**3. Intraoperative techniques to reduce anastomotic failure**

#### **3.1 Omentoplasty of the anastomosis**

The omentum is an organ with widely described properties, including control of intra-abdominal infectious and inflammatory processes, angiogenesis, and wound healing promotion, as well as a key role in tumor spread, thus being characterized as "the abdominal policeman" [31]. It also holds a crucial role as a reconstructive tool, since omental flaps are commonly used for reinforcement of esophagogastric anastomosis after open or minimally invasive esophagectomy, taking advantage of its anatomical and physiological characteristics [10]. Production of high levels of vascular endothelial growth factor (VEGF) under hypoxic circumstances is thought to be the main pathophysiologic mechanism for neoangiogenesis induction [32].

The technique of omentoplasty includes the creation of a pedicled omental flap originating from perforators of the right gastroepiploic artery that covers the esophagogastric anastomosis and the gastric staple line and is sutured with interrupted sutures including the superficial muscular and serosal layers near the anastomosis [10, 12]. Additional time added to the surgical procedure varies from 7–8 minutes up to 20 minutes [12]. In a meta-analysis including 1608 patients, among them 1087 were treated with an intrathoracic anastomosis after resection, Tuo et al. conclude that omentoplasty reduced the AL for intrathoracic anastomosis by 2-fold and led to statistically significant shorter length of hospital stay, without leading to statistically significant difference regarding anastomotic stricture development [12]. Towards the same orientation, Lu et al. studied the role of omentoplasty for intrathoracic esophagogastric anastomosis protection in minimally Ivor-Lewis esophagectomy for patients *Prevention of Anastomotic Leak in Minimally Invasive Esophagectomy: The Role of Anastomotic… DOI: http://dx.doi.org/10.5772/intechopen.106041*

having received neoadjuvant chemoradiation. However, data exported from this study failed to prove any statistically significant difference regarding the protective role of omentoplasty against anastomotic dehiscence and the associated mortality, probably due to damage of omental flap viability due to radiation [32]. In contrary, the beneficial role of omental wrap use in minimally invasive esophagectomy has been highlighted by Van Workum et al., who detected no anastomotic leakage in groups who were treated with omental flap versus group with intrathoracic anastomosis, without omentoplasty. The volume of the omental flap has also clinical significance, since a smaller omental wrap volume combined with intravenous dexamethasone administration resulted in lower pulmonary complications [33].

In conclusion, omentoplasty after performance of esophagogastric anastomosis offers physical protection of a compromised anastomosis from an early leakage, but also promotes granulation formation and enhances neovascularization for later wound healing [12]. Larger clinical studies are needed to identify the role of omentoplasty in the era of minimally invasive esophagectomy and neoadjuvant therapy.

#### **3.2 Anastomosis sealing**

Fibrin glue has also been proposed to prevent anastomotic leakage after minimally invasive esophagectomy with esophagogastric anastomosis [16]. Sdralis and colleagues, after the application of fibrin sealant (Tisseel) on esophagogastric anastomosis during hybrid Ivor-Lewis esophagectomy, conclude that no statistically significant difference emerges from fibrin sealant use regarding anastomosis integrity [34]. In contrary, Lin et al., based on a cohort study with 57 patients undergoing open or minimally invasive McKeown esophagectomy, presented promising results regarding the effect of porcine fibrin sealant in preventing anastomotic failure [35]. Based on the aforementioned study, further randomized clinical trials with a greater number of patients are necessary to establish the role and application fashion of fibrin sealant in intrathoracic anastomoses.

#### **3.3 Preemptive endoluminal vacuum therapy**

Intraoperative application of preemptive endoscopic vacuum therapy (pEVT) is an well accepted method for promoting healing through granulation tissue formation and reducing anastomotic leak rate during minimally invasive Ivor-Lewis esophagectomy. Gubler et al. report promising results from their case series, where pEVT was applied to 19 patients undergoing minimally invasive esophagectomy with intrathoracic anastomosis, after anastomosis creation, and was removed 5 days postoperatively. One anastomotic leakage was noted, which was resolved after reoperation and reapplication of pEVT, while no severe adverse effects were reported. In conclusion, the adoption of pEVT may lead to a crucial reduction of anastomotic leakage, especially in high-risk patients [36]. Similar outcomes are reported by a case series of 67 patients, with an overall AL rate of 7.5%, presenting pEVT as a useful tool to reduce anastomotic leak rate [37].
