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Technical Factors that Affect Anastomotic Integrity Following Esophagectomy: Systematic Review and Meta-analysis

  • Thoracic Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Due to the significant contribution of anastomotic leak, with its disastrous consequences to patient morbidity and mortality, multiple parameters have been proposed and individually meta-analyzed for the formation of the ideal esophagogastric anastomosis following cancer resection. The purpose of this pooled analysis was to examine the main technical parameters that impact on anastomotic integrity.

Methods

Medline, Embase, trial registries, and conference proceedings were searched. Technical factors evaluated included hand-sewn versus stapled esophagogastric anastomosis (EGA), cervical versus thoracic EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. The outcome of interest was the incidence of anastomotic leak, for which pooled odds ratios were calculated for each technical factor.

Results

No significant difference in the incidence of anastomotic leak was demonstrated for the following technical factors: hand-sewn versus stapled EGA, minimally invasive versus open esophagectomy, anterior versus posterior route of reconstruction and ischemic conditioning of the gastric conduit. Four randomized, controlled trials comprising 298 patients were included that compared cervical and thoracic EGA. Anastomotic leak was seen more commonly in the cervical group (13.64 %) than in the thoracic group (2.96 %). Pooled analysis demonstrated a significantly increased incidence of anastomotic leak in the cervical group (pooled odds ratio = 4.73; 95 % CI 1.61–13.9; P = 0.005).

Conclusions

A tailored surgical approach to the patient’s physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.

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References

  1. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet. 2012;379:1887–92.

    Article  PubMed  Google Scholar 

  2. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin. 2011;61:69–90.

    Article  PubMed  Google Scholar 

  3. Siegel R, Naishadham D, Jemal A. Cancer statistics. CA Cancer J Clin. 2012;62(1):10–29.

    Article  PubMed  Google Scholar 

  4. Coupland VH, Lagergren J, Luchtenborg M, et al. Hospital volume, proportion resected and mortality from oesophageal and gastric cancer: a population-based study in England, 2004–2009. Gut. 2013;62(7):961–6.

    Article  PubMed  Google Scholar 

  5. Hanna GB, Boshier PR, Knaggs A, et al. Improving outcomes after gastroesophageal cancer resection: can Japanese results be reproduced in Western centers? Arch Surg. 2012;147(8):738–45.

    PubMed  Google Scholar 

  6. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.

    Article  PubMed  CAS  Google Scholar 

  7. Law S, Fok M, Chu KM, et al. Comparison of hand-sewn and stapled esophagogastric anastomosis after esophageal resection for cancer: a prospective randomized controlled trial. Ann Surg. 1997;226(2):169–73.

    Article  PubMed  CAS  Google Scholar 

  8. Hsu HH, Chen JS, Huang PM, et al. Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a prospective randomized controlled trial. Eur J Cardiothorac Surg. 2004;25(6):1097–101.

    Article  PubMed  Google Scholar 

  9. Laterza E, de’Manzoni G, Veraldi GF, et al. Manual compared with mechanical cervical oesophagogastric anastomosis: a randomised trial. Eur J Surg. 1999;165(11):1051–4.

    Article  PubMed  CAS  Google Scholar 

  10. Valverde A, Hay JM, Fingerhut A, et al. Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: a controlled trial. French Associations for Surgical Research. Surgery. 1996;120(3):476–83.

    Article  PubMed  CAS  Google Scholar 

  11. Luechakiettisak P, Kasetsunthom S. Comparison of hand-sewn and stapled in esophagogastric anastomosis after esophageal cancer resection: a prospective randomized study. J Med Assoc Thai. 2008;91(5):681–5.

    PubMed  Google Scholar 

  12. Walther B, Johansson J, Johansson F, et al. Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: a prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis. Ann Surg. 2003;238(6):803–12.

    Article  PubMed  Google Scholar 

  13. Okuyama M, Motoyama S, Suzuki H, et al. Hand-sewn cervical anastomosis versus stapled intra-thoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer: a prospective randomized controlled study. Surg Today. 2007;37(11):947–52.

    Article  PubMed  Google Scholar 

  14. Craig SR, Walker WS, Cameron EW, et al. A prospective randomized study comparing stapled with handsewn oesophagogastric anastomoses. J R Coll Surg Edinb. 1996;41(1):17–9.

    PubMed  CAS  Google Scholar 

  15. George WD, West of Scotland and Highland Anastomosis Study Group. Suturing or stapling in gastrointestinal surgery: a prospective randomized study. Br J Surg. 1991;78:337–41.

    Article  Google Scholar 

  16. Saluja SS, Ray S, Pal S, et al. Randomized trial comparing side-to-side stapled and hand-sewn esophagogastric anastomosis in neck. J Gastrointest Surg. 2012;16(7):1287–95.

    Article  PubMed  Google Scholar 

  17. Chasseray VM, Kiroff GK, Buard JL, et al. Cervical or thoracic anastomosis for esophagectomy for carcinoma. Surg Gynecol Obstet. 1989;169(1):55–62.

    PubMed  CAS  Google Scholar 

  18. Ribet M, Debrueres B, Lecomte-Houcke M. Resection for advanced cancer of the thoracic esophagus: cervical or thoracic anastomosis? Late results of a prospective randomized study. J Thorac Cardiovasc Surg. 1992;103(4):784–9.

    PubMed  CAS  Google Scholar 

  19. Lam TC, Fok M, Cheng SW, et al. Anastomotic complications after esophagectomy for cancer. A comparison of neck and chest anastomoses. J Thorac Cardiovasc Surg. 1992;104:395–400.

    PubMed  CAS  Google Scholar 

  20. Nurnberger HR, Lohlein D. Experiences with reliability and rate of complications in collar or thoracic anastomosis after subtotal esophagectomy. Zentralbl Chir. 1994;119:233–9.

    PubMed  CAS  Google Scholar 

  21. Blewett CJ, Miller JD, Young JE, et al. Anastomotic leaks after esophagectomy for esophageal cancer: a comparison of thoracic and cervical anastomoses. Ann Thorac Cardiovasc Surg. 2001;7:75–8.

    PubMed  CAS  Google Scholar 

  22. Egberts JH, Schniewind B, Bestmann B, et al. Impact of the site of anastomosis after oncologic esophagectomy on quality of life–a prospective, longitudinal outcome study. Ann Surg Oncol. 2008;15:566–75.

    Article  PubMed  Google Scholar 

  23. Klink CD, Binnebosel M, Otto J, et al. Intrathoracic versus cervical anastomosis after resection of esophageal cancer: a matched pair analysis of 72 patients in a single center study. World J Surg Oncol. 2012;10:1477–9.

    Article  Google Scholar 

  24. Ben-David K, Sarosi GA, Cendan JC, et al. Decreasing morbidity and mortality in 100 consecutive minimally invasive esophagectomies. Surg Endosc. 2012;26:162–7.

    Article  PubMed  Google Scholar 

  25. Berger AC, Bloomenthal A, Weksler B, et al. Oncologic efficacy is not compromised, and may be improved with minimally invasive esophagectomy. J Am Coll Surg. 2011;212(4):560–6.

    Article  PubMed  Google Scholar 

  26. Gao Y, Wang Y, Chen L, et al. Comparison of open three-field and minimally invasive esophagectomy for esophageal cancer. Interact Cardiovasc Thorac Surg. 2011;12:366–9.

    Article  PubMed  Google Scholar 

  27. Hamouda AH, Forshaw MJ, Tsigritis K, et al. Perioperative outcomes after transition from conventional to minimally invasive Ivor-Lewis esophagectomy in a specialized center. Surg Endosc. 2010;24:865–9.

    Article  PubMed  Google Scholar 

  28. Lee JM, Cheng JW, Lin MT, et al. Is there any benefit to incorporating a laparoscopic procedure into minimally invasive esophagectomy? The impact on perioperative results in patients with esophageal cancer. World J Surg. 2011;35:790–7.

    Article  PubMed  Google Scholar 

  29. Nafteux P, Moons J, Coosemans W, et al. Minimally invasive oesophagectomy: a valuable alternative to open oesophagectomy for the treatment of early oesophageal and gastro-oesophageal junction carcinoma. Eur J Cardiothorac Surg. 2011;40:1455–63.

    PubMed  Google Scholar 

  30. Safranek PM, Cubitt J, Booth MI, et al. Review of open and minimal access approaches to oesophagectomy for cancer. Br J Surg. 2010;97:1845–53.

    Article  PubMed  CAS  Google Scholar 

  31. Schroder W, Holscher AH, Bludau M, et al. Ivor-Lewis esophagectomy with and without laparoscopic conditioning of the gastric conduit. World J Surg. 2010;34:738–43.

    Article  PubMed  Google Scholar 

  32. Smithers BM, Gotley DC, Martin I, et al. Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg. 2007;245:232–40.

    Article  PubMed  Google Scholar 

  33. Yamasaki M, Miyata H, Fujiwara Y, et al. Minimally invasive esophagectomy for esophageal cancer: comparative analysis of open and hand-assisted laparoscopic abdominal lymphadenectomy with gastric conduit reconstruction. J Surg Oncol. 2011;104:623–8.

    Article  PubMed  Google Scholar 

  34. Zingg U, McQuinn A, DiValentino D, et al. Minimally invasive versus open esophagectomy for patients with esophageal cancer. Ann Thorac Surg. 2009;87:911–9.

    Article  PubMed  Google Scholar 

  35. Biere SS, Maas KW, Cuesta MA, et al. Cervical or thoracic anastomosis after esophagectomy for cancer: a systematic review and meta-analysis. Dig Surg. 2011;28:29–35.

    Article  PubMed  CAS  Google Scholar 

  36. Bartels H, Thorban S, Siewert JR. Anterior versus posterior reconstruction after transhiatal oesophagectomy: a randomized controlled trial. Br J Surg 1993;80:1141–4.

    Article  PubMed  CAS  Google Scholar 

  37. Gawad KA, Hosch SB, Bumann D, et al. How important is the route of reconstruction after esophagectomy: a prospective randomized study. Am J Gastroenterol. 1999;94:1490–6.

    Article  PubMed  CAS  Google Scholar 

  38. van Lanschot JJ, van Blankenstein M, Oei HY, et al. Randomized comparison of prevertebral and retrosternal gastric tube reconstruction after resection of oesophageal carcinoma. Br J Surg. 1999;86:102–8.

    Article  PubMed  Google Scholar 

  39. Zieren HU, Muller JM, Pichlmaier H. Prospective randomized study of one- or two-layer anastomosis following oesophageal resection and cervical oesophagogastrostomy. Br J Surg. 1993;80:608–11.

    Article  PubMed  CAS  Google Scholar 

  40. Motoyama S, Kitamura M, Saito R, et al. Surgical outcome of colon interposition by the posterior mediastinal route for thoracic esophageal cancer. Ann Thorac Surg. 2007;83:1273–8.

    Article  PubMed  Google Scholar 

  41. Khiria LS, Pal S, Peush S, et al. Impact on outcome of the route of conduit transposition after transhiatal oesophagectomy: a randomized controlled trial. Dig Liver Dis. 2009;41:711–6.

    Article  PubMed  CAS  Google Scholar 

  42. Chan ML, Hsieh CC, Wang CW, et al. Reconstruction after esophagectomy for esophageal cancer: retrosternal or posterior mediastinal route? J Chin Med Assoc. 2011;74:505–10.

    Article  PubMed  Google Scholar 

  43. Akiyama S, Ito S, Sekiguchi H, et al. Preoperative embolization of gastric arteries for esophageal cancer. Surgery. 1996;120:542–6.

    Article  PubMed  CAS  Google Scholar 

  44. Akiyama S, Kodera Y, Sekiguchi H, et al. Preoperative embolization therapy for esophageal operation. J Surg Oncol. 1998;69:219–23.

    Article  PubMed  CAS  Google Scholar 

  45. Isomura T, Itoh S, Akiyama S, et al. Efficacy of gastric blood supply redistribution by transarterial embolization: preoperative procedure to prevent postoperative anastomotic leaks following esophagoplasty for esophageal carcinoma. Cardiovasc Intervent Radiol. 1999;22:119–23.

    Article  PubMed  CAS  Google Scholar 

  46. Diana M, Hubner M, Vuilleumier H, et al. Redistribution of gastric blood flow by embolization of gastric arteries before esophagectomy. Ann Thorac Surg. 2011;91:1546–51.

    Article  PubMed  Google Scholar 

  47. Farran L, Miro M, Alba E, et al. Preoperative gastric conditioning in cervical gastroplasty. Dis Esophagus. 2011;24:205–10.

    Article  PubMed  Google Scholar 

  48. Nguyen NT, Nguyen XT, Reavis KM, et al. Minimally invasive esophagectomy with and without gastric ischemic conditioning. Surg Endosc. 2012;26:1637–41.

    Article  PubMed  Google Scholar 

  49. Perry KA, Enestvedt CK, Pham TH, et al. Esophageal replacement following gastric devascularization is safe, feasible, and may decrease anastomotic complications. J Gastrointest Surg. 2010;14:1069–73.

    Article  PubMed  Google Scholar 

  50. Berrisford RG, Veeramootoo D, Parameswaran R, et al. Laparoscopic ischaemic conditioning of the stomach may reduce gastric-conduit morbidity following total minimally invasive oesophagectomy. Eur J Cardiothorac Surg. 2009;36:888–93.

    Article  PubMed  Google Scholar 

  51. Veeramootoo D, Shore AC, Shields B, et al. Ischemic conditioning shows a time-dependent influence on the fate of the gastric conduit after minimally invasive esophagectomy. Surg Endosc. 2010;24:1126–31.

    Article  PubMed  Google Scholar 

  52. Wajed SA, Veeramootoo D, Shore AC. Surgical optimisation of the gastric conduit for minimally invasive oesophagectomy. Surg Endosc. 2012;26:271–6.

    Article  PubMed  Google Scholar 

  53. Zahedi M, Ganai S, Yetasook AK, et al. Laparoscopic ischemic conditioning as a modality to reduce gastric conduit morbidity following esophagectomy. Digestive Disease Week 2012; Poster presentation.

  54. Law S, Wong KH, Kwok KF, et al. Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg. 2004;240:791–800.

    Article  PubMed  Google Scholar 

  55. Marietter C, Taillier G, Van Seuningen I, et al. Factors affecting postoperative course and survival after en bloc resection for esophageal carcinoma. Ann Thorac Surg. 2004;78:1177–83.

    Article  Google Scholar 

  56. Noble F, Curtis N, Harris S, South Coast Cancer Collaboration-Oesophago-Gastric (SC-OG), et al. Risk assessment using a novel score to predict anastomotic leak and major complications after oesophageal resection. J Gastrointest Surg. 2012;16:1083–95.

    Article  PubMed  Google Scholar 

  57. Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg. 2004;10:71–5.

    PubMed  Google Scholar 

  58. Hulscher JB, Tijssen JG, Obertop H, et al. Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg. 2001;72:306–13.

    Article  PubMed  CAS  Google Scholar 

  59. Verhoef C, van der Weyer R, Schaapveld M, et al. Better survival in patients with esophageal cancer after surgical treatment in university hospitals: a plea for performance by surgical oncologists. Ann Surg Oncol. 2007;14:1678–87.

    Article  PubMed  Google Scholar 

  60. Markar SR, Karthikesalingam A, Vyas S, et al. Hand-sewn versus stapled oesophago-gastric anastomosis: systematic review and meta-analysis. J Gastrointest Surg. 2011;15(5):876–84.

    Article  PubMed  Google Scholar 

  61. Blencowe NS, Strong S, McNair AG, et al. Reporting of short-term clinical outcomes after esophagectomy: a systematic review. Ann Surg. 2012;255:658–66.

    Article  PubMed  Google Scholar 

  62. Carrott PW, Markar SR, Kuppusamy MK, et al. Accordian severity grading system: assessment of relationship between costs, length of hospital stay, and survival in patients with complications after esophagectomy for cancer. J Am Coll Surg. 2012;215(3):331–6.

    Article  PubMed  Google Scholar 

  63. Markar SR, Karthikesalingam A, Low DE. Outcomes assessment of the surgical management of esophageal cancer in younger and older patients. Ann Thorac Surg. 2012;94(5):1652–8.

    Article  PubMed  Google Scholar 

  64. Schroder W, Beckurts KT, Stahler D, et al. Microcirculatory changes associated with gastric tube formation in the pig. Eur Surg Res. 2002;34:411–7.

    Article  PubMed  CAS  Google Scholar 

  65. National Oesophago-Gastric Cancer Audit—The Royal College of Surgeons of England 2010.

  66. Luketich JD, Pennathur A, Awais O, et al. Outcomes after minimally invasive esophagectomy: review of over 1000 patients. Ann Surg. 2012;256(1):95–103.

    Article  PubMed  Google Scholar 

  67. Reavis KM, Chang EY, Hunter JG, Jobe BA. Utilization of the delay phenomenon improves blood flow and reduces collage deposition in esophagogastric anastomoses. Ann Surg. 2005;241:736–47.

    Article  PubMed  Google Scholar 

  68. Urschel JD, Antkowiak JG, Delacure MD, Takita H. Ischemic conditioning (delay phenomenon) improves esophagogastric anastomotic wound healing in the rat. J Surg Oncol. 1997;66:254–6.

    Article  PubMed  CAS  Google Scholar 

  69. Stiles BM, Mirza F, Coppolino A, et al. Clinical T2-T3N0MO esophageal cancer: the risk of node positive disease. Ann Thorac Surg. 2011;92(2):491–6.

    Article  PubMed  Google Scholar 

  70. Hamai Y, Hihara J, Emi M, et al. Esophageal reconstruction using the terminal ileum and right colon in esophageal cancer surgery. Surg Today. 2012;42(4):342–50.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Division of Surgery, Department of Surgery and Cancer, St Mary’s Hospital, Imperial College London, London, UK

    Sheraz R. Markar MRCS, MSc, MA, Shobhit Arya MRCS, BSc & George B. Hanna FRCS, PhD

  2. Department of Outcome Research, St George’s Vascular Institute, St George’s Hospital, London, UK

    Alan Karthikesalingam MRCS, MSc, MA, PhD

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  1. Sheraz R. Markar MRCS, MSc, MA
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Correspondence to Sheraz R. Markar MRCS, MSc, MA.

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Markar, S.R., Arya, S., Karthikesalingam, A. et al. Technical Factors that Affect Anastomotic Integrity Following Esophagectomy: Systematic Review and Meta-analysis. Ann Surg Oncol 20, 4274–4281 (2013). https://doi.org/10.1245/s10434-013-3189-x

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