Comparison of Stapled and Hand-sewn Esophagogastric Anastomoses

• Published in: The American journal of surgery Vol. 175; no. 4; pp. 337 - 340
• Main Authors: Beitler, Alan L, Urschel, John D
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.04.1998; Elsevier; Elsevier Limited
• Subjects: Anastomosis, Surgical - methods; Anastomosis, Surgical - mortality; Anastomotic leak; Bias; Biological and medical sciences; Clinical Trials as Topic; Comparative studies; Complications; Constriction, Pathologic - etiology; Data collection; Esophagus; Esophagus - pathology; Esophagus - surgery; Humans; Ischemia; Medical sciences; Morbidity; Mortality; Patients; Randomized Controlled Trials as Topic; Stomach; Stomach - pathology; Stomach - surgery; Stricture; Surgeons; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the digestive system; Surgical anastomosis; Suture Techniques - adverse effects; Human; Stomach; Manuals; Surgical anastomosis; Suturation; Esophagus; Result; Treatment; Surgery; Complication; Stapled suture; Technique; Comparative study; Bibliographic review
• ISSN: 0002-9610; 1879-1883
• DOI: 10.1016/S0002-9610(98)00002-6

Background: Esophagogastric anastomotic leaks continue to be a major source of morbidity and mortality after esophagectomy. Leaks usually result from technical errors or occult ischemia of the mobilized gastric fundus. The introduction of stapled esophagogastric anastomoses was initially very promising; leak rates appeared to be reduced. Data Sources: The English language medical literature was searched for publications comparing stapled and hand-sewn esophagogastric anastomoses. We reviewed data from four randomized trials and seven nonrandomized comparative studies to determine if stapling was superior to hand suturing for esophagogastric anastomoses. Results: Pooled data from randomized trials comparing stapled with hand-sewn esophagogastric anastomoses showed no significant difference for leaks (stapled 9%, hand-sewn 8%, P <0.67), but a higher incidence of strictures in stapled anastomoses (stapled 27%, hand-sewn 16%, P <0.02). In nonrandomized studies, stapled anastomoses had a lower leak rate (stapled 6%, hand-sewn 11%, P <0.0001), but strictures were more frequent (stapled 31%, hand-sewn 16%, P <0.0001). A major source of bias in the nonrandomized studies was the comparison of contemporary stapled experience and earlier hand-sewn experience. This bias was not present in three of seven nonrandomized studies that featured prospective data collection. Pooled data from these three studies showed no difference in anastomotic leak rate (stapled 4%, hand-sewn 6%, P <0.28). Conclusions: Stapled and hand-sewn esophagogastric anastomotic techniques have equivalent anastomotic leak rates, but strictures are more common in stapled anastomoses. Irrespective of which technique is used, surgical experience and meticulous attention to detail are required to prevent anastomotic complications. Anastomotic technical modifications alone are unlikely to eliminate the problem of leaks, since they do not address the problem of gastric fundal ischemia.