Outcomes of mediastinal envelope closure during minimally invasive esophagectomy

<h2>Abstract</h2><h3>Background</h3> Limited outcomes data exists regarding whether mediastinal envelope closure during minimally invasive esophagectomy (MIE) is related to outcomes including anastomotic leak and postoperative pyloric dilation. We hypothesized that mediastinal envelope closure would be associated with fewer adverse outcomes. <h3>Methods</h3> Patients undergoing MIE between 9/1/2017 and 11/15/2021 were studied. Patients were divided into two groups, complete envelope closure (CC) or partially closed/ not closed (NC), and baseline characteristics and outcomes were compared. Multivariable logistic regression analysis was performed to evaluate variables associated with a composite outcome of anastomotic leak and/or pyloric dilation. <h3>Results</h3> We identified 181 patients. Age, sex, race/ethnicity, BMI, smoking history, CCI, ECOG status, operative duration, cancer stage/histology, intraoperative fluids, EBL, and EEA size were not statistically different between the CC and NC groups, though use of indocyanine green-enhanced fluorescence evaluation (ICG) was significantly different (24.5 % versus 67.6 %, p <0.001). The CC group experienced lower rates of anastomotic leak (2 % vs 14.7 %, p=0.007), postoperative pyloric dilation (15.6 % vs 32.4 %, p=0.025), and delayed gastric emptying (6.1 % vs 20.6 %, p=0.015). Risk factors for a composite outcome defined as anastomotic leak and/or pyloric dilation were evaluated using a multivariable logistic regression, and NC was an independent predictor of this composite outcome (aOR 3.74, p=0.007). <h3>Conclusions</h3> Complete mediastinal envelope closure is associated with decreased rates of anastomotic leak, postoperative pyloric dilation, and delayed gastric emptying. Further prospective trials involving mediastinal envelope closure are warranted to elucidate its positive effect on postoperative outcomes.