Handsewn or stapled esophagogastric anastomoses after esophagectomy for cancer: meta-analysis of randomized controlled trials

Abstract

Gastric transposition with esophagogastric anastomosis is a common method of reconstruction after esophagectomy for cancer. The anastomosis can be fashioned using a handsewn or stapled technique. The choice of anastomotic technique is often debated but there is little evidence to support the use of one method over the other. We performed a meta-analysis of randomized controlled trials (RCTs) to determine the effect of esophagogastric anastomotic method (handsewn or circular stapled) on patient outcomes. Medline and manual searches were done (completed independently and in duplicate) to identify all published RCTs that addressed the issue of handsewn or stapled esophagogastric anastomosis after esophagectomy for cancer. The selection process was inclusive; no trials were excluded. Trial validity assessment was done and a trial quality score was assigned. Major outcomes for quantitative data synthesis included operative mortality, anastomotic leaks, anastomotic strictures, cardiac morbidity, and pulmonary morbidity. A random-effects model was used and relative risk was the principal measure of effect. Systematic qualitative review was used for other outcomes such as duration of operation and time to complete the anastomosis. Data on cancer survival were not available in the RCTs. Five RCTs were selected with quality scores ranging from 2 to 3 (5-point Jadad scale). Selection and validity agreement was strong. Relative risk (95% confidence interval, CI; P-value), expressed as handsewn vs. stapled (treatment vs. control), was 0.45 (0.20, 1.00; P=0.05) for operative mortality, 0.79 (0.44, 1.42; P=0.43) for anastomotic leaks, 0.60 (0.27, 1.33; P=0.21) for anastomotic strictures, 0.99 (0.55, 1.77; P=0.97) for cardiac morbidity, and 0.93 (0.63, 1.37; P=0.72) for pulmonary morbidity. Data synthesized from existing RCTs show that handsewn and circular stapled esophagogastric anastomotic techniques give similar results for anastomotic outcomes, such as leaks and strictures. The stapled anastomotic method appears to increase operative mortality (P=0.05). Although it is difficult to explain this finding, it should not be dismissed. Several hypotheses are discussed.

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

“…A sutura mecânica invertida é dupla e faz com que haja melhor coaptação da linha de anastomose, o que pode explicar a menor incidência de fístula com esse tipo de sutura como tem sido demonstrado por várias séries 3,16,24 . Em revisão recente de vários trabalhos da literatura relacionada à deiscência da anastomose esofagogástrica cervical, Chunwei F., et al 8 , demonstraram que essa complicação foi significantemente maior quando foi realizada sutura manual em 263 pacientes, com 18,7 % de deiscência anastomótica, quando comparado com a sutura mecânica em 195 pacientes, com 8,2%.…”

“…Por ser o esôfago cervical o segmento que apresenta a maior incidência de deiscência anastomótica, vários autores preconizam a sutura mecânica a este nível, devida as vantagens que ela oferece 5,8,11,12,22,24,28 . Nesse pressuposto, pode-se utilizar a sutura mecânica com o tubo gástrico isoperistáltico mesmo no intuito paliativo para tentar minimizar a deiscência anastomótica e oferecer qualidade de vida mais satisfatória.…”

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

“…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.…”

“…Staple with a circular stapler (CS) is regarded as a safe alternative to manual suturing in colonic, rectal [4], and gastric anastomosis [5], as well as esophagogastric anastomosis [6]. With the development of surgical techniques, many advances have been applied to the surgery of esophageal cancer in the past decade [7,8].…”

“…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]. To date, there were no systematic reviews or meta-analyses of the literature only focusing on cervical anastomosis (HS vs CS).…”