Linear- versus circular-stapled esophagogastric anastomosis during esophagectomy: systematic review and meta-analysis

Abstract

Background Different techniques have been described for esophagogastric anastomosis. Over the past decades, surgeons have been improving anastomotic techniques with a gradual shift from hand-sewn to stapled anastomosis. Nowadays, circularstapled (CS) and linear-stapled (LS) anastomosis are commonly used during esophagectomy. Methods PubMed, MEDLINE, Scopus, and Web of Science were searched up to June 2022. The included studies evaluated short-term outcomes for LS vs. CS anastomosis in patients undergoing esophagectomy for cancer. Primary outcomes were anastomotic leak (AL) and stricture (AS). Risk ratio (RR) and standardized mean difference (SMD) were used as pooled effect size measures whereas 95% confidence intervals (95%CI) were used to assess relative inference. Results Eighteen studies (2861 patients) were included. Overall, 1371 (47.9%) underwent CS while 1490 (52.1%) LS. Compared to CS, LS was associated with a significantly reduced RR for AL (RR = 0.70; 95% CI 0.54-0.91; p < 0.01) and AS (RR = 0.32; 95% CI 0.20-0.51; p < 0.0001). Stratified subgroup analysis according to the level of anastomosis (cervical and thoracic) still shows a tendency toward reduced risk for LS. No differences were found for pneumonia (RR 0.78; p = 0.12), reflux esophagitis (RR 0.74; p = 0.36), operative time (SMD −0.25; p = 0.16), hospital length of stay (SMD 0.13; p = 0.51), and 30-day mortality (RR 1.26; p = 0.42). Conclusions LS anastomosis seems associated with a tendency toward a reduced risk for AL and AS. Although surgeon's own training and experience might direct the choice of esophagogastric anastomosis, our meta-analysis encourages the use of LS anastomosis.

Short-term Outcomes of Different Techniques for Gastric Ischemic Pre-Conditioning Before Esophagectomy

“…[57][58][59] The incidence of postoperative AL has been reported up to 30%. 2,3 In line with the literature, our results seem to reflect previously reported data ranging from 8.6% to 14.4% (Table 2). In our study, bot LapGIC (RR = 0.68; 95% CrI 0.47-0.98) and AngioGIC (RR = 0.52; 95% CrI 0.31-0.93) were associated with a significantly reduced risk of AL compared to noGIC.…”

“…The incidence of postoperative AL has been reported up to 30% 2,3 . In line with the literature, our results seem to reflect previously reported data ranging from 8.6% to 14.4% (Table 2).…”

“…1 Anastomotic leak (AL) remains the most feared complication occurring in up to 40% of patients. 2,3 Potential increase in mortality, prolonged hospital stay, delayed oral feeding, risk of reintervention, increased risk of recurrence, and decrease of overall/disease-free survival have been reported to be associated with AL. [4][5][6] Anastomotic stricture (AS) may occur in up to 30% of patients and may require endoscopic dilation with a negative effect of postoperative recovery, nutritional status, and quality of life.…”

“…Esophagectomy, lymphadenectomy and restoration of the gastrointestinal continuity via gastric conduit reconstruction represent the gold standard treatment for esophageal malignancies 1 . Anastomotic leak (AL) remains the most feared complication occurring in up to 40% of patients 2,3 . Potential increase in mortality, prolonged hospital stay, delayed oral feeding, risk of reintervention, increased risk of recurrence, and decrease of overall/disease-free survival have been reported to be associated with AL 4–6 .…”

Long-Term Impact of Severe Postoperative Complications after Esophagectomy for Cancer: Individual Patient Data Meta-Analysis

“…Our results should not be generalized because the sample was principally from Eastern centers, with a possible impact of tumor epidemiology and genomic characterization [89]. The different surgical approaches (i.e., open, hybrid, totally minimally invasive esophagectomy) and operating surgeon expertise/learning curve may have an effect on the incidence of SPCs [90,91]. Unfortunately, all the included studies graded postoperative complications based on the Clavien-Dindo classification, which is not the current standard for assessing esophagectomy-related morbidity and mortality.…”