Comparison of double-layered scallop-shaped anastomosis and circular stapled anastomosis in Ivor-Lewis surgery for esophageal and EGJ cancer: a retrospective cohort study

Abstract

Background: Cancers of the lower esophagus and esophagogastric junction (EGJ) are highly aggressive and have poor prognoses. Minimally invasive Ivor-Lewis surgery (MIIL) is the preferred treatment, but anastomotic leakage (AL) remains a critical complication of this procedure. In the present study, we introduce a novel double-layered scallop-shaped anastomosis (DLSSA) technique and compare its outcomes with those of circular stapled esophagogastric anastomosis (CSEA).

Methods: From April 2016 to February 2023, 117 patients with distal esophageal or EGJ cancer who underwent complete thoracoscopic-laparoscopic Ivor-Lewis surgery were retrospectively analyzed. Patients were divided into DLSSA (n = 50) and CSEA (n = 67) groups. The median value and ranges are used to present the numerical data. Continuous and categorical variables were compared between groups with the Kruskal‒Wallis test and Fisher's exact test or χ2 test, respectively. Multivariable binary logistic regression analyses were performed to identify potential prognostic factors.

Results: The median total operation duration was similar between the groups (280 min). Intraoperative blood loss was slightly greater in the CSEA group (120 ml vs. 100 ml, p = 0.001). Postoperative complications occurred in 32.5% of the patients, with no significant between-group difference. However, the incidence of AL was significantly lower (4.0% vs. 17.9%, p = 0.022) and that of pleural effusion was significantly greater (10.0% vs. 1.5%, p = 0.039) in the DLSSA group than in the CSEA group. Multivariable analysis revealed that a higher body mass index (OR = 1.453, 95% CI: 1.119-1.888; p = 0.005) was a risk factor for AL, whereas undergoing DLSSA was associated with reduced AL risk (OR = 0.052, 95% CI: 0.005-0.525; p = 0.012), and both variables were considered independent predictors of AL risk.

Conclusion: Compared with CSEA, DLSSA was associated with significantly lower risk of AL in thoracoscopic Ivor-Lewis surgery, demonstrating its potential as a safer anastomotic technique. However, its association with increased pleural effusion warrants further investigation. Prospective randomized trials are needed to validate long-term outcomes and optimize procedural efficacy.

Keywords: Carcinoma; Esophagogastric junction; Ivor–Lewis; Postoperative complications; Scallop-shaped anastomosis.

Fig. 1

Flowchart of patient inclusion, allocation, and analysis: A total of 117 patients were included in this study and were subsequently available for outcome comparison. (EGJ:esophagogastric junction, CSEA:circular stapled esophagogastric anastomosis, DLSSA: double-layered scallop-shaped anastomosis)

Fig. 2

Thoracoscopic procedures using DLSSA. a Two small openings were made separately in the right side of the gastric tube and the left side of the lower esophagus. A 3–0 triclosan-coated VICRYL Plus suture was used to fix the two sides. b A linear stapler was inserted between the lumen of the gastric tube and the esophagus. c After we fired the linear stapler, a side-to-side esophagogastrostomy was created. d The mucosal layer was closed with a running 3–0 triclosan-coated VICRYL Plus suture. e The muscular layer was also closed with a running 3–0 triclosan-coated VICRYL Plus suture. f Anastomosis after suturing. g Iodized water radiography of upper digestive tract in POD 7, arrow: pseudo-fundus of the stomach. h gastroscopy in POD 7, arrow: pseudo-fundus of the stomach. (DLSSA: double-layered scallop-shaped anastomosis, POD:post-operative day)

Fig. 3

Schematic representation of the DLSSA. a A linear stapler was inserted between the lumen of the gastric tube and the esophagus. b The mucosal layer was closed with a running 3–0 triclosan-coated VICRYL Plus suture. c The muscular layer was closed with a running 3–0 triclosan-coated VICRYL Plus suture. d Anastomosis after suturing. Its three-dimensional shape resembles that of a scallop

Fig. 4

The violin plot depicts the multivariate logistic regression with the anastomotic leakage outcome, values on the right are reported as the odds ratio with the respective 95% confidence interval in parenthesis. * Statistically significant at p ≤ 0.05. (CSEA: circular stapled esophagogastric anastomosis, DLSSA: double-layered scallop-shaped anastomosis, BMI: body mass index)