Background: Esophageal adenocarcinoma is the most common subtype of esophageal cancer in the U.S. In most of these cases, an Ivor Lewis approach permits a complete resection and dissection of abdominal and mediastinal lymph nodes. Although an esophago-gastric anastamosis that is hand-sewn or created with a linear stapler usually provides a low rate of strictures and leaks, it can be technically challenging and time consuming, particularly when minimally invasive techniques are used.Objective: To present the initial results of a standardized 25mm/4.8mm circular stapled anastomosis using a transorally placed anvil.Methods: We evaluated a prospective cohort of consecutive patients offered minimally invasive Ivor Lewis esophagectomy in a tertiary referral medical center. The esophago-gastric anastomosis was done using a 25mm anvil (Orvil, Autosuture, Norwalk, CT) passed trans-orally, in a tilted position, and connected to a 90cm long PVC delivery tube through an opening in the stapled esophageal stump. The anastomosis was completed by joining the anvil to a circular stapler (EEA XL 25mm with 4.8mm Staples, Autosuture, Norwalk, CT) inserted in the gastric conduit. Primary outcomes were leak and stricture rates.Results: Twenty-two patients (mean age 68 years; range 42 to 84) with distal esophageal cancer (n=19) or high-grade dysplasia in Barrett’s Esophagus (n=3) underwent an Ivor Lewis Esophagectomy between Oct. 2007 and Nov. 2008. Eight patients had received neo-adjuvant therapy. The abdominal portion of the operation was completed laparoscopically in 17 patients (77%). The thoracic portion was completed using a mini-thoracotomy in 13 patients (59%) and thoracoscopic technique in 9 (41%). Proximal and distal margins were negative in all patients. A median of 16 lymph nodes (range 8 to 29) were dissected from each specimen, with a median of 2 (range 0 to 15) histologically positive nodes. No intra-operative technical failures of the anastomosis, post-operative leaks, pleural space infections, or deaths occurred. Twelve general complications occurred in 8 patients (36%); the most common was atrial fibrillation. The average hospital stay was 11 days (range 8 to 17). Two patients had stricture at 21 and 25 days post-operatively, and were successfully treated with a single endoscopic dilation.Conclusions: The circular stapled anastomosis with the transoral anvil technique eliminates the need to insert and secure the anvil into the esophageal stump, and allows for a safe and reproducible anastomosis. This straight-forward technique is particularly suited to the thoracoscopic approach.