Hand-Sewn Versus Stapled Esophagogastric Anastomosis in the Neck: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Comparison of hand-sewn and circular stapled esophagogastric anastomoses in the neck after esophagectomy for thoracic esophageal cancer: a propensity score-matched analysis

Esophagectomy is a highly invasive surgical procedure; however, anastomotic leakage is one of the major surgical complications that should be prevented. Institutions have their own inherited or specialized anastomosis methods. The superior anastomosis procedure remains unknown despite the many studies to determine the optimal method. The present study enrolled 341 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2009 and January 2019. The anastomosis method was changed from circular stapled anastomosis to hand-sewn anastomosis in February 2014 to reduce the risk of anastomotic leakage. We retrospectively compared short-term results (anastomotic leakage and stricture) between hand-sewn and circular stapled anastomoses. Analysis of heterogeneity after propensity score matching between the 107 patients in the hand-sewn anastomosis group and 107 patients in the circular stapled anastomosis group revealed almost equal distributions. The incidence rate of anastomotic leakage was significantly lower in the hand-sewn anastomosis group than in the circular stapled anastomosis group (9 vs. 20%, hazard ratio: 2.521; 95% confidence interval: 1.112-5.716; P = 0.027). No significant difference was found in the incidence of anastomotic stricture (16 vs. 18%, P = 0.844). Furthermore, no significant difference was found in the incidence of anastomotic leakage in any of the tumor locations between the two anastomosis procedures. For esophagogastric anastomosis in the neck after esophagectomy, hand-sewn anastomosis is superior to circular stapled anastomosis with regard to reducing the risk of anastomotic leakage.

Anastomosis oversewing technique to prevent leakage after oesophagectomy: a propensity score-matched analysis

OBJECTIVES

Oesophagogastric anastomosis is a core part of oesophagectomy, and anastomotic leakage is among its main concerns. We used the oversewing technique to reinforce the anastomosis created with a circular stapler. This study investigated the use of oversewing to reduce the incidence of anastomotic leakage without increasing morbidity.

METHODS

This study enrolled 1734 patients who underwent oesophagectomy for oesophageal cancer between April 2012 and December 2019. Using propensity score-matched analysis, the clinical results of postoperative complications were compared between anastomotic-oversewn and -unsewn oesophagectomies.

RESULTS

Of the 1734 patients, 661 were included in the anastomotic-unsewn group and 661 in the anastomotic-oversewn group after propensity score matching. The clinical characteristics did not differ between the 2 groups, but the frequency of anastomotic leakage was significantly higher in the anastomotic-unsewn group than in the anastomotic-oversewn group (10.3% vs 4.7%, P < 0.001). Multivariable logistic analysis showed oversewn anastomosis and smoking history as the independent factors associated with anastomotic leakage (odds ratios, 0.399 and 2.383; P < 0.001 and P = 0.012, respectively). On the sub-group analysis, the relative risk for anastomotic leakage was significantly higher with unsewn than with oversewn anastomosis in patients <65 years old, those with American Association of Anesthesiologists score II, those who had middle segment oesophageal cancer and those who have undergone the McKeown approach and cervical anastomosis.

CONCLUSIONS

Anastomosis oversewing technique may be a practical method to reduce anastomotic leakage, especially in younger patients and those who have undergone the McKeown approach and cervical anastomosis.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results

INTRODUCTION

Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy (MT), with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of MT anastomosis.

METHODS

A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which MT anastomosis was implemented, between October 2017 and March 2020 in our hospital.

RESULTS

14 patients were included, with a mean age of 63 years. The mean operative time was 436 min (360-581), being diagnosed of anastomotic leak (AL) 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis (AS). The median stay was 20 days, without any death in the series.

DISCUSSION

Multiple publications suggest the superiority in terms of AL and AS of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

[Minimally invasive esophagectomy for benign esophageal diseases: results of a two-center study]

OBJECTIVE

To analyze the results of thoracoscopic esophagectomy for benign esophageal diseases.

MATERIAL AND METHODS

The study included 78 patients who underwent thoracoscopic esophagectomy between 2011 and 2019. Peptic and burn strictures of the esophagus were diagnosed in 53 patients, achalasia - in 24 patients. Minimally invasive esophagectomy and esophagoplasty with isoperistaltic gastric tube and esophagogastrostomy on the neck was performed in 68 patients, Ivor Lewis esophagectomy - in 1 patient, coloesophagoplasty - in 9 patients. We used manual technique of anastomosis in 58 patients, stapling device - in 19 patients. In 1 case, surgery was finished with esophagostomy and gastrostomy.

RESULTS

Mean blood loss was 200 ml (10-1200), surgery time - 450 min (265-765 min). Early postoperative complications occurred in 37 patients including anastomotic leakage in 24 cases. In long-term period, anastomotic strictures developed in 9 patients. No mortality was observed.

CONCLUSION

Minimally invasive esophagectomy for benign esophageal diseases ensures favorable clinical outcomes. However, no consensus in the choice of surgical approach and indications, as well as small number of these patients cause challenges in implementation of this technique. There are different opinions regarding technique of anastomosis on the neck and surgical access in thoracoscopic esophagectomy.

Construction of Esophagogastric Anastomosis in Rabbits with Magnetic Compression Technique

PURPOSE

The magnetic compression technique (MCT) is a new surgical method that has been used for gastrointestinal anastomosis, choledochojejunostomy, and intestinal anastomosis, but there are no reports on its use for esophagogastric anastomosis. This study aimed to investigate the feasibility of using MCT to fashion esophagogastric anastomoses in rabbits.

METHODS

Twenty rabbits were randomized into an MCT group (study group, n = 10) and a hand-sewn group (control group, n = 10). The magnetic compression anastomosis device used in this study was made of neodymium iron boron (NdFeB) and possessed parent (PMR) and daughter (DMR) magnetic rings. To fashion the anastomosis, the PMR and DMR were inserted into the lower esophagus and gastric fundus, respectively. The coupled magnets automatically compressed the sandwiched tissues and were expelled once the anastomosis was installed. The two groups were further compared in terms of the anastomosis construction time, survival rate, and postoperative complications. One month after the anastomosis was installed, the burst pressure and gross appearance of the anastomoses were evaluated.

RESULTS

The anastomosis construction time in the study group was significantly shorter than that in the control group (10.50 ± 1.58 min vs. 18.60 ± 2.22 min; P < 0.05), and the magnetic rings were defecated out in 10.70 ± 3.49 days. The incidence of anastomotic blockage in both the study and control groups did not differ significantly (0%, 0/10 vs. 20%, 2/10; P > 0.05). Anastomotic leakage was not found in either of the groups, and the anastomoses burst pressures were similar in the two groups. However, the magnetically compressed anastomoses in the study group had a relatively smoother gross appearance than the hand-sewn anastomoses.

CONCLUSION

The magnetic compression anastomosis device is a safe and feasible tool for fashioning esophagogastric anastomoses in this animal model.

Modified layered hand-sewn cervical end-to-side anastomosis for minimally invasive McKeown esophagectomy

BACKGROUND

Minimally invasive McKeown esophagectomy (MIE McKeown) with cervical anastomosis is a widely used approach for the treatment of esophageal cancer (EC). Anastomotic leak is one of the most serious complications following esophagectomy. This study aimed to summarize the anastomosis procedure and assess the clinical outcomes of our modified layered hand-sewn cervical end-to-side anastomosis for cervical anastomosis during MIE McKeown.

METHODS

We retrospectively reviewed clinical data of 508 consecutive EC patients who underwent MIE McKeown using the modified layered hand-sewn cervical end-to-side anastomosis between June 2016 and June 2020.

RESULTS

The incidence of anastomotic leakage in our cohort was 2.0%. The postoperative stricture rate was 6.9% and the incidence of other postoperative complications was less than 9.3%. The mean time for setting up MIE McKeown was approximately 211.0 min and the average duration of postoperative hospital stay was 9.1 days.

CONCLUSION

This modified layered hand-sewn cervical end-to-side anastomosis is a safe and effective method for MIE McKeown with a low incidence of anastomotic leakage, anastomotic stricture, or other postoperative complications.

Mechanical triangular esophagogastrostomy: Technical aspects and initial results

INTRODUCTION

Esophageal cancer represents the eighth neoplasm worldwide. The therapeutic approach is interdisciplinary, with surgery being the most effective option. Several techniques have been proposed to perform esophagogastrostomy after esophagectomy, among them mechanical triangular esophagogastrostomy, with a little experience published in the Western literature on the latter. The objective of this study is to describe the technical aspects and initial results of triangular esophagogastrostomy anastomosis.

METHODS

A retrospective review of the patients who underwent esophagectomy according to the McKeown technique was performed, those in which triangular esophagogastrostomy anastomosis was implemented, between October 2017 and March 2020 in our hospital.

RESULTS

A total of 14 patients were included, with a mean age of 63 years. The mean operative time was 436minutes (360-581), being diagnosed of anastomotic leak 3 of the 14 patients (21.4%), as well as 3 patients presented anastomotic stenosis. The median stay was 20 days, without any death in the series.

CONCLUSIONS

Multiple publications suggest the superiority in terms of anastomotic leak and anastomotic stenosis of the mechanical triangular anastomosis, which was also observed in our series, in which despite the small sample, a rapid improvement was observed in the indicators after the first cases. Therefore, this type of anastomosis may be a safe option for performing esophagogastric anastomosis after esophagectomy, being necessary more definitive conclusive studies.

Comparison of end-to-side hand-sewn and side-to-side stapled cervical esophagogastric anastomosis in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy: an Iranian retrospective cohort study

Background

Controversies in terms of efficacy and postoperative advantages surround stapled esophagogastric anastomosis compared with the hand-sewn technique as a treatment for patients with esophageal cancer. The purpose of this study was to compare the clinical outcomes of hand-sewn end-to-side esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis after esophagectomy for the aforementioned patients.

Methods

This retrospective cohort study involved examining the medical records of 433 patients who underwent transhiatal esophagectomy for esophageal cancer from March 2010 to March 2016. All the patients were operated using end-to-side hand-sewn esophago-gastrostomy and side-to-side stapled cervical esophagogastric anastomosis. 409 of the patients received a year’s worth of follow-up evaluations. All the cases were revisited in 2 weeks as well as in four, eight, and 12 months after surgery. The patients were assessed in terms of postoperative outcomes, including reflux symptoms, anastomotic leakage and stricture, and the need for anastomotic dilatation.

Results

Hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (8 cases or 5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02).

Conclusion

Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy.

Anastomotic techniques for oesophagectomy for malignancy: systematic review and network meta-analysis

Background

Current evidence on the benefits of different anastomotic techniques (hand‐sewn (HS), circular stapled (CS), triangulating stapled (TS) or linear stapled/semimechanical (LSSM) techniques) after oesophagectomy is conflicting. The aim of this study was to evaluate the evidence for the techniques for oesophagogastric anastomosis and their impact on perioperative outcomes.

Methods

This was a systematic review and network meta‐analysis. PubMed, EMBASE and Cochrane Library databases were searched systematically for randomized and non‐randomized studies reporting techniques for the oesophagogastric anastomosis. Network meta‐analysis of postoperative anastomotic leaks and strictures was performed.

Results

Of 4192 articles screened, 15 randomized and 22 non‐randomized studies comprising 8618 patients were included. LSSM (odds ratio (OR) 0·50, 95 per cent c.i. 0·33 to 0·74; P = 0·001) and CS (OR 0·68, 0·48 to 0·95; P = 0·027) anastomoses were associated with lower anastomotic leak rates than HS anastomoses. LSSM anastomoses were associated with lower stricture rates than HS anastomoses (OR 0·32, 0·19 to 0·54; P < 0·001).

Conclusion

LSSM anastomoses after oesophagectomy are superior with regard to anastomotic leak and stricture rates.

Meta-Analysis of Two Different Methods for Cervical Esophagogastric Anastomosis: Triangulating Versus Circular Stapling

Background: The standard treatment for esophageal carcinoma is extensive resection of the tumor and esophagogastric anastomosis despite the high incidence of related anastomotic complications, such as stricture and leakage. Thus, the choice of the cervical esophagogastric anastomotic method-triangulating stapling (TS) versus circular stapling (CS)-is a critical decision for the surgeon. Aim: To compare the incidence of major adverse outcomes between TS and CS in patients with resectable thoracic esophageal cancer. Methods: For this meta-analysis, PubMed, Embase, Wiley Online Library, Google Scholar, Wanfang, and China National Knowledge Infrastructure databases were searched for subject-relevant studies by using a rigorous study protocol established according to the recommendations of the Cochrane Handbook. Anastomotic leakage, anastomotic stricture, and postoperative pulmonary complications were the primary endpoints used for comparison. Relative risk (RR) with 95% confidence intervals (CI) were calculated to assess the strength of association. Results: Six studies were selected by our inclusion/exclusion criteria and represented a total of 739 patients in our meta-analysis of TS (n = 376) versus CS (n = 363). The TS group showed a lower incidence of anastomotic stricture (RR: 0.23 [95% CI: 0.08-0.63]; P = .004) and pulmonary complications (RR: 0.57 [95% CI: 0.37-0.87]; P = .01). However, the incidence of anastomotic leakage was similar for the two groups (RR: 0.66 [95% CI: 0.41-1.09]; P = .1). Subgroup analysis of four studies in which the surgical methods were minimally invasive demonstrated the TS group to have a lower incidence of lung complications (RR: 0.55 [95% CI: 0.35-0.87]; P = .01), anastomotic leakage (RR: 0.36 [95% CI: 0.18-0.74]; P = .005), and anastomotic stricture (RR: 0.23 [95% CI: 0.05-0.98]; P = .05). Conclusion: The TS method for cervical esophagogastric anastomosis after esophagectomy had a lower incidence of anastomotic stricture and postoperative lung complications.

Completely Linear Stapled Versus Handsewn Cervical Esophagogastric Anastomosis After Esophagectomy

Very limited data is present which compares completely linear stapled to handsewn cervical esophagogastric anastomosis. Primary objective was to determine whether linearly stapled (LS) anastomosis has lower clinically apparent leaks, when compared to handsewn anastomosis (HS). Secondary objectives were morbidity, mortality, overall leak and stricture rates, and presence of a symptomatic cervical stricture. This is a comparative study of 77 patients who underwent LS (n = 29) and HS (n = 48) cervical anastomosis. Anastomotic leak was found to be 19.4% (15/77). In the HS group, 27.08% (13/48) and in the LS group, 6.89% (2/29), respectively, leaked (p = 0.03), relative risk (RR)-3.93 (95% CI 1.21-15.25). 32.5% (23/77) patients remained admitted for more than 14 days. 52.1% (25/48) patients in the HS group were discharged within 14 days of surgery; whereas; 93.1% (27/29) were discharged in LS group (p = 0.001), RR-6.95 (95% CI 2.13-25.94). Overall, 90-day mortality was 7.8% (6/77). In the HS group, 8.3% (4/48) patients died while in the LS group, 6.8% (2/29) patients died (p = 0.82), RR-1.21(95% CI 0.27-5.53). In the HS group, 6.25% (3/48) patients were diagnosed with stricture compared to 6.8% (2/29) patients in the LS group (p = 0.9), RR-0.91 (95% CI 0.19-4.44). Overall stricture rate was 6.4% (5/77). Cervical anastomosis done with linear staplers has less leak rates compared to handsewn anastomosis.

The effect of disc-shaped gastric resection of anastomosis site on reducing postoperative dysphagia and stricture after esophagogastric anastomosis in patients with esophageal cancer

Background: Esophagectomy remains the most reliable technique for managing esophageal cancer, but anastomotic complications including postoperative leak, ischemia and stricture negatively affect outcomes of this specific surgery. The aim of this study was to evaluate the effects of a novel method of esophagogastric anastomosis for reducing postoperative dysphagia and stricture formation.

Methods: Eighty patients who were scheduled for esophagectomy due to esophageal cancer were randomly assigned into two groups: intervention and control (40 each). In the control group, the esophagogastric anastomosis was performed with a linear gastric incision, whilst in the intervention group a new method of disc-shaped gastric resection for anastomosis was applied. Postoperative outcomes were compared between the two groups.

Results: The incidence of postoperative dysphagia and anastomotic stricture was significantly lower in the disc-shaped resection group (dysphagia 45% vs 75%, P = 0.02; stricture 12.5% vs 32.5%, P = 0.03), whilst the length of stay in an intensive care unit (ICU), anastomotic leakage and other complications were not significantly different between the two groups (all P > 0.05).

Conclusion: Anastomotic complications can be reduced by improving surgical techniques. The decreased incidence of postoperative dysphagia and anastomotic stricture in our study may be partly due to providing the proper diameter for the site of anastomosis when using the disc-shaped gastric resection method. Hence, this new method can improve the clinical outcomes of patients who undergo esophagectomy with esophagogastric anastomosis.