^1,2Assistant Professor, Department of General Surgery, Kakatiya Medical College, Warangal, Telangana State,

Email: poojarykishorekumar1978@gmail.com

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.

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