Comparison of Stapled and Hand-sewn Esophagogastric Anastomoses

Beitler, Alan L.; Urschel, John D.

doi:10.1016/s0002-9610(98)00002-6

Cited by 105 publications

(80 citation statements)

References 26 publications

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“…A non-randomised comparison of 580 anastomoses and a subsequent large RCT showed that there was no significant difference in leak rate between sutured and stapled anastomoses but that the stapled technique produced a much higher rate of stricture. 33,34 These findings have been supported by a meta-analysis 35 and numerous other studies. Stricture formation is also more common after cervical than after thoracic anastomosis, with strictures requiring dilation in 30-66% of cases.…”

Section: Anastomotic Techniquesupporting

confidence: 57%

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A personal perspective on controversies in the surgical management of oesophageal cancer

Manson

Beasley

2014

annals

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Significant disagreement and debate persist regarding several aspects of the optimal surgical management of oesophageal cancer. We address some of these issues based on our consecutive series of 165 patients undergoing oesophageal resection (reported in full elsewhere) and the available literature. The areas considered are controversial but we argue in favour of a 'traditional' two-stage open approach (Ivor-Lewis), leaving the pylorus alone, making no attempt to perform a radical lymphadenectomy and fashioning a hand sewn anastomosis. KEYWORDSOesophagectomy -Ivor-Lewis -Oesophageal cancer -Gastro-oesophageal anastomosisPyloroplasty -Lymphadenectomy The aim of this paper is to outline and justify the approach we favour for oesophageal resection in malignant disease. In order to accomplish this aim, we draw on our own experience 1 and review of the relevant literature. Surgical approachPerhaps because the oesophagus is present in the neck, the thorax and the abdomen, multiple surgical approaches (and combination of approaches) to oesophageal resection are described. Inevitably, there is controversy over the optimal approach. We favour a laparotomy and right lateral thoracotomy. This is preferred to other approaches such as a threestage, transhiatal or minimally invasive oesophagectomy (MIO).In the three-stage (McKeown) approach, gastro-oesophagectomy is followed by a further cervical incision and an anastomosis fashioned in the neck. We are unable to identify any compelling argument to support this approach. It is claimed that anastomosis is technically easier in the neck than in the chest. In south Wales, the majority of patients with oesophageal cancer are overweight with a barrel chest and a short neck. In our experience, no matter how high in the chest it located, an intrathoracic anastomosis is unarguably technically easier than in the neck.It is also argued that anastomotic leakage following cervical anastomosis is less dangerous than in the chest. Not all oesophageal surgeons accept this. There is evidence that a cervical anastomosis often comes to lie in the upper part of the thoracic cavity.2 Since our rate of anastomotic leakage is, fortunately, very low (overall leak rate 1.2%, clinical leak rate 0.6%), this is not an issue in our practice.A further potential argument in favour of the three-stage approach is a greater proximal resection margin; the advantage has been estimated at 1cm.2 No patient in our series had an involved proximal margin, which suggests that adequate clearance can be obtained with an intrathoracic approach. The majority of the available evidence suggests that the rate of benign anastomotic stricture is significantly lower in intrathoracic than in cervical anastomoses.3-5 (See 'Anastomotic technique' section below.) We can identify no advantages to a three-stage procedure. In our series of 165 patients, access to the neck was needed in only two patients who developed significant complications. It is claimed that a transhiatal approach to oesophageal resection is associated wi...

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Section: Anastomotic Techniquesupporting

confidence: 57%

“…The majority of the available evidence suggests intrathoracic location and hand sewn technique are both predictors of a low rate of anastomotic stricture. [3][4][5][33][34][35] It seems difficult to justify the use of stapling devices to fashion anastomoses after oesophageal resection. A hand sewn anastomosis is cheap.…”

Section: Anastomotic Techniquementioning

confidence: 99%

A personal perspective on controversies in the surgical management of oesophageal cancer

Manson

Beasley

2014

annals

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“…Both HS and CS methods are fashioned in conducting the esophagogastric anastomosis in the past two decades [37]. Several retrospective studies [6,22,38], as well as firm evidence from relevant RCTs, have showed that both of them were safe. Meanwhile, with higher costs [17,34] and being less time-consuming [25,35], the CS method was associated with higher stricture rate related to high mortality.…”

Section: Summary Of the Current Researchesmentioning

confidence: 99%

“…However, some debates still exist. Several previous systematic reviews on this topic [6,[22][23][24] concluded that the evidence was weak due to the clinical heterogeneity, such as different sites (cervical vs thoracic) and configurations (end to end vs end to side), which could not be strong enough to guide the clinical applications. The controversy concerning on cervical esophagogastric anastomoses was more obvious [6,25].…”

Section: Introductionmentioning

confidence: 99%

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

Wang

Shi

et al. 2013

Indian J Surg

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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.

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“…Entretanto, o grande óbice deste procedimento é a deiscência da anastomose do tubo gástrico com o esôfago cervical, retardando a deglutição normal e, consequentemente, comprometendo em demasia a qualidade de vida do paciente que já se apresenta com condições nutricionais bem comprometidas devido ao caráter avançado da doença 7,9,18 . Estudo anterior em 53 pacientes com câncer de esôfago irressecável no qual estes autores utilizaram tubo gástrico isoperistaltico paliativo, a anastomose esofagogástrica cervical foi confeccionada com sutura manual, com deiscência anastomótica em 29,5%, o que comprometeu muito a qualidade de vida destes pacientes, impedindo que eles pudessem deglutir por via oral em média por um mês 4 .…”

Section: Introductionunclassified

Tubo gástrico isoperistáltico de grande curvatura gástrica com sutura mecânica no tratamento cirúrgico do câncer de esôfago irressecável

Aquino¹,

Said²,

Brandi³

et al. 2009

ABCD, arq. bras. cir. dig.

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INTRODUÇÃOA neoplasia de esôfago é doença muito comum em regiões com populações de baixa renda e naquelas habituadas à ingestão de álcool e abuso de tabaco 15,19 . Quase sempre o diagnóstico dessa afecção é tardio, pois a disfagia -principal sintoma da neoplasia de esôfago -, ocorre somente quando mais de 2/3 da luz esofágica esta preenchida por lesão tumoral. O diagnóstico retardado, perda de peso excessiva consequente à disfagia e associação de doenças cardiopulmonares decorrente do abuso de tabaco, tornam o portador dessa neoplasia paciente de difícil controle clínico, tendo o médico que o assiste poucas possibilidades terapêuticas. Este fato é muito comum, uma vez que em vários centros de tratamento da neoplasia esofágica, principalmente no mundo ocidental, apenas cerca de 20-30% dos pacientes conseguem realizar tratamento cirúrgico radical 15,17,18 .Dessa forma, muitas vezes o tratamento para essa afecção torna-se paliativo, sendo que o ideal seriam procedimentos que restaurassem satisfatoriamente a deglutição, sem a necessidade de novas internações hospitalares, com menores índices de complicações e que proporcionassem qualidade de vida mais adequada9. Assim, com o evoluir da técnica cirúrgica, passou-se procurar alternativas que atingissem essas finalidades, sendo o tubo gástrico isoperistáltico de grande curvatura um dos métodos de eleição 18,20 .Entretanto, o grande óbice deste procedimento é a deiscência da anastomose do tubo gástrico com o esôfago cervical, retardando a deglutição normal e, consequentemente, comprometendo em demasia a qualidade de vida do paciente que já se apresenta com condições nutricionais bem comprometidas devido ao caráter avançado da doença 7,9,18 . Estudo anterior em 53 pacientes com câncer de esôfago irressecável no qual estes autores utilizaram tubo gástrico isoperistaltico paliativo, a anastomose esofagogástrica cervical foi confeccionada com sutura manual, com deiscência anastomótica em 29,5%, o que comprometeu muito a qualidade de vida destes pacientes, impedindo que eles pudessem deglutir por via oral em média por um mês 4 .Com o advento da sutura mecânica, divulgada a partir da década de 60, tornou-se possível desenvolver nos dias atuais

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Comparison of Stapled and Hand-sewn Esophagogastric Anastomoses

Cited by 105 publications

References 26 publications

A personal perspective on controversies in the surgical management of oesophageal cancer

A personal perspective on controversies in the surgical management of oesophageal cancer

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

Tubo gástrico isoperistáltico de grande curvatura gástrica com sutura mecânica no tratamento cirúrgico do câncer de esôfago irressecável

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