Table of Content - Volume 19 Issue 3 - September 2021
Study of completely linear stapled versus handsewn cervical esophagogastric anastomosis after esophagectomy at a tertiary hospital
Kishore Kumar Pujari1*, Koduru Naveen Kumar2
1,2Assistant Professor, Department of General Surgery, Kakatiya Medical College, Warangal, Telangana State,
Abstract Background: Among various surgical procedures and nonsurgical palliative approaches, the current standard for the management of esophageal cancer is esophagectomy. An important requirement therefore is to choose a surgical procedure that can accurately and effectively prevent and reduce post-anastomotic complications. Present retrospective study of database from our institute was aimed to compare linearly stapled (LS) anastomosis versus handsewn (HS) cervical esophagogastric anastomosis. Material and Methods: Present study was single-center, retrospective, comparative, study of patients underwent esophagectomy with cervical esophagogastric anastomosis (CEGA), followed up for a minimum of 12 months post-surgery or till death of the patient. Results: In present retrospective study of database, 20 patients underwent linearly stapled (LS) anastomosis while 27 patients underwent handsewn (HS) anastomosis cervical esophagogastric anastomosis. We noted statistically significant difference Operative findings such as Operation time (210.46 ± 72.33 min vs 241.55 ± 49.31 min, p=0.031), Anastomotic time (32.2 ± 13.6 min vs 49.1 ± 10.9 min p=0.001) and 90-day mortality (5 % vs 11.11 %, p=0.001). While blood loss (ml), mean transfusions received (no. of units), hospital stay (days) and ICU stay (days) were comparable in both groups and difference was not significant statistically. Postoperative complications such as anastomotic leakage (minor/major), wound infection, pneumonia, pleural effusion, pneumothorax, RLN injury, anastomotic stricture followed by leak, pathologic positive margin, tracheal injury, conduit necrosis were more in handsewn group as compared to linearly stapled (LS) anastomosis group and difference was statistically significant. Conclusion: In linearly stapled (LS) anastomosis group less operative time, 90 days mortality, anastomotic leak, anastomotic stricture followed by leak and other complications were noted as compared to handsewn (HS) cervical esophagogastric anastomosis. Keywords: Linear stapled, esophagogastric anastomosis, Handsewn cervical anastomosis, anastomotic leaks
INTRODUCTION Esophageal cancer is sixth leading cause of mortality among cancers.1 Among various surgical procedures and nonsurgical palliative approaches, the current standard for the management of esophageal cancer is esophagectomy.2,3 Esophagectomy is one of the most technically challenging and potentially morbid procedures in thoracic surgery. Goals of esophagectomy include resection of the diseased esophagus with negative margins, an adequate lymphadenectomy, and restoration of gastrointestinal continuity. Restoration of gastrointestinal continuity is most commonly accomplished using the stomach with an esophagogastric anastomosis for esophageal reconstruction. Overall 5-year survival rates as high as 30-40% have been reported after resection with curative intent.4 Esophagogastric anastomosis, including the popular variants hand-sewn and stapled anastomoses, is the most critical procedure during esophagectomy.5,6 It is widely accepted that surgery offers the best form of palliation but the quality of palliation is commonly jeopardized by anastomotic complications e.g., anastomotic leaks. An important requirement therefore is to choose a surgical procedure that can accurately and effectively prevent and reduce post-anastomotic complications. Present retrospective study of database from our institute was aimed to compare linearly stapled (LS) anastomosis versus handsewn (HS) cervical esophagogastric anastomosis.
MATERIAL AND METHODS Present study was single-center, retrospective, comparative, study of patient database maintained prospectively in Department of Gastrointestinal Surgery, at MGM Hospital, Warangal, India. Study duration was of 2 years (July 2018 to June 2019). Study was approved by institutional ethical committee. Inclusion criteria: Patients underwent esophagectomy with cervical esophagogastric anastomosis (CEGA), followed up for a minimum of 12 months post-surgery or till death of the patient. Exclusion criteria: Patients with locally advanced unresectable disease, inoperable cases, metastatic disease. Patients with upper third esophagus tumors, patients required esophagectomy with intrathoracic anastomosis/ total gastrectomy with intra-abdominal anastomosis were excluded. Patients lost to follow up. Demographic details, clinical history, examination findings, routine laboratory/radiological investigations (upper gastrointestinal endoscopy and biopsy, CECT scan from the neck to the pelvis, PET scan, bronchoscopy) were noted. Surgeries were performed either through a transhiatal approach or through a right posterior thoracotomy. The gastric conduit based on the right gastric and right gastroepiploic vessels was constructed using a linear cutter stapler along the lesser curvature. The stomach was brought up into the left side of the neck through posterior mediastinal route. The CEGA was done either by a partial side-to-side stapled technique (EZ45 Endoscopic Linear Cutter, Endopath, EndoGIA, Ethicon surgical, Delhi) or end-to-side hand-sewn technique using single layer interrupted 3-0 vicryl suture. All the patients were followed up for a minimum of 12 months post-surgery or till death of the patient. The surgical procedure details, operating time, blood loss, post operative complications (SSI, Anastomotic leak, Anastomotic stricture, anastomotic recurrence), duration of hospital stay and operative mortality (died within 30 days of the procedure or during the same hospital admission) were noted. Data was collected and compiled using Microsoft Excel, analysed using SPSS 23.0 version. Frequency, percentage, means and standard deviations (SD) was calculated for the continuous variables, while ratios and proportions were calculated for the categorical variables. Difference of proportions between qualitative variables were tested using chi- square test or Fisher exact test as applicable. P value less than 0.5 was considered as statistically significant.
RESULTS In present retrospective study of database, 20 patients underwent linearly stapled (LS) anastomosis while 27 patients underwent handsewn (HS) anastomosis cervical esophagogastric anastomosis. General characteristics such as mean age, gender (male/female) and disease (benign/malignant) were comparable in both groups and difference was not significant statistically.
Table 1: General Characteristics
we noted statistically significant difference Operative findings such as Operation time (210.46 ± 72.33 min vs 241.55 ± 49.31 min, p=0.031), Anastomotic time (32.2 ± 13.6 min vs 49.1 ± 10.9 min p=0.001) and 90-day mortality (5 % vs 11.11 %, p=0.001). While blood loss (ml), mean transfusions received (no. of units), hospital stay (days) and ICU stay (days) were comparable in both groups and difference was not significant statistically. Postoperative complications such as anastomotic leakage (minor/major), wound infection, pneumonia, pleural effusion, pneumothorax, RLN injury, anastomotic stricture followed by leak, pathologic positive margin, tracheal injury, conduit necrosis were more in handsewn group as compared to linearly stapled (LS) anastomosis group and difference was statistically significant. Table 2: Operative and postoperative findings
DISCUSSION Esophagectomy is a major surgery that has both a high morbidity rate (60%) and mortality rate, which may reach 26.7%, mainly due to pulmonary complications, cervical fistulas, stenosis of anastomosis, necrosis of the tubularized stomach, and mediastinitis.7 Generally, handsewn techniques are often preferred when creating a cervical anastomosis as the length of the conduit may prohibit use of a mechanical stapler. Conversely, creation of an intrathoracic handsewn anastomosis requires considerable technical skill and is often time-consuming, thus a stapled technique is most often utilized.8,9 A linear stapled anastomosis is most commonly performed using a 30- or 45-mm gastrointestinal anastomosis (GIA) stapler, which places a triple staggered row of titanium staples to create a side-to-side anastomosis.10,11 In the review by Price et al.,12 with 83 LS and 14 HS anastomosis they noted increased odds for leak with handsewn anastomosis compared to fully stapled anastomosis i.e. 64.3% vs. 13.2% (p = 0.001). They noted a non-significant difference in stricture rates between HS and LS anastomoses (35.1 vs. 21.5%, p = 0.92), with the fully stapled cohort having a lower stricture rate. Mishra PK et al.,8 studied 140 patients underwent esophagectomy with cervical esophagogastric anastomosis. 66 patients underwent a hand sewn anastomosis and 74 patients had a side-to-side stapled anastomosis fashioned. The overall morbidity and mortality was 32.8% and 6.4%, respectively. Overall leak rate was 17%. There was no difference in the leak rates among two groups (12 in the hand-sewn group and 12 in the Stapled group; p ¼ 0.82). The rate of anastomotic stricture was significantly higher for the hand sewn group (16.1% vs 4.3%; p ¼ 0.03) at median follow up of 30 months. They concluded that both hand sewn and stapled anastomotic techniques are equally effective way of performing a cervical esophagogastric anastomosis. However, patients having anastomotic leak develop anastomotic stricture more often in those having hand-sewn anastomosis compared to stapled anastomosis. Similar findings were noted in present study. Kumar T et al.,13 conducted a comparative study of 77 patients who underwent LS (n = 29) and HS (n = 48) cervical anastomosis. Anastomotic leak was found to be 19.4%. 27.08% and 6.89% in the HS group, and LS group respectively (p=0.03). 52.1% patients in the HS group were discharged within 14 days of surgery; whereas; 93.1% were discharged in LS group (p = 0.001). Overall, 90-day mortality was 7.8%. In the HS group, 8.3% patients died while in the LS group, 6.8% patients died (p = 0.82). In the HS group, 6.25% patients were diagnosed with stricture compared to 6.8% patients in the LS group (p = 0.9). Overall stricture rate was 6.4% (5/77). Cervical anastomosis done with linear staplers has less leak rates compared to handsewn anastomosis. In an Iranian study by Seyed ZR et al.,14 hand-sewn anastomosis was carried out in 271 (62.5%) patients, whereas stapled anastomosis was performed in 162 (37.4%) patients. The mean operative times were 214.46 ± 84.33 min and 250.55 ± 43.31 min for the stapled and hand-sewn anastomosis groups, respectively (P = 0.028). The two groups showed no significant differences with respect to stays in intensive care units and hospitals. Postoperatively, 38 (14.67%) cases of anastomotic leakage were detected in the hand-sewn anastomosis group, with incidence being significantly higher than that in the stapled anastomosis group (5.33%; P = 0.002). Anastomotic stricture occurred less frequently in the patients who underwent stapled anastomosis (P = 0.004). Within the one-year follow-up period, the patients treated via hand-sewn anastomosis more frequently required anastomotic dilatation (P = 0.02). Side-to-side stapled cervical esophagogastric anastomosis may reduce operation times and decrease the rates of anastomotic leakage, anastomotic stricture, and anastomotic dilatation in patients with lower thoracic esophageal cancer undergoing transhiatal esophagectomy. In a comparative study by Xu QR et al.,15 in patients undergoing linear stapled (LS group, n=166), conventional hand-sewn (HS group, n=59), or circular stapled intrathoracic esophagogastric anastomosis (CS group, n=68), operative complications were documented in 15 patients (5.1%), with no difference among three groups (χ2=2.215, P=0.330). The anastomotic diameter was 1.6±0.4 cm in the LS group, 1.2± 0.3 cm in the HS group, and 1.0±0.4 cm in the CS group, respectively (F=58.110, P<0.001). The anastomotic stricture rates were 1.9% (3/162) in the LS group, 9.3% (5/54) in the HS group, and 20.9% (14/67) in the CS group, respectively (χ2=24.095, P<0.001). The reflux score in LS group was lower than other two groups (H=6.995, P=0.030). The linear stapled esophagogastrostomy could decrease anastomotic stricture without increasing gastroesophageal reflux. Manometric studies on the two techniques of anastomosis showed that the mean diameter of anastomosis in the handsewn group was 1.67 and 1.70 cm in patients with and without dysphagia respectively. These dimensions were 3 and 3.014 cm for the stapled group with and without dysphagia respectively.16 The accurate mucosa-to-mucosa apposition, considered important for good anastomotic healing was achieved preferably in the manually sutured anastomosis. Earlier high stricture rate (40%) for circular stapled intrathoracic esophagogastric anastomosis was reported, presumably explained by wound contraction in the annular incision effected by the circular knife of the stapler that cuts through the anastomotic tissue.17 However, no such findings were reported in later studies. In a Circular stapled anastomosis, the anastomosis cannot be dilated beyond the stapled line, and the staples can damage the endoscopic balloon dilator.18 Whereas, Linear cutting stapler side to side anastomosis is wide, conical, and less prone to leak. It is also a quick and easy technique to learn.
CONCLUSION In linearly stapled (LS) anastomosis group less operative time, 90 days mortality, anastomotic leak, anastomotic stricture followed by leak and other complications were noted as compared to handsewn (HS) cervical esophagogastric anastomosis. Further large sample studies in various cancer stages are required to confirm results.
REFERENCES
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