ObjectiveThe optimal technique for the thoracoscopic construction of an intrathoracic esophagogastric anastomosis continues to be a subject of controversy. The aim of this study was to compare the perioperative outcomes of circular-stapled anastomosis using a transorally inserted anvil (Orvil (TM)) with those of circular-stapled anastomosis using a transthoracically placed anvil (non-Orvil (TM)) in totally minimally invasive Ivor Lewis esophagectomy (Ivor Lewis TMIE). MethodsThe data of 272 patients who underwent Ivor Lewis TMIE for esophageal cancer at multiple centers were collected from January 1, 2014 to December 31, 2017. After propensity score matching (1:1) for patient baseline characteristics, 65 paired cases were selected for statistical analysis. Logistic regression analysis was performed to investigate the significant factors of anastomotic leakage. ResultsIn the propensity score-matched analysis, compared with the non-Orvil (TM) group, the Orvil (TM) group was associated with a significantly shorter operation time (p=0.031), less intraoperative hemorrhage (p<0.001), lower need for intraoperative transfusions (p=0.009), earlier postoperative oral feeding time (p=0.010), longer chest tube duration (p<0.001), shorter postoperative hospital stays (p=0.001), lower total hospitalization costs (p<0.001) and a lower postoperative anastomotic leakage rate (p=0.033). Multivariate logistic regression analysis showed that anastomotic technique and pulmonary infection were independent factors for the development of postoperative anastomotic leakage (p< 0.05). ConclusionsOrvil (TM) anastomosis exhibited better perioperative effects than non-Orvil (TM) anastomosis after the propensity score-matched analysis. Remarkably, the Orvil (TM) technique contributed to a lower postoperative anastomotic leakage rate than the non-Orvil (TM) technique.