Technical Factors that Affect Anastomotic Integrity Following Esophagectomy: Systematic Review and Meta-analysis
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.
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.
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).
A tailored surgical approach to the patient’s physiology and esophageal cancer stage is the most important factor that influences anastomotic integrity after esophagectomy.
- 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.PubMedCrossRefGoogle 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.PubMedCrossRefGoogle 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.Google Scholar
- 65.National Oesophago-Gastric Cancer Audit—The Royal College of Surgeons of England 2010.Google Scholar