Performance of the transoral circular stapler for oesophagogastrectomy after induction therapy

Patients undergoing oesophageal anastomosis may be at an increased risk for leak after induction therapy for oesophageal cancer, with intrathoracic leaks having significant morbidity. The outcomes of utilizing transoral circular stapler for the creation of a thoracic anastomosis have not been well studied in this patient population.

Patients with oesophageal cancer undergoing induction chemotherapy/radiation followed by Ivor Lewis oesophagogastrectomy were evaluated. All thoracic anastomoses were constructed with transoral circular stapler. Primary outcomes evaluated were the rates of anastomotic leak and stricture.

Over 7 years, 87 consecutive patients were evaluated, among whom 69 (79%) were male. The median age was 63 years, median body mass index (BMI) was 27 kg/m2 and median age-adjusted comorbidity index was 5. Median operative blood loss was 400 ml and median operative time was 300 min. Major complications (grade ≥3) were seen in 19 (22%), including anastomotic leak in 2 (2.3%), both successfully treated with temporary covered metal stent. The median duration of hospital stay was 10 days, and 1 (1.2%) death was reported at 90 days due to cancer recurrence. Stricture occurred in 8 (9.2%), and median time to dilation was 109 days and median number of dilations was 1. Univariable analysis found BMI to be significantly higher in patients with an anastomotic leak versus those without (43 vs 27 kg/m2, P = 0.002). No variables were found to be predictive of anastomotic stricture.

The use of the transoral circular stapler for thoracic anastomosis results in a consistent formation of the anastomosis, with low leak and stricture rates in the setting of induction chemotherapy/radiation. Leaks that do occur appear to be amenable to stent therapy.