Circular stapling anastomosis with indocyanine green fluorescence imaging for cervical esophagogastric anastomosis after thoracoscopic esophagectomy: A propensity score-matched analysis

Background: Thoracoscopic esophagectomy has been widely used worldwide as a curative surgery for esophageal cancer, but complications, such as anastomotic leakage and stenosis remain a major concern. Therefore, this study aimed to evaluate the efficacy of circular stapling anastomosis with indocyanine green (ICG) fluorescence imaging, which was standardized for cervical esophagogastric anastomosis after thoracoscopic esophagectomy. Methods: : In total, 121 patients with esophageal cancer who underwent thoracoscopic esophagectomy with radical lymph node dissection and cervical esophagogastric anastomosis between November 2009 and December 2020 at Tottori University Hospital were enrolled in this study. Patients who underwent surgery before the anastomotic method was standardized were included in the classical group (n = 82), and patients who underwent surgery after standardization were included in the ICG circular group (n = 39). We compared the short-term postoperative outcomes, including anastomotic complications, between the two groups using propensity matched analysis, and evaluated the risk factors for anastomotic leakage using logistic regression analyses. Results: : Of 121 patients, 33 were respectively included in each group after propensity score matching. The clinicopathological characteristics of patients between the two groups did not differ after matching. In perioperative outcomes, a significantly higher proportion of patients who underwent surgery using the laparoscopic approach ( P < 0.001) and narrow gastric tube ( P = 0.003), as well as those who had a lower volume of blood loss ( P = 0.009) in the ICG circular group were seen after matching. Moreover, the ICG circular group had a significantly lower incidence of anastomotic leakage (39% vs. 9%, P = 0.004) and anastomotic stenosis (46% vs. 21%, P = 0.037) and a shorter postoperative hospital stay (30 vs. 20 days, P < 0.001) than the classical group. In the multivariate analysis, anastomotic method was an independent risk factor for anastomotic leakage after thoracoscopic esophagectomy ( P = 0.013). Conclusions: : Circular stapling anastomosis with ICG fluorescence imaging is effective in reducing complications including anastomotic leakage and stenosis.