Use of efficient purse-string stapling technique for esophagogastric anastomosis in minimally invasive Ivor Lewis esophagectomy

Minimally invasive esophagectomy (MIE) is increasingly accepted in the treatment of locoregional or advanced esophageal cancer. Laparoscopic-thoracoscopic Ivor-Lewis esophagectomy has been proved to be effective in treating middle and distal esophageal cancer, however, intrathoracic esophagogastric anastomosis is technically complex. When using circular stapler for making intrathoracic anastomosis in MIE, both transoral and transthoracic methods are frequently used for delivering the anvil into the esophageal stump. Herein, we report a new method to construct a thoracoscopic esophagogastric anastomosis by using a circular stapler: efficient purse-string stapling technique (EST). This technique is easy to handle and especially good to be used in patients with distal esophageal cancer or expanded esophageal cavity.KEYWORDS : Minimally invasive esophagectomy (MIE), Ivor Lewis esophagectomy, esophageal cancer, esophagogastric anastomosis, efficient purse-string stapling technique (EST)     

Application of a modified McKeown procedure (thoracoscopic esophageal mobilization three‐incision esophagectomy) in esophageal cancer surgery: Initial experience with 30 cases

Early efforts with minimally invasive esophagectomy (MIE) were hybrid approaches. No conclusive benefit was seen with this approach compared with the standard open procedure. Total MIE has demonstrated its advantages in single institution series. The drawbacks of total MIE include the steep learning curve and the high cost of the disposable instrumentation. We sought to determine the feasibility of modifying the surgical technique involved in the hybrid approach in an effort to decrease the cost of the surgery without compromising the outcome. From December 2007 to September 2008, the modified McKeown procedure (thoracoscopic esophageal mobilization three‐incision esophagectomy) was performed in 30 cases. The median operative time was 225 minutes (range, 195 ?290 minutes) and the median average time of VATS was 70 minutes (range, 50 ?130 minutes). Median lymph node retrieval was 25.6 ± 4.8 nodes (15.1 ± 3.4 intrathoracic) per patient. The median postoperative hospital stay was 17.1 ± 6.3 days. There was no in‐hospital (30 days) mortality. Postoperative complications occurred in 9 patients (30%), including 2 (6.7%) pneumonia, 1 (3.3%) chylothorax, 1 (3.3%) delayed gastric emptying ,1 (3.3%) vocal cord palsy, 2 (6.7%) neck anastomotic leaks, and 2 (6.7%) arrhythmias. This procedure is technically feasible and safe with lower mortality and mobility. The short‐term surgical outcomes are comparable with most of the total MIE reports. Performing the gastric mobilization and spontaneous neck anastomosis first greatly facilitate and simplifies the VATS maneuver.     

Robot-assisted minimally invasive esophagectomy is equivalent to thoracoscopic minimally invasive esophagectomy

The use of the surgical robot has been increasing in thoracic surgery. Its three-dimensional view and instruments with surgical wrists may provide advantages over traditional thoracoscopic techniques. Our initial experience with thoracoscopic robot-assisted minimally invasive esophagectomy (RAMIE) for esophageal cancer was compared with our traditional thoracoscopic minimally invasive esophagectomy (MIE) approach for esophageal cancer. A retrospective review of a prospective database was performed. From July 2008 to October 2009, 43 patients underwent MIE resection. Patients who had benign disease and intrathoracic anastomosis were excluded. Results are presented as mean ± SD. Significance was set as P < 0.05. Eleven patients who underwent RAMIE and 26 who underwent MIE were included in the cohort. No differences in age, sex, race, body mass index, or preoperative radiotherapy or chemotherapy between the groups were observed. No significant differences in operative time, blood loss, number of resected lymph nodes, postoperative complications, days of mechanical ventilation, length of intensive care unit stay, or length of hospital stay were also observed. In this short-term study, RAMIE was found to be equivalent to thoracoscopic MIE and did not offer clear advantages.     

Thoracoscopic purse string technique for minimally invasive Ivor Lewis esophagectomy

Objective

Thoracolaparoscopic esophagectomy with chest anastomosis (TLE-chest) is increasingly performed for middle and lower esophageal cancer; however, gastroesophageal anastomosis for this surgery remains both challenging and inefficient. To address this issue, we previously reported our MIE technique with Ivor-Lewis anastomosis. Here we present the video to introduce our TLE-chest operation procedures.

Methods

TLE-chest with a combined thoracoscopic and laparoscopic technique was performed by one group of surgeons. From October 2011 to September 2013, 80 esophageal cancer patients were treated with TLE-chest using this improved anastomotic technique.

Results

The surgery was successful for all patients, although the anastomosis in one patient required intraoperative manual repair. No patients required open conversion. In this video, dissociation of stomach, and dissection of lymph nodes, creation of gastric tube and staple line embedding, jejunostomy were carried out by laparoscopic surgery. Dissection of esophageal cancer and mediastinal lymph nodes were done through rib 3 or 4 by a 3-4 cm video-assisted right anterior minithoracotomy, then esophago-gastric anastomosis was performed in right thoracic cavity This video shows the R0 resection of T3N0M0 esophageal cancer. Totally, 36 lymph nodes were dissected, including 21 mediastinal lymph nodes and 15 abdominal lymph nodes. The patient recovered well and was discharged on day 8 after the surgery, with good short term outcomes.

Conclusions

A safe, cost effective purse string stapled anastomotic technique has been presented for TLE-chest in our video. It is consistent with the oncology principles.     

Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomsis

We retrospectively analyzed the clinical data of 112 patients who underwent esophagectomy for esophageal carcinoma and gastro-esophageal anastomosis in right thoracic cavity from October 2011 to June 2013. First, the gastric tube was created with the aid of linear stapling device by removing the stomach and dissecting lymph nodes under laparoscopy and making a 3-4 cm incision through the subxiphoid area in the upper abdomen. Second, the thoracic esophagus and lymph nodes were dissected during thoracoscopic procedure. Gastric tube was inserted into the chest cavity and placed in the posterior mediastinum. The thoracic gastro-esophageal anastomosis was stapled with a circular stapler. Combined laparoscopic-thoracoscopic esophagectomy and intrathoracic esophagogastric anastomosis is technically feasible and safe, with minimized trauma, less operative blood loss and quick recovery.KEYWORDS : Laparoscopic, thoracoscopic, esophagectomy, esophagogastric anastomosis, esophageal carcinoma     

Thoracoscopic and laparoscopic esophagectomy with cervical manual anastomosis for esophageal cancer

Evidence on the benefits of minimally invasive approach over traditional open procedure in gastrointestinal surgery is continuing to accumulate. This is also the case for esophageal surgery.Although laparoscopic esophageal surgery was initially reserved for benign pathology, the technical development, increasing experience with laparoscopic and thoracoscopic techniques and the theoretical advantages of minimally invasive surgery have widened the scope of minimally invasive approach to esophageal cancer. The surgical treatment of esophageal cancer often requires extensive procedures and is therefore, considered one of the most challenging and invasive procedure of gastrointestinal surgery. While transhiatal and transthoracic esophagectomy are common approaches for esophageal resection, data regarding the combined thoracoscopic and laparoscopic approach to esophagectomy are limited. The minimally invasive technique of esophagectomy to be described consists of three phases: thoracoscopic esophageal mobilization and mediastinal lymphadenectomy followed by laparoscopic gastric mobilization, abdominal lymphadenectomy and gastric conduit formation and finally retrieval of the resection specimen followed by an esophagogastric anastomosis via a left cervical incision.     

Esophageal anastomosis following gastrectomy for gastric cancer: comparison of hand-sewn and stapling technique

BACKGROUND/AIMS: During the past 4 years, we have experienced a marked reduction in the incidence of esophageal anastomotic leakage and/or stricture coinciding with the use of a mechanical circular stapler for gastric cancer patients. METHODOLOGY: We reviewed medical records of gastric cancer patients who underwent a total or proximal gastrectomy, and compared the leakage or stricture of stapled anastomosis with the hand-sewn anastomosis technique. A total of 390 esophageal anastomosis were performed between January 1978 and August 1997. Two types of mechanical circular staplers were used (EEA and CDH). RESULTS: Anastomotic leakage occurred in 13 (3.3%) of 390 cases; three (4.5%) of 66 cases with hand-sewn anastomosis, and 10 (3.1%) of 324 cases with stapled anastomosis (EEA: 4.5%, CDH: 0%). The anastomotic leakage rate was significantly lower in the CDH stapler group than in the EEA stapler group. Anastomotic stricture occurred in one (1.5%) of 66 cases of hand-sewn anastomosis, and 16 (4.9%) of 324 cases of stapled anastomosis (EEA: 5.9%, CDH: 2.9%). There were no significant differences in the stricture rate between the hand-sewn group and the stapler group. CONCLUSIONS: Stapling anastomosis using a CDH stapler led to a reduction in the incidence of anastomotic leakage. Surgeons must, however, continue to be aware of anastomotic stricture.     

Combined thoracoscopic and laparoscopic esophagectomy: experience,technique and cautions

We described a 59-year-old female, who came to our institute with the diagnosis of esophageal squamous cell carcinoma. The preoperative clinical diagnosis was stage II esophageal squamous cell carcinoma. The three-stage minimally invasive esophagectomy (MIE), combined thoracoscopic-laparoscopic esophagectomy with cervical anastomosis, was performed in this case. The lateral-prone decubitus position and Harmonic scalpel facilitate the operation.KEYWORDS : Minimally invasive esophagectomy (MIE), thoracoscopic, laparoscopic     

Minimally invasive esophageal resection and intrathoracic anastomosis for lower thoracic esophageal cancer with single position

There are various esophagectomy approaches for lower thoracic esophageal cancer, and the minimally invasive esophagectomy (MIE) approach shows the advantages of less discomfort, shorter length of stay and a faster recovery to baseline status than open approaches. The current study reports a case of lower thoracic esophageal cancer was treated using a single-position, minimally invasive surgical technique with laparoscopy and thoracoscopy. A 68-year-old man, whose gastroscopy identified the esophageal carcinoma, came to our medical center due to dysphagia for over 1 year. The patient underwent tumor radical resection and intrathoracic anastomosis by laparoscopy and thoracoscopy with single position. The patient has recovered well after the surgery.     

Outcomes of robotic esophagectomy

Esophagectomy has long been considered the standard of care for early-stage (≤ T2N0) esophageal cancer. Minimally invasive esophagectomy (MIE), using a combined laparoscopic and thoracoscopic approach, was first performed in the 1990s and showed significant improvements over open approaches. Refinement of MIE arrived in the form of robotic-assisted minimally invasive esophagectomy (RAMIE) in 2004. MIE is a challenging procedure for which consensus on optimal technique is still elusive. Although nonrobotic MIE confers significant advantages over open approaches, MIE remains associated with stubbornly high rates of complications, including pneumonia, aspiration, arrhythmia, anastomotic leakage, surgical site infection, and vocal cord palsy. RAMIE was envisioned to improve operative-associated morbidity while achieving equivalent or superior oncologic outcomes to nonrobotic MIE. However, owing to RAMIE’s significant upfront costs, steep learning curve, and other requirements, adoption remains less than widespread and convincing evidence supporting its use from well-designed studies is lacking. In this review, we compare operative, oncologic, and quality-of-life outcomes between open esophagectomy, nonrobotic MIE, and RAMIE. Although RAMIE remains a relatively new and underexplored modality, several studies in the literature show that it is feasible and results in similar outcomes to other MIE approaches. Moreover, RAMIE has been associated with favorable patient satisfaction and quality of life.     

Laparoscopic ischemic conditioning of the stomach prior to esophagectomy

Several complications after esophagectomy with gastric pull‐up are associated with ischemia within the gastric conduit. The aim of this study is to assess the feasibility of laparoscopic ischemic preconditioning of the stomach prior to thoracotomy, esophagectomy, and gastric pull‐up with an intrathoracic anastomosis. A retrospective review of 24 consecutive patients between October 2008 and July 2011 with esophageal adenocarcinoma (stage I–III) undergoing laparoscopic gastric ischemic conditioning prior to esophagectomy was conducted. Conditioning included laparoscopic ligation of the left and short gastric arteries, celiac node dissection, and jejunostomy tube placement. Formal resection and reconstruction was then performed 4–10 days later. Of the 24 patients, 88% received neoadjuvant chemotherapy/radiation therapy. Twenty‐three of the 24 patients underwent successful laparoscopic ischemic conditioning and subsequent esophagectomy. Total mean number of lymph nodes harvested was 21.8 (±8.0), and a mean of 5.3 (±2.4) celiac lymph nodes identified. There were no conversions to an open procedure. Length of stay was 3.8 (±4.8) days with a median length of stay of 2 (1–24) days. Three patients experienced anastomotic leak, six patients experience delayed gastric emptying, and two patients developed anastomotic stricture. There were no surgical site infections. R0 resection was achieved in all patients who underwent laparoscopic ischemic conditioning followed by esophagectomy. Laparoscopic ischemic conditioning of the gastric conduit has been shown to be feasible and safe.     

A preliminary experience with minimally invasive Ivor Lewis esophagectomy

With several small series examining minimally invasive Ivor Lewis esophagectomies, we look to contribute to a growing experience. In reporting our initial results, safety, initial oncologic completeness, and preliminary outcomes with a minimally invasive Ivor Lewis esophagectomy were demonstrated. From 2007 to 2010, 40 minimally invasive Ivor Lewis esophagectomies were carried out. The approach was a laparoscopic mobilization of the stomach and a thoracoscopic esophageal mobilization and creation of a high intrathoracic anastomosis. Indications included esophageal cancer in 39 patients and esophageal gastrointestinal stromal tumor in one patient. Median age was 62 (range 39-77) with 31 (78%) male patients. Non-emergent conversion was required in two (5%) patients. Twenty-five (63%) patients underwent neoadjuvant therapy. Mean operative time was 364 minutes (range 285-455), and mean blood loss was 205 cc (range 100-400). All patients underwent an R0 resection including the removal of all Barrett's esophagus, and mean number of nodes harvested was 21 (range 11-41). Median intensive care unit stay was 1 day (range 1-3), and hospital stay was 7 days (range 6-19). There were no anastomotic leaks and no 30-day mortality. Postoperative complications included eight (21%) patients with atrial fibrillation and two (5%) chylothorax, one requiring ligation. At a mean follow-up of 16.5 months (range 1-39 months), five (13%) patients have had a distant recurrence; there have been no local recurrences. Minimally invasive Ivor Lewis esophagectomy, although technically challenging, can be carried out with reasonable operative times, a short length of stay, and minimal complication. Final oncologic validity is pending longer follow-up and a larger series.     

The use of circular stapler for cervical esophagogastric anastomosis after esophagectomy: surgical technique and early postoperative outcome

Stapled esophagogastric anastomosis after esophagectomy is considered to be superior to traditional handsewn techniques. Linear staplers are usually used. The aim of this study is to evaluate early postoperative results of circular stapler in cervical esophagogastric anastomosis. Records of all patients who underwent esophagectomy during the years 2003–2008 were reviewed. Patients that underwent transthoracic esophagectomy, colon transposition, or linear stapler anastomosis were excluded. Esophagogastric anastomosis was done either handsewn or using circular stapler. Patients underwent either pyloromyotomy, pyloroplasty, or no pyloric intervention. Postoperative leakage was diagnosed either clinically or radiologically. The end-point of this study was the incidence of anastomotic leak in the immediate postoperative period. Eighty-two patients (average age 66 years, male/female, 52/30) met the inclusion criteria. In 30 patients, the anastomosis was handsewn, and in 52 patients, it was done using a circular stapler. Overall operative mortality rate was 4.8% (four patients because of pulmonary or cardiac complications). Anastomotic leak occurred in five ( n  = 5, 16.6%) patients in the handsewn group and eight ( n  = 7, 13.4%) patients in the circular stapler group. Pyloric manipulation had no significant effect over the leakage rate. Routine upper-gastrointestinal (GI) series done on the fifth or sixth postoperative day did not reveal any of the leaks. Cervical esophagogastric anastomosis using an end-to-side circular stapler is feasible and safe, and has comparable outcomes to handsewn anastomosis in regard of leakage rates or other major surgical or general complications. Postoperative GI series seems to be a poor diagnostic tool for anastomotic leakage and could be omitted as a routine study for occult anastomotic leak.     

老年食管癌病人微创手术中不同胸腔内吻合方法的比较

目的比较老年食管癌病人经右胸微创、腹正中切口食管癌根治术中分别采用倒穿刺法和常规法进行胸腔内吻合的可行性、安全性及优劣势。方法回顾性分析2017年1月至2020年1月42例60岁以上经右胸微创、腹正中两切口食管癌手术病人的临床资料。根据胸部吻合方法的不同将42例病人分为A、B两组,每组各21例。A组采用倒穿刺法完成吻合,B组采用常规法完成吻合。比较2组手术吻合时间、吻合部位、术中出血量、术后吻合口并发症、术后住院天数等资料。结果A组病人中共17例顺利完成手术,4例病人因各种原因中转手术;B组病人均顺利完成。2组病人性别、年龄等一般资料无明显差异(P>0.05)。2组吻合时间、吻合部位差异有统计学意义(P<0.05),术中出血量、术后吻合口并发症发生率以及住院天数比较,差异无统计学意义(P>0.05)。结论倒穿刺法操作相对简单,但操作稳定性差,常规法操作相对复杂,但吻合成功率高,2种方法均可用于食管癌微创手术。     

Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosis

SUMMARY.   Trans-hiatal esophagectomy with a hand-sewn anastomosis was for 2 decades the preferred approach in our institution for patients with esophageal cancer. In our experience, this anastomotic technique was associated with a 12% leak rate and a 48% rate of stricture requiring dilatation. We sought to determine if a side-to-side intra-thoracic anastomosis was associated with a lower rate of anastomotic stricture and leak. Thirty-three consecutive patients with distal esophageal cancer or Barrett's esophagus with high grade dysplasia underwent a trans-thoracic esophagectomy with a side-to-side stapled intra-thoracic anastomosis. The overall morbidity was 27%, with no anastomotic stricture or leaks. One patient died (3%). The median time to the resumption of an oral diet was 7 days (range 5–28), and the median length of stay in hospital was 9 days (range 6–45). Trans-thoracic esophagectomy with a side-to-side stapled anastomosis is safe and it is associated with a very low rate of anastomotic complications. We consider this to be the procedure of choice for patients with distal esophageal cancers.     

Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer

This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand‐assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA‐preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.     

Thoracoscopic and laparoscopic radical esophagectomy with left neck anastomosis

We described a 50-year-old female, who came to our institute with the diagnosis of esophageal squamous cell carcinoma. The preoperative clinical diagnosis was stage II esophageal squamous cell carcinoma. The minimally invasive esophagectomy (MIE), combined thoracoscopic-laparoscopic esophagectomy with cervical anastomosis, was performed in this case. Total surgery time was 190 min and blood loss was 100 mL. Postoperative pathological exam suggested squamous cell carcinoma, without evidence of lymph node metastasis in any station (T2N0M0 IIb stage). The patient was discharged home on the 12^th postoperative day.     

Short-term postoperative superiority and 5-year follow-up outcomes of video-assisted thoracoscopic esophagectomy for treatment of esophageal carcinoma: a historical comparison with conventional open esophagectomy under a single experienced surgeon

Background

Few reports have provided a direct comparison of thoracoscopic and open esophagectomy for treatment of esophageal carcinoma in a sufficiently large number of patients with an adequate follow-up period.

Methods

We compared the short- and long-term (up to 5 years after surgery) outcomes of 121 patients who had undergone video-assisted thoracoscopic esophagectomy with 3-field lymphadenectomy (the VATE group) and 74 patients who had undergone conventional open esophagectomy with 3-field lymphadenectomy (the OE group) for treatment of esophageal squamous cell carcinoma.

Results

Total and intrathoracic operation times were longer and total and intrathoracic blood losses were lower in the VATE group than in the OE group. The number of dissected lymph nodes around the left recurrent laryngeal nerve was significantly higher, while both the intensive care unit stay and postoperative hospital stay were significantly shorter in the VATE group. Moreover, the frequency of postoperative analgesia use was lower in the VATE group. Overall morbidity and mortality rates were similar, and the incidences of overall, surgical-site, and thoracic wound infections were significantly lower in the VATE group. Additionally, the incidence of postoperative pneumonia was also lower in the VATE group, although the difference was not statistically significant. No differences were observed in recurrence or survival rates.

Conclusion

Video-assisted thoracoscopic esophagectomy with 3-field lymphadenectomy is a safe and effective surgical method that can be used as an alternative to conventional open esophagectomy in patients with curable esophageal carcinoma.     

A comparison of short-term outcomes between Ivor-Lewis and McKeown minimally invasive esophagectomy

Background

Only few comparative studies have been reported on the outcomes of minimally invasive esophagectomy (MIE) with intrathoracic anastomosis (MIE Ivor-Lewis) and MIE with cervical anastomosis (MIE McKeown) for patients with mid and lower esophageal cancer. The objective of this study is to compare the safety, feasibility, and short-term outcomes between two groups.

Methods

Clinical and surgical data of patients with esophageal cancer who underwent either MIE Ivor-Lewis or MIE McKeown between January 2013 and October 2014 were retrospectively analyzed. Demographic characteristics, pathological data, operative procedures, and perioperative outcomes and survival in patients were compared between both groups.

Results

Of the 72 patients included in this retrospective analysis, 32 underwent MIE Ivor-Lewis and 40 underwent MIE McKeown. Demographics, pathologic data, inpatient mortality, and surgical morbidity in both cohorts were almost identical. A significant difference was observed in Pulmonary complication (18.8% vs. 42.5%, P=0.032), Anastomotic leakage (9.4% vs. 30%, P=0.032), Anastomotic stenosis (12.5% vs. 35%, P=0.028), recurrent laryngeal nerve (RLN) injury (6.3% vs. 22.5%, P=0.034) between MIE Ivor-Lewis and MIE McKeown groups; however, no difference in operative time (312.6±82.0 vs. 339.4±80.0, P=0.249), blood loss (246.3±82.4 vs. 272.9±136.3, P=0.443), lymph nodes harvested (19.3±8.1 vs. 20.2±7.2, P=0.655) and 90-day mortality (3.1% vs. 5%, P=0.692) was observed between two groups.

Conclusions

The procedure of MIE Ivor-Lewis for esophageal cancer possesses advantages in perioperative outcomes and less complications compared with MIE McKeown.     

Surgical attempts to avoid anastomotic leaks and reduce reflux esophagitis following esophagectomy for cancer

Background  We analyzed the results of our surgical attempts to establish a safe reconstruction after esophagectomy for cancer that withstands both early and subsequent complications. Methods  Patients who underwent an intrathoracic or cervical esophagogastrostomy were selected. We preserved the esophagus keeping an oral margin of at least 3 cm and made an anastomosis with the gastric wall as low as possible to avoid an anastomotic leak. We included an antireflux procedure in the intrathoracic anastomosis. We examined the effect of these surgical approaches in three patient groups: one group with cervical anastomosis (CA group, n = 21), and the other two groups with intrathoracic anastomosis after resection of cancer in the upper or middle thoracic esophagus (UM group, n = 104) or in the lower thoracic or abdominal esophagus (LA group, n = 30). Results  No leak was found in the esophagogastric anastomosis in any group. A gastric suture line dehiscence developed in two cases in the UM group. Postoperative endoscopy revealed that mean anastomotic height in the UM group was 4.1 cm lower than in the CA group (P < 0.0001) and 2.1 cm higher than in the LA group (P = 0.0006). The incidence of reflux esophagitis was 0% in the CA group, 43% in the UM group, and 37% in the LA group, with significant differences between the CA group and the other groups. Conclusions  Our surgical attempts to avoid leaks of esophagogastrostomy were entirely successful. An intrathoracic anastomosis combined with an antireflux procedure was not advantageous for the incidence of reflux esophagitis compared to cervical anastomosis, but it minimized the effects of anastomotic height on the development of reflux esophagitis.