**1. Introduction**

Esophageal cancer is an aggressive neoplasm with a higher prevalence among the male gender, associated with high rates of cancer-related mortality. The two

histological subtypes mainly described in the literature include squamous cell carcinoma and adenocarcinoma [1]. Esophageal cancer represents the eighth most common type of cancer and the sixth leading cause of mortality due to neoplasia, with a 5-year survival of less than 25% [2]. Management strategy for patients with esophageal cancer is multidisciplinary, depending on the neoplasia stage, and includes endoscopic procedures such as radiofrequency ablation, endoscopic mucosal resection, and endoscopic submucosal dissection and/or chemoradiotherapy (CRT) as an esophagus-preserving treatment for early esophageal cancer, while most cases are treated with surgical resection, combined with chemoradiotherapy [3]. The advent of minimally invasive esophageal surgery has led to lower rates of morbidity, mortality, shorter hospital stay, enhanced life quality, as well as better long-term oncological outcomes, compared with open esophagectomy [4, 5].

Commonly performed minimally invasive esophageal procedures include Ivor-Lewis, McKeown, and transhiatal esophagectomy. Ivor-Lewis esophagectomy has been associated with a shorter length of hospital stay, lower rate of postoperative complications, and lower readmission rates compared to the McKeown esophagectomy [5]. Moreover, advances in anastomotic leak management options, including endoscopic stent placement or endoscopic vacuum-assisted closure device placement, led to wider and more confident adoption of intrathoracic anastomosis, rendering minimally invasive Ivor-Lewis the most common approach performed in clinical practice [6]. Nowadays, robotic-assisted minimally invasive esophagectomy (RAMIE) has also emerged as an alternative approach to totally and hybrid minimally invasive esophagectomy (MIE), followed by enhanced tissue manipulation ability, better lymph node dissection, superior intraoperative image quality as well as reduced morbidity and mortality rates and improved postoperative outcomes [7]. However, RAMIE is also combined with lack of experience, longer operative times, and higher costs [7].

Anastomosis construction is considered the most crucial step during esophagectomy. Despite the advantages offered by the adoption of minimally invasive Ivor-Lewis esophagectomy and the development of high-tech anastomotic staplers, anastomotic leakage (AL) remains a serious and possibly fatal complication after esophagectomy, with incidence higher than the open approach in numerous studies [4, 8]. AL is defined as a "full-thickness gastrointestinal defect involving the esophagus, anastomosis, staple line, or conduit, irrespective of presentation or method of identification" by the Esophagectomy Complications Consensus Group and is classified into three types, depending on the management approach [9]. AL is the main cause of perioperative mortality, prolonged hospital stay, delayed oral feeding, need for reintervention, decreased overall survival, and increased risk of recurrence [10]. The steep learning curve of minimally invasive Ivor-Lewis esophagectomy is proposed as the main factor contributing to higher rates of AL, since AL incidence is limited to 4.5 % after the learning curve plateau had been achieved [4].

Α thorough investigation of pathophysiology and risk factors for anastomotic leakage is necessary for the optimization of perioperative results as well as for the development of preventive strategies. The anatomic location of anastomosis has been proven as a factor affecting AL rate, since cervical anastomosis is followed by a higher rate of AL (10–25%), compared to intrathoracic anastomosis (<10%) [11]. Reasons leading to increased AL rate apart from cervical anastomosis include compromised perfusion of the fundus, increased risk of tension, local compression, and neoplasia characteristics, such as neoadjuvant radiation or extended resection [6]. The serosal status may also affect the rate of AL [12]. Preoperative irradiation has a conflicting effect on AL

*Prevention of Anastomotic Leak in Minimally Invasive Esophagectomy: The Role of Anastomotic… DOI: http://dx.doi.org/10.5772/intechopen.106041*

rate, while patient characteristics, including obese or underweight patients, preoperative malnutrition, cardiovascular comorbidities, diabetes mellitus, renal failure, and tobacco and steroid use have been associated with increased AL risk [6]. Finally, the anastomotic technique has not been proven to influence the AL rate [6]. ΑL related complications remain the main cause of perioperative morbidity and mortality, as well as poor quality of life after open and minimally invasive esophagectomy [13]. In addition, management of an intrathoracic anastomotic leak, contrary to the cervical anastomosis, demands more aggressive interventions, such as re-operation, thoracotomy, thoracoscopic drainage, or complete gastrointestinal diversion [10].

In conclusion, intrathoracic anastomosis, although more challenging technically, is associated with a series of advantages including lower anastomotic leak rate, lower stricture formation rate, decreased nerve injury rate, and improved oncological outcomes [10]. In addition, the emergence of interventional methods for the management of anastomotic leakage have led to wide adoption of intrathoracic anastomosis [14]. As a result, Ivor-Lewis MIE now ranks first as the most common approach to MIE used clinically [10]. No consensus has been achieved regarding the optimal esophageal anastomotic method. This chapter aims to provide a critical review of current strategies for intrathoracic anastomosis creation during minimally invasive Ivor-Lewis esophagectomy, as well as to discuss the methods proposed for minimizing anastomotic leakage.
