesiologists score 3 in 62.2% of COSU and 67.7% of LIST (p = 0.771). Concerning tumor characteristics there were 91.1% adenocarcinomas in COSU and 96.8% in LIST (p = 0.642), whereas the others were squamous cell carcinomas and one neuroendocrine tumor in COSU. The tumors were stage II in 22.2% respectively 32.3% and stage III in 57.8% respectively 48.4% of COSU and LIST (p = 0.555). Comparison of minor morbidity occurring in 60.0% of COSU and 54.8% of LIST (p = 0.813), major morbidity in 8.9% respectively 16.1% (p = 0.473), incidence of anastomotic insufficiency in 8.9% of COSU and 6.5% of LIST (p = 1.000), rate of surgical reintervention necessary in 2.2% respectively 9.7% (p = 0.298) as well as mortality of 2.2% in COSU and 3.2% in LIST (p = 1.000) showed no difference. Median duration of hospitalization of 20 (13-49) days in COSU and 20 (14-62) in LIST (p = 0.423) did not differ. Conclusion In rob-E COSU and LIST show comparable results and a preferable technique cannot be determined yet. Our results do not support the results of previous reports (Cerfolio et al.) that demonstrated a superiority of LIST. While stapling the backside of the anastomosis in LIST impresses as an elegant way to overcome the surgical demanding part of the anastomosis, other disadvantages such as compromising perfusion of the gastric conduit may prevail and limit the benefits. Further studies with a larger cohort are planned in order to draw more decisive conclusions.

Purpose Symptom recurrence after initial surgical management of esophageal achalasia occurs in 10–25% of patients. The aim of this study was to analyze safety and efficacy of revisional therapy after failed Heller myotomy (HM). Methods A retrospective review of a prospective database was performed searching for patients with recurrent symptoms after primary surgical therapy for achalasia. Patients with previously failed HM were considered for the final analysis. The Foregut questionnaire, and the Atkinson and Eckardt scales were used to assess severity of symptoms. Objective investigations routinely included upper gastrointestinal endoscopy and barium swallow study. Redo treatments consisted of endoscopic pneumatic dilation (PD), laparoscopic HM, hybrid Ivor Lewis esophagectomy, or stapled cardioplasty. A yearly clinical and endoscopic follow-up was scheduled in all patients. Results Over a 20-year period, 26 patients with a median age of 66 years (IQR 19.5) underwent revisional therapy after failed HM for achalasia at a tertiary-care university hospital. The median time after index procedure was 10 years (IQR 21). Revisional therapy consisted of endoscopic pneumatic dilation (n=13), laparoscopic HM and fundoplication (n=10), esophagectomy (n=2), and stapled cardioplasty and fundoplication (n=1). Nine (34.6%) of these patients required further endoscopic or surgical treatments. There was no mortality, and the overall complication rate was 7.7%. At a median follow-up of 42 months (range 10–149), a significant decrease of dysphagia, regurgitation, chest pain, respiratory symptoms, and median Eckardt score (p Conclusion In specialized and multidisciplinary centers, revisional therapy for achalasia is feasible, safe, and effective.

Due to the difficulties in the intra-thoracic esophagogastric anastomosis creation, totally minimally invasive Ivor Lewis esophagectomy (MIE) did not encountered a large diffusion, preferring hybrid techniques or cervical anastomosis. Robot-assisted minimally invasive esophagectomy (RAMIE) has gained popularity due to an easy reproducibility of the open anastomotic technique. In this feasibility study, we described the RAMIE technique introduced in our Center, providing innovative details for a mechanical end-to-end anastomosis. With patient in prone position, esophagectomy is conducted through the meso-esophagus plan. Robotic hand-sewn purse-string is realized above Azygos vein. A 4-cm thoracotomy in the fifth intercostal space is performed by enlarging the trocar incision. The tubulization is performed to create an access pouch for the introduction of the circular stapler. After the creation of the end-to-end anastomosis, the access pouch is resected and a robotic over-sewn is realized. From January 2020 until July 2020, ten patients were enrolled. No restriction in term of age, BMI, ASA grade or previous surgery were applied. Median operative time was 700 min. R0 resection was achieved in all cases with a good lymph node harvesting. No anastomotic leak or stricture were observed. One chyle leak was treated conservatively. Median length of stay was 8 days and 90 days mortality was 0%. This study evidenced how robotic surgery allowed us to perform the same anastomosis of our open technique with good oncological results and morbidity and length of stay comparable with our previous results. Of note, longer operative time has been recorded. Further studies after the completion of the learning curve are necessary to address more definite conclusions.