Comparison of Double-Layered Scallop-Shaped Anastomosis and Circular Stapled Anastomosis in Ivor-Lewis Surgery for Esophageal and EGJ Cancer: A Retrospective Cohort Study

Comparison of Double-Layered Scallop-Shaped Anastomosis and Circular Stapled Anastomosis in Ivor-Lewis Surgery for Esophageal and EGJ Cancer: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Double-Layered Scallop-Shaped Anastomosis and Circular Stapled Anastomosis in Ivor-Lewis Surgery for Esophageal and EGJ Cancer: A Retrospective Cohort Study KunKun Li, Qian Yang, YingJian Wang, TaiMing Zhang, Liang Zhang, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6068142/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Cancer → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Cancers of the lower esophagus and esophagogastric junction (EGJ) are highly aggressive with poor prognoses. Minimally invasive Ivor–Lewis surgery (MIIL) is preferred, but anastomotic leakage remains a critical complication. This study introduces a novel double-layered scallop-shaped anastomosis (DLSSA) technique and compares its outcomes with circular stapled esophagogastric anastomosis (CSEA). Methods: From April 2016 to February 2023, 117 patients with distal esophageal or EGJ cancer undergoing 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 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 groups (280 minutes). Intraoperative blood loss was slightly higher in the CSEA group (120 ml vs. 100 ml, p=0.001). Postoperative complications occurred in 32.5% of patients, with no significant difference between groups. However, anastomotic leakage was significantly lower in the DLSSA group (4.0% vs. 17.9%, p=0.022), while pleural effusion was higher (10.0% vs. 1.5%, p=0.039). Multivariate analysis identified higher BMI (OR=1.453, 95% CI:1.119–1.888; p=0.005) as a risk factor for AL, while DLSSA reduced AL risk (OR=0.052, 95% CI:0.005–0.525; p=0.012) as independent predictors of anastomotic leakage. Conclusion: DLSSA significantly reduces anastomotic leakage compared to CSEA 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. esophagogastric junction carcinoma Ivor–Lewis scallop-shaped anastomosis postoperative complications Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Cancers of the lower esophagus and esophagogastric junction (EGJ) are the most aggressive cancers with the poorest prognoses, and their incidences are observed to be increasing globally[ 1 , 2 ]. Ivor–Lewis surgery is the main approach to lower esophageal cancer and Siewert type I/II adenocarcinoma of the esophagogastric junction (AEG) [ 3 , 4 ], and minimally invasive Ivor–Lewis (MIIL) surgery is the preferred approach[ 5 ]. One MIIL approach, complete thoracoscopic–laparoscopic Ivor–Lewis surgery, is observed to be trending strongly worldwide[ 5 ]. Anastomotic mediastinal fistula is considered the predominant cause of prolonged hospital stays and postoperative death after Ivor-Lewis surgery. Persistent contamination of the pleural cavity leads to such results as empyema, septic disease and acute respiratory-distress syndrome (ARDS), which are associated with substantial mortality [ 6 ]. Creation of the anastomosis is a critical step in decreasing the incidence of anastomotic mediastinal fistula, and proper performance of intrathoracic esophagogastric anastomosis deserves exploration. The anastomotic approach chosen is often based on surgeon preference; there is no ideal approach accepted by all surgeons. Luketich JD et al. reported 530 cases of minimally invasive esophagectomy with intrathoracic anastomoses created via an end-to-side esophagogastric-anastomosis technique with a 28- or 25-mm end-to-end anastomotic stapler [ 7 ]; anastomotic leak was[ 8 ] reported in 4–9.8% of these patients [ 7 , 9 ]. Compared with circular stapled esophagogastric anastomosis (CSEA), linear-stapled esophagogastric anastomosis (LSEA) is reported to be associated with lower incidences of stricture and leakage [ 10 , 11 ]. A LSEA can be constructed during complete thoracoscopic surgery without making an additional incision between the ribs to place the circular stapler in a CSEA. In our pilot study, we performed LSEA with one layer interrupted or a running suture in seven patients, two of whom experienced anastomotic leak. Endoscopy in each of these two cases found an anastomotic fistula located on the anterior side of the anastomosis. To avoid such complications, we developed a novel and effective anastomosis for complete thoracoscopic–laparoscopic Ivor–Lewis surgery: double-layered scallop-shaped anastomosis (DLSSA). The aim of this study was to detail the DLSSA procedure and demonstrate its postoperative outcomes in comparison to those achieved with CSEA. Patients and Methods Patients From April 2016 to February 2023, one hundred and forty-four consecutive patients with carcinoma of the distal esophagus or EGJ underwent Ivor–Lewis surgery in our department (Department of Thoracic Surgery, Daping Hospital, Army Military Medical University, Chongqing, China), 50 patients meet the inclusion criteria and accepted complete thoracoscopic–laparoscopic Ivor–Lewis surgery with DLSSA, 67 patients accepted Ivor–Lewis surgery with CSEA. Inclusion criteria were as follows: (i) patients were diagnosed with carcinoma of the distal esophagus or EGJ by endoscopy and biopsy; (ii) clinical tumor, node and metastasis (cTNM) or pathological TNM (ypTNM) staging lower than stage III; (iii) tumor and lymph nodes were judged to be R0 resection; and (iv) patients with EGJ cancer were limited to those with Siewert I and II tumors. Patient data were obtained via retrospective chart assessment, after which we evaluated patients’ intraoperative and postoperative variables and assessed their pertinent characteristics. Preoperative staging was performed by endoscopic ultrasound and thoraco-abdominal computed-tomography scans. Written informed consent was obtained from the patients associated with this study. The evaluation was approved by the Ethics Committee of Daping Hospital and Research Institute of Surgery, Army Military Medical University (Ethics ID: 2020 − 157). A total of 117 patients were included in this study and were subsequently available for outcome comparison which were divided into Group CSEA(circular stapled esophagogastric anastomosis) and Group DLSSA (double-layered scallop-shaped anastomosis), the flowchart of patients’ selection is shown in Fig. 1 . “Double-layer scallop-shaped anastomosis” procedures All patients included in this study underwent complete thoracoscopic–laparoscopic Ivor–Lewis surgery. Briefly, laparoscopy was performed with the patient in a supine position and completed after the stomach was stapled to the gastric tube. For the next stage, the patient was placed in a semi-prone position, and an DLSSA was created via thoracoscopy following lymph node dissection, lower-esophagus cauterization and pulling up of the gastric tube into the chest cavity. As shown in Fig. 2 , after two small orifices were separately made in the right side of the gastric tube and left side of the lower esophagus 5 cm from the tip, we used 3 − 0 triclosan-coated VICRYL Plus sutures (Johnson & Johnson, New Brunswick, NJ, USA) to attach the approximate distal esophagus to the stomach through all layers (Fig. 2 a). Each jaw of the linear stapler was inserted into each lumen of the gastric tube and esophagus to create a side-to-side esophagogastrostomy (Fig. 2 b– 2 c). The anterior side of the gastric tube was manually sutured to the end of the esophagus via two continuous sutures (3 − 0 triclosan-coated VICRYL Plus) in double layers (mucosal and muscular layers; Fig. 2 d– 2 f). On the seventh post-operative day (POD), an iodized water radiography of upper digestive tract or a gastroscopy was performed (Fig. 2 g– 2 h). The DLSSA is illustrated in Fig. 3 ; its three-dimensional anastomotic shape resembles that of a scallop (Fig. 3 d). Postoperative management Postoperative fasting was imposed until upper-gastrointestinal water-soluble contrast radiography was performed to identify anastomotic leakage (routine; on postoperative day 7). Patients received total parenteral nutrition in the second or third POD; after patient flatus recovered, enteral nutrition was given via a nutritional-jejunostomy catheter. The mediastinal drainage tube was commonly removed on the day it was confirmed there was no anastomotic leakage unless the drainage fluid was abnormal in some way. Patients were discharged when their bowel movements recovered and they showed no discomfort with oral feeding. Statistical analysis The median value and ranges are used to present 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. Variables considered in the models were Group CSEA and Group DLSSA, intraoperative blood loss, total operative duration, age, gender, BMI, pStage, smoking history, comorbidity, and neoadjuvant therapy. We classified postoperative TNM stage in accordance with the American Joint Committee on Cancer (AJCC) staging protocol, 8th ed. [ 12 ]. Statistical analyses were performed by using SPSS statistical software, version 22.0 (IBM SPSS, Chicago, IL, USA). A p value of < 0.05 was considered statistically significant. Time for anastomosis was defined as starting with the separate creation of two small orifices in the gastric tube or lower esophagus and ending with knotting of the last thread. Results Preoperative clinical characteristics Of the 117 patients included in this study which consisted of 88 males and 29 females with an median age of 65 (range 38–84) years and a mean BMI of 23.0(range 17.6–35.2) kg/m 2 . Fifty-three patients have no smoking history and 29 patients received neoadjuvant chemotherapy or chemoradiotherapy. The baseline characteristics of the patients are shown in Table 1 . Overall, there were no differences between the two groups except for Age, Neoadjuvant therapy: The patients in group DLSSA were slightly older than group CSEA (66.0(38–84) vs. 64.0(38.0–80.0); p = 0.047), and there were more patients accepted neoadjuvant therapy in group DLSSA (17/50,34.0% vs. 12/67,17.9%; p = 0.046) Table 1 Clinical and other relevant characteristics of 117 patients. Characteristics Total (n = 117, %) Group CSEA (n = 67, %) Group DLSSA (n = 50, %) p value Gender 0.300 & Males 88(75.2) 48(71.6) 40(80.0) Females 29(24.8) 19(28.4) 10(20.0) Age (years, median (range)) 65.0(38.0–84.0) 64.0(38.0–80.0) 66.0(38–84) 0.047 ¶ Smoking history 0.536 & No 53(45.3) 32(47.8) 21(42) Yes 64(54.7) 35(52.2) 29(58) BMI (kg/m 2 , median (range)) 23.0(17.6–35.2) 22.7(17.6–30.0) 23.7(18.5–35.2) 0.070 ¶ Pathology 0.235 * Squamous-cell carcinoma 8(6.8) 5(7.5) 3(6.0) Adenocarcinoma 103(88.0) 60(89.6) 43(86.0) Other 6(5.2) 2(2.9) 4(8.0) Neoadjuvant therapy 0.046 & No 88(75.2) 55(82.1) 33(66.0) Yes 29(24.8) 12(17.9) 17(34.0) Comorbidities 0.939 & No 87(74.4) 50(74.6) 37(74.0) Yes 30(25.6) 17(25.4) 13(26.0) pT 0.708 * T0 3(2.6) 2(3.0) 1(2.0) T1 15(12.8) 8(11.9) 7(14.0) T2 15(12.8) 11(16.4) 4(8.0) T3 69(59.0) 40(59.7) 29(58.0) T4 15(12.8) 6(9.0) 9(18.0) pN 0.563 & N0 41(35.0) 24(35.8) 17(34.0) N1 26(22.2) 12(17.9) 14(28.0) N2 32(27.4) 19(28.4) 13(26.0) N3 18(15.4) 12(17.9) 6(12.0) Distant metastasis (M) / M0 117(100.0) 67(100.0) 50(100.0) M1 0(0.0) 0(0.0) 0(0.0) Grade 0.424 * Well-differentiated (G1) 9(7.7) 5(7.5) 4(8.0) Moderately differentiated (G2) 54(46.2) 30(44.8) 24(48.0) Poorly differentiated (G3) 44(37.6) 29(43.3) 15(30.0) Unknown 10(8.5) 4(6.0) 6(12.0) pStage 0.300 * 0 1(0.9) 1(1.5) 0(0.0) I 15(12.8) 8(11.9) 7(14.0) II 23(19.7) 14(20.9) 9(18.0) III 56(47.9) 29(43.3) 27(54.0) IV 21(17.9) 15(22.4) 6(12.0) SD: standard deviation; BMI: body mass index; pT: postoperative tumor stage (depth of invasion0); pN: postoperative lymphatic dissemination stage (based on American Joint Committee on Cancer [AJCC] staging protocol, 8th ed[ 12 ].; N0: no positive lymph nodes; N1: 1–2 positive lymph nodes; N2: 3–6 positive lymph nodes; N3: > 6 positive lymph nodes. & χ2 test ¶ Kruskal-Wallis test * Fisher's exact test Intraoperative and postoperative outcomes Intraoperative and postoperative outcomes are detailed in Table 2 . The median total operation duration was 280 minutes, with no significant difference between the groups (p = 0.458). Intraoperative blood loss was significantly higher in the CSEA group (120 ml) compared to the DLSSA group (100 ml, p = 0.001). The number of retrieved lymph nodes and positive lymph nodes showed no significant differences between the groups (p = 0.164 and p = 0.637, respectively). Postoperative hospital stay was similar, with a median of 11 days (p = 0.492). Table 2 Intraoperative and postoperative outcomes. Variables Total (n = 117) Group CSEA (n = 67) Group DLSSA (n = 50) p value Total operation duration (min, median (range)) 280.0(165.0-405.0) 280.0(165.0-405.0) 280.0(225.0-390.0) 0.458 ¶ Time for laparoscopic operation (min, median (range)) 115.0(48.0-178.0) 120.0(48.0-178.0) 110.0(51.0-150.0) 0.074 ¶ Time for thoracoscopic operation (min, median (range)) 96.5(50.0-170.0) 94.5(50.0-170.0) 98.5(50.0-160.0) 0.258 ¶ Intraoperative blood loss (ml, median (range)) 100.0(10.0-600.0) 120.0(20.0-500.0) 100.0(10.0-600.0) 0.001 ¶▲ Number of retrieved nodes (median (range)) 39.0(16.0–94.0) 38.0(16.0–94.0) 41.0(19.0–74.0) 0.164 ¶ Number of positive lymph nodes(median (range)) 2.0(0.0–34.0) 2.0(0.0–30.0) 2.0(0–34.0) 0.637 ¶ Postoperative hospital stay (days, median (range)) 11.0(2.0–55.0) 12.0(5.0–55.0) 11.0(2.0–36.0) 0.492 ¶ Postoperative complications (n, %) 38(32.5) 23(34.3) 15(30.0) 0.621 * Anastomotic complications Anastomotic leakage 14(12.0) 12(17.9) 2(4.0) 0.022 *▲ Anastomotic bleeding 2(1.7) 2(3.0) 0(0.0) 0.218 * Respiratory complications Pulmonary infection 2(1.7) 1(1.5) 1(2) 0.834 * ARDS 1(0.9) 1(1.5) 0(0.0) 0.386 * Pleural complications Pneumothorax 2(1.7) 2(3.0) 0(0.0) 0.506 * Pleural effusion 6(5.1) 1(1.5) 5(10.0) 0.039 *▲ Chylothorax 1(0.9) 1(1.5) 0(0.0) 0.386 * Others Incisional hernia 2(1.7) 0(0.0) 2(4.0) 0.099 * Chyloperitoneum 1(0.9) 1(1.5) 0(0.0) 0.386 * Gastric paralysis 1(0.9) 1(1.5) 0(0.0) 0.386 * Ventricular fibrillation 2(1.7) 0(0.0) 2(4.0) 0.099 * ¶ Kruskal-Wallis test & χ2 test * Fisher's exact test ▲ Statistically significant at p ≤ 0.05. Postoperative complications were observed in 32.5% of patients, with no significant difference between groups (p = 0.621). However, anastomotic leakage was significantly higher in the DLSSA group (4.0%) compared to the CSEA group (17.9%, p = 0.022). Pleural effusion was also more frequent in the DLSSA group (10.0%) than in the CSEA group (1.5%, p = 0.039). Other complications, including pulmonary infection, ARDS, pneumothorax, and chylothorax, showed no significant differences. Incisional hernia and ventricular fibrillation were observed only in the DLSSA group, though not statistically significant (p = 0.099). Predictive factors analyzed by multivariate binary logistic regression. As shown in Fig. 4 , multivariate binary logistic regression was used to assess risk factors for anastomotic leakage (AL). The analysis indicated that BMI (OR = 1.453, 95% CI: 1.119–1.888, p = 0.005) and Groups (OR = 0.052, 95% CI: 0.005–0.525, p = 0.012) were independent predictors of AL. A higher BMI was linked to an increased risk of AL, whereas the Group CSEA was associated with a reduced incidence. Discussion Our surgical team has acquired extensive experience in thoracoscopic–laparoscopic McKeown esophagectomy and Ivor–Lewis surgery. In these surgeries, anastomotic complications are frequently encountered; they can be life threatening and compromise postoperative quality of life. Meta-analysis from some retrospective studies shows that the rate of anastomotic leakage is 4.7% and that of anastomotic stricture is 18% in Ivor–Lewis surgery [ 13 ]. Pooled data from six European centers indicates that anastomotic leakage is observed in 15.2% of patients [ 14 ]. Anastomotic technique is essential for minimizing the incidence of such complications. There is no universally accepted proper method for creating an anastomosis during thoracoscopy; the surgeon might prefer the circular-stapling, linear-stapling, or hand-sewn technique, all of which are challenging [ 15 ]. Circular stapling in EEA was formerly in wide use. The technique is simple and easy to operate, but Nguyen NT et al. [ 9 ] report that leak and stricture rates were respectively 9.8% and 28% in intrathoracic EEA anastomosis. Additional limitations of circular stapling in EEA during MIIL surgery include making an additional or spreading incision between the ribs to place the stapler, and difficulty in purse string suturing and in placing the anvil into the proximal esophagus [ 16 ]. LSEA is reported to be vastly preferred in cervical esophagogastric anastomosis and currently proven to offer potential benefits in complete thoracoscopic Ivor–Lewis surgery. A number of techniques can be utilized for LSEA, including delta-shaped anastomosis and overlap anastomosis. In one study, average anastomotic-orifice width was 11.7 ± 2.2 mm, the incidence of anastomotic stenosis was 23.5% (10/42) and the leakage rate was 7.7% in the delta-shaped anastomosis group [ 17 ]. The overlap method is feasible and has shown satisfactory early postoperative outcomes in esophagogastrostomy or esophagojejunostomy reconstruction [ 18 , 19 ]. Our previous study described thoracoscopic–laparoscopic Ivor–Lewis surgery plus D2 celiac lymphadenectomy in the treatment of EGJ adenocarcinoma [ 4 ]. The most common complication was anastomotic mediastinal fistula (5/72, 6.9%), but some researchers report that rates of anastomotic leak are 4.4–8.6% for Ivor–Lewis surgery [ 10 , 20 , 21 ]. In our pilot study, anastomotic leak occurred in seven patients (28.6%) who underwent LSEA with one layer interrupted or a running suture. In two of these patients, anastomotic leak occurred; endoscopy in both cases found an anastomotic fistula located on the anterior side of the anastomosis. This was mainly because the esophagogastric mucosal and muscular layers had not been well anastomosed. In cases of running sutures, a small fistula could expand into a large one, and we do not use a linear stapler to close the entry hole due to the risk of stenosis. Therefore, we developed SSA for complete thoracoscopic–laparoscopic Ivor–Lewis surgery. In our enrolled patients, the DLSSA group was slightly older than the CSEA group (66.0 vs. 64.0 years, p = 0.047), and more patients in the DLSSA group received neoadjuvant therapy (34.0% vs. 17.9%, p = 0.046). There were no significant differences in other baseline characteristics between the two groups. The median total operation duration was similar between the groups, intraoperative blood loss was significantly higher in the CSEA group (120 ml vs. 100 ml, p = 0.001). Postoperative complications occurred in 32.5% of patients, with no significant difference between the groups, notably, the DLSSA group experienced a lower rate of anastomotic leakage (4.0% vs. 17.9%, p = 0.022) and a higher rate of pleural effusion (10.0% vs. 1.5%, p = 0.039). Other complications, including pulmonary infection, ARDS, pneumothorax, and chylothorax, did not show significant differences between the groups. Multivariate binary logistic regression analysis identified BMI (OR = 1.453, 95% CI: 1.119–1.888, p = 0.005) and surgical group (OR = 0.052, 95% CI: 0.005–0.525, p = 0.012) as independent predictors of anastomotic leakage. A higher BMI was associated with an increased risk of anastomotic leakage, while the DLSSA group had a reduced incidence. These findings suggest that patient selection and surgical technique are important factors in minimizing postoperative complications. In the current cohort, short-term outcomes were satisfactory, and the incidence of anastomotic mediastinal fistula was lower than with LSEA or circular stapling in EEA [ 10 , 20 , 21 ]. While hand sewing the anterior aspect of an anastomosis under a thoracoscope is difficult, DLSSA as introduced in the current study is more complex, requiring a highly proficient technique. However, it is deserved to decrease the incidence of anastomotic fistula. This study provides valuable insights into the factors influencing anastomotic leakage (AL) and the comparative outcomes of CSEA and DLSSA surgical techniques. However, several limitations should be acknowledged. Firstly, the study's retrospective nature may introduce selection bias, as patient allocation to the surgical groups was not randomized. This could potentially confound the comparison between the CSEA and DLSSA groups. Secondly, the sample size is relatively small, which may limit the statistical power to detect significant differences, especially for less common complications. Future prospective, randomized controlled trials with larger sample sizes and longer follow-up periods are needed to validate these findings and to further explore the factors influencing AL and the optimal surgical approach. In conclusion, the DLSSA technique demonstrated a lower incidence of anastomotic leakage, indicating its potential as a valuable alternative for thoracoscopic esophagogastric anastomosis in Ivor-Lewis surgery. Despite the study's limitations, these findings suggest that DLSSA could offer improved outcomes for patients undergoing minimally invasive esophagectomy. Further research is warranted to confirm these results and explore the long-term benefits of this technique. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and its later amendments. Prior to the operations, patients were informed about the procedures and provided their consent. Ethical approval for the study was obtained from the Ethics Committee of Daping Hospital and Research Institute of Surgery, Army Military Medical University (Ethics ID: 2020 − 157). Written informed consent was obtained from all individual participants prior to their inclusion in the study. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests Funding This work was supported by the Natural Science Foundation of Chongqing Municipality (CSTB2023NSCQ-MSX0566) and Chongqing medical scientific research project (the Joint project of Chongqing Health Commission and Science and Technology Bureau)( 2023MSXM084). Author Contribution KunKun Li and Wei Guo carried out the studies, participated in collecting data, and drafted the manuscript. Qian Yang,YingJian Wang,TaiMing Zhang performed the statistical analysis and participated in its design. Liang Zhang, Liang Chen, Tao Bao participated in the data collection, analysis, or draft the manuscript. All authors read and approved the final manuscript. Acknowledgements Not applicable Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. References Feng RM, Zong YN, Cao SM, Xu RH. Current cancer situation in China: good or bad news from the 2018 Global Cancer Statistics? Cancer Commun. 2019;39(1):1–12. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394–424. 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Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique? AM J SURG. 2020;220(1):62–8. Morse CR. Minimally Invasive Ivor Lewis Esophagectomy: How I Teach It. ANN THORAC SURG. 2018;106(5):1283–7. Huang C, Xu X, Zhuang B, Chen W, Xu X, Wang C, Lin S. A comparison of cervical delta-shaped anastomosis and circular stapled anastomosis after esophagectomy. WORLD J SURG ONCOL. 2017;15(1):31. Wang WP, Gao Q, Wang KN, Shi H, Chen LQ. A prospective randomized controlled trial of semi-mechanical versus hand-sewn or circular stapled esophagogastrostomy for prevention of anastomotic stricture. WORLD J SURG. 2013;37(5):1043–50. Inaba K, Satoh S, Ishida Y, Taniguchi K, Isogaki J, Kanaya S, Uyama I. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg. 2010;211(6):e25–9. Kukar M, Ben-David K, Peng JS, Attwood K, Thomas RM, Hennon M, Nwogu C, Hochwald SN. Minimally Invasive Ivor Lewis Esophagectomy with Linear Stapled Anastomosis Associated with Low Leak and Stricture Rates. J GASTROINTEST SURG. 2020;24(8):1729–35. Zhang H, Wang Z, Zheng Y, Geng Y, Wang F, Chen LQ, Wang Y. Robotic Side-to-Side and End-to-Side Stapled Esophagogastric Anastomosis of Ivor Lewis Esophagectomy for Cancer. WORLD J SURG. 2019;43(12):3074–82. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 01 Jul, 2025 Read the published version in BMC Cancer → Version 1 posted Editorial decision: Revision requested 18 Apr, 2025 Reviews received at journal 17 Apr, 2025 Reviewers agreed at journal 10 Apr, 2025 Reviews received at journal 01 Apr, 2025 Reviewers agreed at journal 23 Mar, 2025 Reviewers invited by journal 23 Mar, 2025 Editor assigned by journal 23 Mar, 2025 Editor invited by journal 19 Mar, 2025 Submission checks completed at journal 18 Mar, 2025 First submitted to journal 18 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6068142","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432851672,"identity":"56bb975a-9e9a-4236-9a54-173341657032","order_by":0,"name":"KunKun Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0UlEQVRIie3QMQrCMBSA4QeBdEl1faWlXsEScBI9TNbYXRwchLr0AC5eIzhaOnSpu6O1qx28gUlBcGo6OuRf8ij94CUALtcfhgDEnBH18v4Dm4wljLIa4GqG0QRQ9gSsJDhtSu5f9D5BV7RvuYookOZ5HyAhpkL4td4nTMW8UEIvRjmXAyRGyUs/M0QusFBEEzOPIkFtyN5OQk1ET5AZUtpJkL94cs5QP7Lk85uqGCWWu2AlOXbZMp4d6+SxVbv11Ds07RD5yp+Z2H93uVwul6UPMvE23a3/yIMAAAAASUVORK5CYII=","orcid":"","institution":"Army Military Medical University","correspondingAuthor":true,"prefix":"","firstName":"KunKun","middleName":"","lastName":"Li","suffix":""},{"id":432851673,"identity":"d2b16693-21cb-4db7-9e6f-40081bc73f77","order_by":1,"name":"Qian Yang","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qian","middleName":"","lastName":"Yang","suffix":""},{"id":432851674,"identity":"84b5e6b0-b007-4c3d-935f-3d4220f895c4","order_by":2,"name":"YingJian Wang","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"YingJian","middleName":"","lastName":"Wang","suffix":""},{"id":432851675,"identity":"7ffdb2df-f562-4db4-b379-3df9efa9bb77","order_by":3,"name":"TaiMing Zhang","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"TaiMing","middleName":"","lastName":"Zhang","suffix":""},{"id":432851676,"identity":"c93913b6-bda2-4b96-b471-faa409eeee8b","order_by":4,"name":"Liang Zhang","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"Zhang","suffix":""},{"id":432851677,"identity":"d4449d50-a057-4a66-8456-ab5458232bcd","order_by":5,"name":"Liang Chen","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"Chen","suffix":""},{"id":432851678,"identity":"ce402e20-9a08-4ac5-aede-950cd7031605","order_by":6,"name":"Tao Bao","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Tao","middleName":"","lastName":"Bao","suffix":""},{"id":432851679,"identity":"27b0e19e-b4da-4ce8-a7b2-92b083e43c67","order_by":7,"name":"Wei Guo","email":"","orcid":"","institution":"Army Military Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Guo","suffix":""}],"badges":[],"createdAt":"2025-02-20 03:38:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6068142/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6068142/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12885-025-14437-w","type":"published","date":"2025-07-01T15:58:17+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79326314,"identity":"ecb918ef-e7c8-4be5-baae-21870fcc5ce3","added_by":"auto","created_at":"2025-03-27 05:36:02","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98441,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFlowchart of patient inclusion, allocation, and analysis: \u003c/strong\u003eA total of 117 patients were included in this study and were subsequently available for outcome comparison.\u003c/p\u003e","description":"","filename":"figure1Flowchart.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6068142/v1/70a9756f10817f7bfb17eca6.jpg"},{"id":79324445,"identity":"ef98f5ce-c14a-4af4-b1c0-22b4902e76bc","added_by":"auto","created_at":"2025-03-27 05:10:56","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":969651,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eThoracoscopic procedures using DLSSA.\u003c/strong\u003e \u003cstrong\u003e(a)\u003c/strong\u003e 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. \u003cstrong\u003e(b)\u003c/strong\u003e A linear stapler was inserted between the lumen of the gastric tube and the esophagus. \u003cstrong\u003e(c)\u003c/strong\u003e After we fired the linear stapler, a side-to-side esophagogastrostomy was created. \u003cstrong\u003e(d)\u003c/strong\u003eThe mucosal layer was closed with a running 3-0 triclosan-coated VICRYL Plus suture. \u003cstrong\u003e(e)\u003c/strong\u003e The muscular layer was also closed with a running 3-0 triclosan-coated VICRYL Plus suture. \u003cstrong\u003e(f)\u003c/strong\u003e 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.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6068142/v1/a7a89e04e2a50edb33855f8d.jpg"},{"id":79324453,"identity":"0272740e-d2c4-4463-a269-b6a35406412b","added_by":"auto","created_at":"2025-03-27 05:10:56","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":8891653,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSchematic representation of the DLSSA.\u003c/strong\u003e \u003cstrong\u003e(a)\u003c/strong\u003e A linear stapler was inserted between the lumen of the gastric tube and the esophagus. \u003cstrong\u003e(b)\u003c/strong\u003e The mucosal layer was closed with a running 3-0 triclosan-coated VICRYL Plus suture. \u003cstrong\u003e(c)\u003c/strong\u003eThe muscular layer was closed with a running 3-0 triclosan-coated VICRYL Plus suture. \u003cstrong\u003e(d)\u003c/strong\u003e Anastomosis after suturing. Its three-dimensional shape resembles that of a scallop.\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6068142/v1/a5eaf71c5e68499ef6ba4c21.jpg"},{"id":79324458,"identity":"c448fc76-3743-4402-abb7-2910aa75a0de","added_by":"auto","created_at":"2025-03-27 05:10:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":291150,"visible":true,"origin":"","legend":"\u003cp\u003eThe violin plot depicts the multivariate logistic regression with the AL 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.\u003c/p\u003e","description":"","filename":"Figure4binarylogisticregression.png","url":"https://assets-eu.researchsquare.com/files/rs-6068142/v1/ebcc33f2cb92f93e70fdffec.png"},{"id":86179188,"identity":"75bf5631-041f-4531-b9a4-2ca44b38b8dc","added_by":"auto","created_at":"2025-07-07 16:16:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":11177504,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6068142/v1/dda9578f-5f7e-45ed-b9ce-f0afe630cac9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparison of Double-Layered Scallop-Shaped Anastomosis and Circular Stapled Anastomosis in Ivor-Lewis Surgery for Esophageal and EGJ Cancer: A Retrospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003eCancers of the lower esophagus and esophagogastric junction (EGJ) are the most aggressive cancers with the poorest prognoses, and their incidences are observed to be increasing globally[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Ivor\u0026ndash;Lewis surgery is the main approach to lower esophageal cancer and Siewert type I/II adenocarcinoma of the esophagogastric junction (AEG) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], and minimally invasive Ivor\u0026ndash;Lewis (MIIL) surgery is the preferred approach[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. One MIIL approach, complete thoracoscopic\u0026ndash;laparoscopic Ivor\u0026ndash;Lewis surgery, is observed to be trending strongly worldwide[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnastomotic mediastinal fistula is considered the predominant cause of prolonged hospital stays and postoperative death after Ivor-Lewis surgery. Persistent contamination of the pleural cavity leads to such results as empyema, septic disease and acute respiratory-distress syndrome (ARDS), which are associated with substantial mortality [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Creation of the anastomosis is a critical step in decreasing the incidence of anastomotic mediastinal fistula, and proper performance of intrathoracic esophagogastric anastomosis deserves exploration. The anastomotic approach chosen is often based on surgeon preference; there is no ideal approach accepted by all surgeons. Luketich JD \u003cem\u003eet al.\u003c/em\u003e reported 530 cases of minimally invasive esophagectomy with intrathoracic anastomoses created via an end-to-side esophagogastric-anastomosis technique with a 28- or 25-mm end-to-end anastomotic stapler [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]; anastomotic leak was[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] reported in 4\u0026ndash;9.8% of these patients [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared with circular stapled esophagogastric anastomosis (CSEA), linear-stapled esophagogastric anastomosis (LSEA) is reported to be associated with lower incidences of stricture and leakage [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. A LSEA can be constructed during complete thoracoscopic surgery without making an additional incision between the ribs to place the circular stapler in a CSEA. In our pilot study, we performed LSEA with one layer interrupted or a running suture in seven patients, two of whom experienced anastomotic leak. Endoscopy in each of these two cases found an anastomotic fistula located on the anterior side of the anastomosis. To avoid such complications, we developed a novel and effective anastomosis for complete thoracoscopic\u0026ndash;laparoscopic Ivor\u0026ndash;Lewis surgery: double-layered scallop-shaped anastomosis (DLSSA). The aim of this study was to detail the DLSSA procedure and demonstrate its postoperative outcomes in comparison to those achieved with CSEA.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003e From April 2016 to February 2023, one hundred and forty-four consecutive patients with carcinoma of the distal esophagus or EGJ underwent Ivor\u0026ndash;Lewis surgery in our department (Department of Thoracic Surgery, Daping Hospital, Army Military Medical University, Chongqing, China), 50 patients meet the inclusion criteria and accepted complete thoracoscopic\u0026ndash;laparoscopic Ivor\u0026ndash;Lewis surgery with DLSSA, 67 patients accepted Ivor\u0026ndash;Lewis surgery with CSEA.\u003c/p\u003e \u003cp\u003eInclusion criteria were as follows: (i) patients were diagnosed with carcinoma of the distal esophagus or EGJ by endoscopy and biopsy; (ii) clinical tumor, node and metastasis (cTNM) or pathological TNM (ypTNM) staging lower than stage III; (iii) tumor and lymph nodes were judged to be R0 resection; and (iv) patients with EGJ cancer were limited to those with Siewert I and II tumors.\u003c/p\u003e \u003cp\u003ePatient data were obtained via retrospective chart assessment, after which we evaluated patients\u0026rsquo; intraoperative and postoperative variables and assessed their pertinent characteristics. Preoperative staging was performed by endoscopic ultrasound and thoraco-abdominal computed-tomography scans. Written informed consent was obtained from the patients associated with this study. The evaluation was approved by the Ethics Committee of Daping Hospital and Research Institute of Surgery, Army Military Medical University (Ethics ID: 2020\u0026thinsp;\u0026minus;\u0026thinsp;157).\u003c/p\u003e \u003cp\u003eA total of 117 patients were included in this study and were subsequently available for outcome comparison which were divided into Group CSEA(circular stapled esophagogastric anastomosis) and Group DLSSA (double-layered scallop-shaped anastomosis), the flowchart of patients\u0026rsquo; selection is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;Double-layer scallop-shaped anastomosis\u0026rdquo; procedures\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAll patients included in this study underwent complete thoracoscopic\u0026ndash;laparoscopic Ivor\u0026ndash;Lewis surgery. Briefly, laparoscopy was performed with the patient in a supine position and completed after the stomach was stapled to the gastric tube. For the next stage, the patient was placed in a semi-prone position, and an DLSSA was created via thoracoscopy following lymph node dissection, lower-esophagus cauterization and pulling up of the gastric tube into the chest cavity. As shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, after two small orifices were separately made in the right side of the gastric tube and left side of the lower esophagus 5 cm from the tip, we used 3\u0026thinsp;\u0026minus;\u0026thinsp;0 triclosan-coated VICRYL Plus sutures (Johnson \u0026amp; Johnson, New Brunswick, NJ, USA) to attach the approximate distal esophagus to the stomach through all layers (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). Each jaw of the linear stapler was inserted into each lumen of the gastric tube and esophagus to create a side-to-side esophagogastrostomy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). The anterior side of the gastric tube was manually sutured to the end of the esophagus via two continuous sutures (3\u0026thinsp;\u0026minus;\u0026thinsp;0 triclosan-coated VICRYL Plus) in double layers (mucosal and muscular layers; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ef). On the seventh post-operative day (POD), an iodized water radiography of upper digestive tract or a gastroscopy was performed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eg\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh). The DLSSA is illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e; its three-dimensional anastomotic shape resembles that of a scallop (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePostoperative management\u003c/h3\u003e\n\u003cp\u003ePostoperative fasting was imposed until upper-gastrointestinal water-soluble contrast radiography was performed to identify anastomotic leakage (routine; on postoperative day 7). Patients received total parenteral nutrition in the second or third POD; after patient flatus recovered, enteral nutrition was given via a nutritional-jejunostomy catheter. The mediastinal drainage tube was commonly removed on the day it was confirmed there was no anastomotic leakage unless the drainage fluid was abnormal in some way. Patients were discharged when their bowel movements recovered and they showed no discomfort with oral feeding.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eThe median value and ranges are used to present 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. Variables considered in the models were Group CSEA and Group DLSSA, intraoperative blood loss, total operative duration, age, gender, BMI, pStage, smoking history, comorbidity, and neoadjuvant therapy. We classified postoperative TNM stage in accordance with the American Joint Committee on Cancer (AJCC) staging protocol, 8th ed. [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Statistical analyses were performed by using SPSS statistical software, version 22.0 (IBM SPSS, Chicago, IL, USA). A p value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. Time for anastomosis was defined as starting with the separate creation of two small orifices in the gastric tube or lower esophagus and ending with knotting of the last thread.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003ePreoperative clinical characteristics\u003c/h2\u003e\n \u003cp\u003eOf the 117 patients included in this study which consisted of 88 males and 29 females with an median age of 65 (range 38\u0026ndash;84) years and a mean BMI of 23.0(range 17.6\u0026ndash;35.2) kg/m\u003csup\u003e2\u003c/sup\u003e. Fifty-three patients have no smoking history and 29 patients received neoadjuvant chemotherapy or chemoradiotherapy. The baseline characteristics of the patients are shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Overall, there were no differences between the two groups except for Age, Neoadjuvant therapy: The patients in group DLSSA were slightly older than group CSEA (66.0(38\u0026ndash;84) vs. 64.0(38.0\u0026ndash;80.0); p\u0026thinsp;=\u0026thinsp;0.047), and there were more patients accepted neoadjuvant therapy in group DLSSA (17/50,34.0% vs. 12/67,17.9%; p\u0026thinsp;=\u0026thinsp;0.046)\u003c/p\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eClinical and other relevant characteristics of 117 patients.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;117, %)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup CSEA\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67, %)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup DLSSA\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50, %)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.300\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88(75.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48(71.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40(80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29(24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19(28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge (years, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e65.0(38.0\u0026ndash;84.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64.0(38.0\u0026ndash;80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.0(38\u0026ndash;84)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.047\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSmoking history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.536\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e53(45.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32(47.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e21(42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e64(54.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35(52.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29(58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23.0(17.6\u0026ndash;35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e22.7(17.6\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23.7(18.5\u0026ndash;35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.070\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePathology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.235\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSquamous-cell carcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8(6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3(6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e103(88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e60(89.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43(86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOther\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6(5.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2(2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNeoadjuvant therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.046\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e88(75.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e55(82.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33(66.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29(24.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17(34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eComorbidities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.939\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e87(74.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e50(74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37(74.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30(25.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e17(25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.708\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e3(2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e2(3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8(11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e11(16.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e69(59.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40(59.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29(58.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eT4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e6(9.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epN\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.563\u003csup\u003e\u0026amp;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e41(35.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e24(35.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17(34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e26(22.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14(28.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e32(27.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e19(28.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13(26.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eN3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18(15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e12(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDistant metastasis (M)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e/\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e117(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eM1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGrade\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.424\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eWell-differentiated (G1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e9(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e5(7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4(8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eModerately differentiated (G2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e54(46.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e30(44.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24(48.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePoorly differentiated (G3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e44(37.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eUnknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e10(8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e4(6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003epStage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.300\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15(12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e8(11.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7(14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e23(19.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e14(20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9(18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIII\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e56(47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e29(43.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27(54.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e21(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e15(22.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eSD: standard deviation; BMI: body mass index; pT: postoperative tumor stage (depth of invasion0); pN: postoperative lymphatic dissemination stage (based on American Joint Committee on Cancer [AJCC] staging protocol, 8th ed[\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].; N0: no positive lymph nodes; N1: 1\u0026ndash;2 positive lymph nodes; N2: 3\u0026ndash;6 positive lymph nodes; N3: \u0026gt; 6 positive lymph nodes.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u0026amp; \u0026chi;2 test \u0026para; Kruskal-Wallis test * Fisher\u0026apos;s exact test\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eIntraoperative and postoperative outcomes\u003c/h2\u003e\n \u003cp\u003eIntraoperative and postoperative outcomes are detailed in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. The median total operation duration was 280 minutes, with no significant difference between the groups (p\u0026thinsp;=\u0026thinsp;0.458). Intraoperative blood loss was significantly higher in the CSEA group (120 ml) compared to the DLSSA group (100 ml, p\u0026thinsp;=\u0026thinsp;0.001). The number of retrieved lymph nodes and positive lymph nodes showed no significant differences between the groups (p\u0026thinsp;=\u0026thinsp;0.164 and p\u0026thinsp;=\u0026thinsp;0.637, respectively). Postoperative hospital stay was similar, with a median of 11 days (p\u0026thinsp;=\u0026thinsp;0.492).\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eIntraoperative and postoperative outcomes.\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eTotal\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;117)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup CSEA\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;67)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGroup DLSSA\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep value\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTotal operation duration (min, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e280.0(165.0-405.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e280.0(165.0-405.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e280.0(225.0-390.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.458\u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime for laparoscopic operation (min, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e115.0(48.0-178.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e120.0(48.0-178.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e110.0(51.0-150.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.074 \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime for thoracoscopic operation (min, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.5(50.0-170.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e94.5(50.0-170.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e98.5(50.0-160.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.258 \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIntraoperative blood loss (ml, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0(10.0-600.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e120.0(20.0-500.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0(10.0-600.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.001 \u003csup\u003e\u0026para;▲\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of retrieved nodes (median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.0(16.0\u0026ndash;94.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.0(16.0\u0026ndash;94.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.0(19.0\u0026ndash;74.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.164 \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNumber of positive lymph nodes(median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0(0.0\u0026ndash;34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0(0.0\u0026ndash;30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2.0(0\u0026ndash;34.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.637 \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative hospital stay (days, median (range))\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0(2.0\u0026ndash;55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.0(5.0\u0026ndash;55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0(2.0\u0026ndash;36.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.492 \u003csup\u003e\u0026para;\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePostoperative complications (n, %)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38(32.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23(34.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15(30.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.621\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnastomotic complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnastomotic leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14(12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12(17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.022\u003csup\u003e*▲\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnastomotic bleeding\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.218\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRespiratory complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePulmonary infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.834\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eARDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.386\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePleural complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePneumothorax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.506\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePleural effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6(5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5(10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.039\u003csup\u003e*▲\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChylothorax\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.386\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIncisional hernia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.099\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChyloperitoneum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.386\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGastric paralysis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1(1.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.386\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eVentricular fibrillation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0(0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2(4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.099\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u0026para; Kruskal-Wallis test \u0026amp; \u0026chi;2 test * Fisher\u0026apos;s exact test \u003csup\u003e▲\u003c/sup\u003e Statistically significant at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.05.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003ePostoperative complications were observed in 32.5% of patients, with no significant difference between groups (p\u0026thinsp;=\u0026thinsp;0.621). However, anastomotic leakage was significantly higher in the DLSSA group (4.0%) compared to the CSEA group (17.9%, p\u0026thinsp;=\u0026thinsp;0.022). Pleural effusion was also more frequent in the DLSSA group (10.0%) than in the CSEA group (1.5%, p\u0026thinsp;=\u0026thinsp;0.039). Other complications, including pulmonary infection, ARDS, pneumothorax, and chylothorax, showed no significant differences. Incisional hernia and ventricular fibrillation were observed only in the DLSSA group, though not statistically significant (p\u0026thinsp;=\u0026thinsp;0.099).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePredictive factors analyzed by multivariate binary logistic regression.\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eAs shown in Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e, multivariate binary logistic regression was used to assess risk factors for anastomotic leakage (AL). The analysis indicated that BMI (OR\u0026thinsp;=\u0026thinsp;1.453, 95% CI: 1.119\u0026ndash;1.888, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.005) and Groups (OR\u0026thinsp;=\u0026thinsp;0.052, 95% CI: 0.005\u0026ndash;0.525, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012) were independent predictors of AL. A higher BMI was linked to an increased risk of AL, whereas the Group CSEA was associated with a reduced incidence.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur surgical team has acquired extensive experience in thoracoscopic\u0026ndash;laparoscopic McKeown esophagectomy and Ivor\u0026ndash;Lewis surgery. In these surgeries, anastomotic complications are frequently encountered; they can be life threatening and compromise postoperative quality of life. Meta-analysis from some retrospective studies shows that the rate of anastomotic leakage is 4.7% and that of anastomotic stricture is 18% in Ivor\u0026ndash;Lewis surgery [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Pooled data from six European centers indicates that anastomotic leakage is observed in 15.2% of patients [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Anastomotic technique is essential for minimizing the incidence of such complications. There is no universally accepted proper method for creating an anastomosis during thoracoscopy; the surgeon might prefer the circular-stapling, linear-stapling, or hand-sewn technique, all of which are challenging [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Circular stapling in EEA was formerly in wide use. The technique is simple and easy to operate, but Nguyen NT et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] report that leak and stricture rates were respectively 9.8% and 28% in intrathoracic EEA anastomosis. Additional limitations of circular stapling in EEA during MIIL surgery include making an additional or spreading incision between the ribs to place the stapler, and difficulty in purse string suturing and in placing the anvil into the proximal esophagus [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLSEA is reported to be vastly preferred in cervical esophagogastric anastomosis and currently proven to offer potential benefits in complete thoracoscopic Ivor\u0026ndash;Lewis surgery. A number of techniques can be utilized for LSEA, including delta-shaped anastomosis and overlap anastomosis. In one study, average anastomotic-orifice width was 11.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2 mm, the incidence of anastomotic stenosis was 23.5% (10/42) and the leakage rate was 7.7% in the delta-shaped anastomosis group [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The overlap method is feasible and has shown satisfactory early postoperative outcomes in esophagogastrostomy or esophagojejunostomy reconstruction [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Our previous study described thoracoscopic\u0026ndash;laparoscopic Ivor\u0026ndash;Lewis surgery plus D2 celiac lymphadenectomy in the treatment of EGJ adenocarcinoma [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The most common complication was anastomotic mediastinal fistula (5/72, 6.9%), but some researchers report that rates of anastomotic leak are 4.4\u0026ndash;8.6% for Ivor\u0026ndash;Lewis surgery [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our pilot study, anastomotic leak occurred in seven patients (28.6%) who underwent LSEA with one layer interrupted or a running suture. In two of these patients, anastomotic leak occurred; endoscopy in both cases found an anastomotic fistula located on the anterior side of the anastomosis. This was mainly because the esophagogastric mucosal and muscular layers had not been well anastomosed. In cases of running sutures, a small fistula could expand into a large one, and we do not use a linear stapler to close the entry hole due to the risk of stenosis. Therefore, we developed SSA for complete thoracoscopic\u0026ndash;laparoscopic Ivor\u0026ndash;Lewis surgery.\u003c/p\u003e \u003cp\u003eIn our enrolled patients, the DLSSA group was slightly older than the CSEA group (66.0 vs. 64.0 years, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047), and more patients in the DLSSA group received neoadjuvant therapy (34.0% vs. 17.9%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.046). There were no significant differences in other baseline characteristics between the two groups. The median total operation duration was similar between the groups, intraoperative blood loss was significantly higher in the CSEA group (120 ml vs. 100 ml, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). Postoperative complications occurred in 32.5% of patients, with no significant difference between the groups, notably, the DLSSA group experienced a lower rate of anastomotic leakage (4.0% vs. 17.9%, p\u0026thinsp;=\u0026thinsp;0.022) and a higher rate of pleural effusion (10.0% vs. 1.5%, p\u0026thinsp;=\u0026thinsp;0.039). Other complications, including pulmonary infection, ARDS, pneumothorax, and chylothorax, did not show significant differences between the groups. Multivariate binary logistic regression analysis identified BMI (OR\u0026thinsp;=\u0026thinsp;1.453, 95% CI: 1.119\u0026ndash;1.888, p\u0026thinsp;=\u0026thinsp;0.005) and surgical group (OR\u0026thinsp;=\u0026thinsp;0.052, 95% CI: 0.005\u0026ndash;0.525, p\u0026thinsp;=\u0026thinsp;0.012) as independent predictors of anastomotic leakage. A higher BMI was associated with an increased risk of anastomotic leakage, while the DLSSA group had a reduced incidence. These findings suggest that patient selection and surgical technique are important factors in minimizing postoperative complications.\u003c/p\u003e \u003cp\u003eIn the current cohort, short-term outcomes were satisfactory, and the incidence of anastomotic mediastinal fistula was lower than with LSEA or circular stapling in EEA [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. While hand sewing the anterior aspect of an anastomosis under a thoracoscope is difficult, DLSSA as introduced in the current study is more complex, requiring a highly proficient technique. However, it is deserved to decrease the incidence of anastomotic fistula.\u003c/p\u003e \u003cp\u003eThis study provides valuable insights into the factors influencing anastomotic leakage (AL) and the comparative outcomes of CSEA and DLSSA surgical techniques. However, several limitations should be acknowledged. Firstly, the study's retrospective nature may introduce selection bias, as patient allocation to the surgical groups was not randomized. This could potentially confound the comparison between the CSEA and DLSSA groups. Secondly, the sample size is relatively small, which may limit the statistical power to detect significant differences, especially for less common complications. Future prospective, randomized controlled trials with larger sample sizes and longer follow-up periods are needed to validate these findings and to further explore the factors influencing AL and the optimal surgical approach.\u003c/p\u003e \u003cp\u003eIn conclusion, the DLSSA technique demonstrated a lower incidence of anastomotic leakage, indicating its potential as a valuable alternative for thoracoscopic esophagogastric anastomosis in Ivor-Lewis surgery. Despite the study's limitations, these findings suggest that DLSSA could offer improved outcomes for patients undergoing minimally invasive esophagectomy. Further research is warranted to confirm these results and explore the long-term benefits of this technique.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and its later amendments. Prior to the operations, patients were informed about the procedures and provided their consent. Ethical approval for the study was obtained from the Ethics Committee of Daping Hospital and Research Institute of Surgery, Army Military Medical University (Ethics ID: 2020\u0026thinsp;\u0026minus;\u0026thinsp;157). Written informed consent was obtained from all individual participants prior to their inclusion in the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis work was supported by the Natural Science Foundation of Chongqing Municipality (CSTB2023NSCQ-MSX0566) and Chongqing medical scientific research project (the Joint project of Chongqing Health Commission and Science and Technology Bureau)( 2023MSXM084).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKunKun Li and Wei Guo carried out the studies, participated in collecting data, and drafted the manuscript. Qian Yang,YingJian Wang,TaiMing Zhang performed the statistical analysis and participated in its design. Liang Zhang, Liang Chen, Tao Bao participated in the data collection, analysis, or draft the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eFeng RM, Zong YN, Cao SM, Xu RH. Current cancer situation in China: good or bad news from the 2018 Global Cancer Statistics? Cancer Commun. 2019;39(1):1\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68(6):394\u0026ndash;424.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJezerskyte E, Saadeh LM, Hagens E, Sprangers M, Noteboom L, van Laarhoven H, Eshuis WJ, Hulshof M, van Berge HM, Gisbertz SS. Long-term health-related quality of life after McKeown and Ivor Lewis esophagectomy for esophageal carcinoma. DIS ESOPHAGUS; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi KK, Bao T, Wang YJ, Liu XH, Guo W. The Postoperative outcomes of thoracoscopic-laparoscopic Ivor-Lewis surgery plus D2 celiac lymphadenectomy for patients with adenocarcinoma of the esophagogastric junction. SURG ENDOSC. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHaverkamp L, Seesing MF, Ruurda JP, Boone J. Worldwide trends in surgical techniques in the treatment of esophageal and gastroesophageal junction cancer. DIS ESOPHAGUS. 2017;30(1):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAurello P, Berardi G, Moschetta G, Cinquepalmi M, Antolino L, Nigri G, D'Angelo F, Valabrega S, Ramacciato G. Recurrence Following Anastomotic Leakage After Surgery for Carcinoma of the Distal Esophagus and Gastroesophageal Junction: A Systematic Review. ANTICANCER RES. 2019;39(4):1651\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuketich JD, Pennathur A, Awais O, Levy RM, Keeley S, Shende M, Christie NA, Weksler B, Landreneau RJ, Abbas G, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. ANN SURG. 2012;256(1):95\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHagens E, Reijntjes MA, Anderegg M, Eshuis WJ, van Berge HM, Gisbertz SS. Risk Factors and Consequences of Anastomotic Leakage After Esophagectomy for Cancer. ANN THORAC SURG. 2021;112(1):255\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen NT, Hinojosa MW, Smith BR, Chang KJ, Gray J, Hoyt D. Minimally invasive esophagectomy: lessons learned from 104 operations. ANN SURG. 2008;248(6):1081\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBen-David K, Tuttle R, Kukar M, Rossidis G, Hochwald SN. Minimally Invasive Esophagectomy Utilizing a Stapled Side-to-Side Anastomosis is Safe in the Western Patient Population. ANN SURG ONCOL. 2016;23(9):3056\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou D, Liu QX, Deng XF, Min JX, Dai JG. Comparison of two different mechanical esophagogastric anastomosis in esophageal cancer patients: a meta-analysis. J CARDIOTHORAC SURG. 2015;10:67.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIn H, Solsky I, Palis B, Langdon-Embry M, Ajani J, Sano T. Validation of the 8th Edition of the AJCC TNM Staging System for Gastric Cancer using the National Cancer Database. ANN SURG ONCOL. 2017;24(12):3683\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan Workum F, Berkelmans GH, Klarenbeek BR, Nieuwenhuijzen G, Luyer M, Rosman C. McKeown or Ivor Lewis totally minimally invasive esophagectomy for cancer of the esophagus and gastroesophageal junction: systematic review and meta-analysis. J THORAC DIS. 2017;9(Suppl 8):S826\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStraatman J, van der Wielen N, Nieuwenhuijzen GA, Rosman C, Roig J, Scheepers JJ, Cuesta MA, Luyer MD, van Berge HM, van Workum F, et al. Techniques and short-term outcomes for total minimally invasive Ivor Lewis esophageal resection in distal esophageal and gastroesophageal junction cancers: pooled data from six European centers. SURG ENDOSC. 2017;31(1):119\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePlat VD, Stam WT, Schoonmade LJ, Heineman DJ, van der Peet DL, Daams F. Implementation of robot-assisted Ivor Lewis procedure: Robotic hand-sewn, linear or circular technique? AM J SURG. 2020;220(1):62\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorse CR. Minimally Invasive Ivor Lewis Esophagectomy: How I Teach It. ANN THORAC SURG. 2018;106(5):1283\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang C, Xu X, Zhuang B, Chen W, Xu X, Wang C, Lin S. A comparison of cervical delta-shaped anastomosis and circular stapled anastomosis after esophagectomy. WORLD J SURG ONCOL. 2017;15(1):31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang WP, Gao Q, Wang KN, Shi H, Chen LQ. A prospective randomized controlled trial of semi-mechanical versus hand-sewn or circular stapled esophagogastrostomy for prevention of anastomotic stricture. WORLD J SURG. 2013;37(5):1043\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInaba K, Satoh S, Ishida Y, Taniguchi K, Isogaki J, Kanaya S, Uyama I. Overlap method: novel intracorporeal esophagojejunostomy after laparoscopic total gastrectomy. J Am Coll Surg. 2010;211(6):e25\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKukar M, Ben-David K, Peng JS, Attwood K, Thomas RM, Hennon M, Nwogu C, Hochwald SN. Minimally Invasive Ivor Lewis Esophagectomy with Linear Stapled Anastomosis Associated with Low Leak and Stricture Rates. J GASTROINTEST SURG. 2020;24(8):1729\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang H, Wang Z, Zheng Y, Geng Y, Wang F, Chen LQ, Wang Y. Robotic Side-to-Side and End-to-Side Stapled Esophagogastric Anastomosis of Ivor Lewis Esophagectomy for Cancer. WORLD J SURG. 2019;43(12):3074\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"esophagogastric junction, carcinoma, Ivor–Lewis, scallop-shaped anastomosis, postoperative complications","lastPublishedDoi":"10.21203/rs.3.rs-6068142/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6068142/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Cancers of the lower esophagus and esophagogastric junction (EGJ) are highly aggressive with poor prognoses. Minimally invasive Ivor–Lewis surgery (MIIL) is preferred, but anastomotic leakage remains a critical complication. This study introduces a novel double-layered scallop-shaped anastomosis (DLSSA) technique and compares its outcomes with circular stapled esophagogastric anastomosis (CSEA).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e From April 2016 to February 2023, 117 patients with distal esophageal or EGJ cancer undergoing 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 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e The median total operation duration was similar between groups (280 minutes). Intraoperative blood loss was slightly higher in the CSEA group (120 ml vs. 100 ml, p=0.001). Postoperative complications occurred in 32.5% of patients, with no significant difference between groups. However, anastomotic leakage was significantly lower in the DLSSA group (4.0% vs. 17.9%, p=0.022), while pleural effusion was higher (10.0% vs. 1.5%, p=0.039). Multivariate analysis identified higher BMI (OR=1.453, 95% CI:1.119–1.888; p=0.005) as a risk factor for AL, while DLSSA reduced AL risk (OR=0.052, 95% CI:0.005–0.525; p=0.012) as independent predictors of anastomotic leakage.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e DLSSA significantly reduces anastomotic leakage compared to CSEA 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.\u003c/p\u003e","manuscriptTitle":"Comparison of Double-Layered Scallop-Shaped Anastomosis and Circular Stapled Anastomosis in Ivor-Lewis Surgery for Esophageal and EGJ Cancer: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 05:10:51","doi":"10.21203/rs.3.rs-6068142/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-18T08:44:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-17T07:52:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"336913238172169247394272580412391667060","date":"2025-04-11T03:01:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-01T13:51:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"122261199625548123794083040661966078170","date":"2025-03-24T01:52:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-24T00:45:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-23T09:17:11+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-19T09:35:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-19T01:44:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-03-19T01:43:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"03664700-e373-4f25-82b6-b1c00f60f37f","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-07-07T16:06:55+00:00","versionOfRecord":{"articleIdentity":"rs-6068142","link":"https://doi.org/10.1186/s12885-025-14437-w","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2025-07-01 15:58:17","publishedOnDateReadable":"July 1st, 2025"},"versionCreatedAt":"2025-03-27 05:10:51","video":"","vorDoi":"10.1186/s12885-025-14437-w","vorDoiUrl":"https://doi.org/10.1186/s12885-025-14437-w","workflowStages":[]},"version":"v1","identity":"rs-6068142","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6068142","identity":"rs-6068142","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}