Comparison of anastomotic leakage and stricture formation following layered and stapler oesophagogastric anastomosis for cancer: a prospective randomized controlled trial

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis

BACKGROUND

Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy.

METHODS

A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test.

RESULTS

A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation.

CONCLUSION

Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Hand-sewn versus stapled anastomoses for esophagectomy: We will probably never know which is better

Objective

Methods

Results

Conclusions

Interventions to prevent anastomotic leak after esophageal surgery: a systematic review and meta-analysis

Background

Anastomotic leakage (AL) is a common and serious complication following esophagectomy. We aimed to provide an up-to-date review and critical appraisal of the efficacy and safety of all previous interventions aiming to reduce AL risk.

Methods

We searched MEDLINE and Embase from 1946 to January 2019 for randomized controlled trials (RCTs) evaluating interventions to minimize esophagogastric AL. Pooled risk ratios (RR) for AL were obtained using a random effects model.

Results

Two reviewers screened 441 abstracts and identified 17 RCTs eligible for inclusion; 11 studies were meta-analyzed. Omentoplasty significantly reduced the risk of AL by 78% [RR: 0.22; 95% CI: 0.10, 0.50] compared to conventional anastomosis (3 studies, n = 611 patients). Early removal of NG tube significantly reduced the risk of AL by 62% [RR: 0.38; 95% CI: 0.02, 0.65] compared to prolonged NG tube removal (2 studies, n = 293 patients); Stapled anastomosis did not significantly reduce the risk of AL [RR: 0.92; 95% CI: 0.45, 1.87] compared to hand-sewn anastomosis (6 studies, n = 1454 patients). The quality of evidence was high for omentoplasty (vs. conventional anastomosis), moderate for early NG tube removal (vs. prolonged NG tube removal), and very low for stapled anastomosis (vs. hand-sewn anastomosis).

Conclusions

This is the first meta-analysis to summarize the graded quality of evidence for all RCT interventions designed to reduce the risk of AL following esophagectomy. Our findings demonstrated that omentoplasty significantly reduced the risk of AL with a high quality of evidence. Although early NG tube removal significantly reduced AL risk, there is a need for further research to strengthen the quality of evidence for this finding. Evidence profiles presented in our review may help inform the development of future clinical practice recommendations.

Systematic review registration: CRD42019127181.

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.

Practice of cervical end-esophageal exteriorization in patients with severe intrathoracic anastomotic leakage after esophagectomy

Objective

This study aimed to summarize the clinical experience of severe intrathoracic anastomotic leakage encountered in clinical practice by using cervical end-esophageal exteriorization.

Methods

We undertook a retrospective review of four patients who developed severe anastomotic leakage after subtotal esophagectomy at our department. Four patients with a life-threatening condition and failed conservative management were re-operated on from the original incision using an exteriorized cervical end-esophageal gastric conduit. We returned the gastric conduit to the abdomen and placed a feeding jejunostomy or gastrostomy catheter. Until inflammation was controlled, we re-established intestinal continuity with the gastric or colon conduit, pulled up to the neck by a retrosternal channel.

Results

Four patients with esophagectomy and severe intrathoracic anastomotic leakage underwent re-operation. The gastric conduit was returned to the abdomen and cervical end-esophageal exteriorization was performed. Inflammation was rapidly controlled after surgery. Three patients received a second re-operation to re-establish intestinal continuity on days 63, 63, and 16 after the first re-operation. One patient refused re-operation to re-establish intestinal continuity. All four patients survived.

Conclusion

Cervical end-esophageal exteriorization in patients with severe intrathoracic anastomotic leakage results in rapid control of inflammation. This creates an opportunity to re-establish gastrointestinal continuity, leading to survival of patients.

Predictive factors for major postoperative complications related to gastric conduit reconstruction in thoracoscopic esophagectomy for esophageal cancer: a case control study

Background

Regardless of developments in thoracoscopic esophagectomy (TE), postoperative complications relative to gastric conduit reconstruction are common after esophagectomy. The aim of the present study was to evaluate the predictive factors of major complications related to gastric conduit after TE.

Methods

From 2006 to 2015, 75 patients with esophageal cancer who underwent TE were evaluated to explore the predictive factors of major postoperative complications related to gastric conduit.

Results

Patients with major complications related to gastric conduit had a significantly longer postoperative hospital stay than patients without these complications (P <  0.01). Multivariate analysis demonstrated that three-field lymph node dissection (3FLND) and high serum levels of creatine phosphokinase (CPK) and C-reactive protein (CRP) at 1 postoperative day (1POD) after TE were significant predictive factors of major complications related to gastric conduit [odds ratio (OR) 5.37, 95% confidence interval (CI) 1.41–24.33, P = 0.02; OR 5.40, 95% CI 1.60–20.20, P <  0.01; OR 5.07, 95% CI 1.47–20.25, P = 0.01, respectively]. The incidence rates of major complications related to gastric conduit for 0, 1, 2, and 3 predictive factors were 5.3%, 18.8%, 58.8%, and 85.7%, respectively (P <  0.01).

Conclusions

Two or more factors in 3FLND and the high levels of CPK and CRP at 1POD after TE were identified as the risk model for major complications related to gastric conduit after TE.

Trial registration

UMIN Clinical Trials Registry, ID: UMIN000024436, Registered date: Oct/17/2016.

[Management of delayed complications after esophagectomy]

Esophagectomy and subsequent reconstruction represent major physiological insults to the upper gastrointestinal (GI) tract, which as a consequence can lead to malnutrition, dysphagia and reflux. From a technical perspective, operative reconstruction involving gastric pull-up with a 2-3 cm wide tube and an anastomosis cranial to the azygos vein may minimize the symptoms. Overall, the problems tend to improve approximately 6 months after the operation. Newly occurring delayed physical functional impairments with previously known underlying malignant disease may be indicative of cancer relapse. Interventional techniques, such as stent placement or brachytherapy may be better suited for treatment of recurrent disease.

Hand-sewn versus stapler esophagogastric anastomosis after esophageal ressection: systematic review and meta-analysis

INTRODUCTION

Postoperative anastomotic leak and stricture are dramatic events that cause increased morbidity and mortality, for this reason it's important to evaluate which is the best way to perform the anastomosis.

AIM

To compare the techniques of manual (hand-sewn) and mechanic (stapler) esophagogastric anastomosis after resection of malignant neoplasm of esophagus, as the occurrence of anastomotic leak, anastomotic stricture, blood loss, cardiac and pulmonary complications, mortality and surgical time.

METHODS

A systematic review of randomized clinical trials, which included studies from four databases (Medline, Embase, Cochrane and Lilacs) using the combination of descriptors (anastomosis, surgical) and (esophagectomy) was performed.

RESULTS

Thirteen randomized trials were included, totaling 1778 patients, 889 in the hand-sewn group and 889 in the stapler group. The stapler reduced bleeding (p <0.03) and operating time (p<0.00001) when compared to hand-sewn after esophageal resection. However, stapler increased the risk of anastomotic stricture (NNH=33), pulmonary complications (NNH=12) and mortality (NNH=33). There was no significant difference in relation to anastomotic leak (p=0.76) and cardiac complications (p=0.96).

CONCLUSION

After resection of esophageal cancer, the use of stapler shown to reduce blood loss and surgical time, but increased the incidence of anastomotic stricture, pulmonary complications and mortality.

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

The application of cervical esophagogastric anastomoses was of great concern. However, between circular stapler (CS) and hand-sewn (HS) methods with anastomosis in the neck, which one has better postoperative effects still puzzles surgeons. This study aims to systematically evaluate the effectiveness, security, practicality, and applicability of CS compared with the HS method for the esophagogastric anastomosis after esophageal resection. A systematic literature search, as well as other additional resources, was performed which was completed in January 2013. The relevant randomized controlled trials (RCTs) about the surgical technique for esophageal resection were included. Trial data was reviewed and extracted independently by two reviewers. The quality of the included studies was assessed by the recommended standards basing on Cochrane handbook 5.1.0, and the data was analyzed via RevMan 5 software (version 5.2.0). Nine studies with 870 patients were included. The results showed that in comparing HS to CS methods with cervical anastomosis, no significant differences were found in the risk of developing anastomotic leakages (relative risk (RR) = 1.30, 95 % confidence intervals (CI) 0.87-1.92, p = 0.20), as well as the anastomosis stricture (RR = 0.97, 95 % CI 0.47-1.99, p = 0.93), postoperative mortality (RR = 0.83, 95 % CI 0.43-1.58, p = 0.57), blood loss (mean difference (MD) = 39.68; 95 % CI -6.97, 86.33; p = 0.10) and operative time (MD = 18.05; 95 % CI -3.22, 39.33; p = 0.10). However, the results also illustrated that the CS methods with cervical anastomosis might be less time-consuming and have shorter hospital stay and higher costs. Based upon this meta-analysis, there were no differences in the postoperative outcomes between HS and CS techniques. And the ideal technique of cervical esophagogastric anastomosis following esophagectomy remains under controversy.

Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis

AIM: To compare the outcome of hand sewing and stapling for anastomotic leakage after esophagectomy.

METHODS: A rigorous study protocol was established according to the recommendations of the Cochrane Collaboration. An electronic database search, hand search, and reference search were used to retrieve all randomized controlled trials that compared hand-sewn and mechanical esophagogastric anastomoses.

RESULTS: This study included 15 randomized controlled trials with a total of 2337 patients. The results revealed that there was no significant difference in the incidence of anastomotic leakage between the methods [relative risk (RR) = 0.77, 95% confidence interval (CI): 0.57-1.04; P = 0.09], but a subgroup analysis yielded a significant difference for the sutured layer and year of publication (Ps < 0.05). There was also no significant difference in the incidence of postoperative mortality (RR = 1.52, 95%CI: 0.97-2.40; P = 0.07). However, the anastomotic strictures rate was increased in the stapler group compared with the hand-sewn group (RR = 1.45, 95%CI: 1.11-1.91; P < 0.01) in the end-to-side subgroup, while the incidence of anastomotic strictures was decreased (RR = 0.34, 95%CI: 0.16-0.76; P < 0.01) in the side-to-side subgroup.

CONCLUSION: The stapler reduces the anastomotic leakage rate compared with hand sewing. End-to-side stapling increases the risk of anastomotic strictures, but side-to-side stapling decreases the risk.

Surgical quality of care in esophageal malignancies

Aim: Esophagectomy is the primary surgical treatment for localized malignant neoplasms of the esophagus, and while outcomes have shown that substantial improvement has been made, the ceiling for improvement is still high. Methods: A total of 2506 publications published from January 2002 to March 2012 were identified from PubMed, MEDLINE and the Cochrane Library using the keywords: ‘esophagectomy’, ‘esophagus’, ‘neoplasm’ and ‘cancer’ to identify quality key surgical articles in esophagectomy that were broken down into three groups: preoperative, intraoperative and postoperative care. Discussion: There have been limited preoperative surgical trials, mostly in preoperative antibiotic use, which have led to changes in surgical management. Key and substantial changes have occurred in the intraoperative management for esophageal malignancies around surgical anastomosis technique and anesthesia. Nutritional outcomes still remain a key challenge, and currently there is no established standard of care in the postoperative management of esophagectomy patients. Conclusion: We established quality parameters for leak rates, overall morbidity and mortality, and these form the foundation from which all esophageal surgeons should rank their results. We then utilized the techniques described above to maintain those rates or, better yet, to significantly improve those rates in each surgeons’ practice.

The Role of Esophagogastric Anastomotic Technique in DecreasingBenign Stricture Formation in the Surgery of Esophageal Carcinoma

INTRODUCTION

Postoperative stenosis and dysphagia after esophageal carcinoma resection is the major problem. The aim of this study is to compare two types cervical esophagogastric anastomosis in reduction of stricture formation in esophageal cancer surgery.

METHODS

The subjects of this study were 223 patients undergoing esophageal carcinoma resection during 1998 to 2007. Twenty two patients were excluded from the study because of recurrent malignancy of anastomosis, mortality and losing in follow up period. Two hundred and one patients remained by the end of study were classified into two groups: 98 patients were treated by routinely transverse hand-sewn cervical esophagogastric anastomosis (group 1); and 103 patients were treated by the proposed oblique hand-sewn esophagogastric anastomotic technique (group 2). All the operations were with high abdominal and left cervical incisions (Transhiatal esophagectomy). All patients of both groups were followed up at least 6-month for detection of anastomotic strictures.

RESULTS

Postoperative dysphagia occurred in 20 patients of group 1 versus 5 patients of group 2. In working up by rigid esophagoscopy, two patients of group 2 and four patients of group 1 had not true strictures. Anastomotic strictures occurred in 16 cases of group 1, versus 3 cases of group 2. Statistical comparative analysis results of two groups about stricture formation were significant (3% versus 16% P= 0.003).

CONCLUSION

The oblique hand-sewn esophagogastric anastomostic techniques reduce markedly the rate of stricture formation after esophagectomy.

Hand-sewn versus mechanical esophagogastric anastomosis after esophagectomy: a systematic review and meta-analysis. Ann Surg. 2013;257:238-248. [PMID: 23001084 DOI: 10.1097/sla.0b013e31826d4723]

OBJECTIVE

To evaluate the risks and benefits of using a circular stapler (CS) compared with the hand-sewn (HS) method for the esophagogastric anastomosis after esophageal resection.

BACKGROUND DATA

Previous randomized controlled trials (RCTs) indicated that the use of a CS might prevent anastomotic leakage, whereas it was more likely to lead to anastomotic strictures. The relative efficacy of this intervention in comparison with the HS method has not been conclusively determined.

METHODS

A systematic review and meta-analysis of all RCTs that compared HS versus mechanical anastomosis using a CS was conducted regarding the leakage, strictures, operative time, and mortality. The study protocol was established a priori according to the recommendations of the Cochrane Collaboration.

RESULTS

Twelve RCTs were included with a total of 1407 patients. The use of a CS, compared with the HS method, (1) led to no significant difference in the incidence of anastomotic leakage [risk ratio (RR): 1.02, 95% confidence interval (CI): 0.66-1.59] or postoperative mortality (RR: 1.64, 95% CI: 0.95-2.83), (2) increased the incidence of anastomotic strictures (RR: 1.67, 95% CI: 1.16-2.42), and (3) reduced the length of the operation time (mean: -15.3 minutes, range: -28.1 to -2.39). For these results, a subgroup analysis and a meta-regression analysis yielded no significant differences for the anastomotic site, diameter of the CS, layer, or configuration.

CONCLUSION

The use of a CS contributed to reducing the length of the operation, but was associated with an increased risk of anastomotic strictures. Both the CS and the HS method are viable alternatives in the reconstruction after esophagectomy.

[Anastomoses in the upper gastrointestinal tract]

BACKGROUND

Anastomotic leaks are the major postoperative complications mainly due to technical difficulties. The aim was to review anastomotic techniques and risk factors for leak development.

METHODS

A Pubmed search was performed using the terms esophagogastric/esophagojejunal anastomosis, gastrojejunostomy, gastric bypass, esophagectomy, anastomotic leak/risk factors, gastrectomy, TEA, fluid management, early enteral feeding and reinforcement. English and German literature sources were included with the accent on recent prospective randomized controlled trials (pRCT) with high numbers of cases as well as meta-analyses.

CONCLUSIONS

There is not enough evidence to recommend either hand sewn or mechanical anastomoses. Surgical skills and routine as well as precise work are necessary to reduce complications. Although stapling leads to uniformity of anastomoses it cannot compensate for surgical deficits.