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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 2  |  Page : 61-66

Hand-sewn versus stapled cervical esophagogastric anastomosis for esophageal carcinoma: A study of postoperative clinical outcomes from a high-incidence center of northeast India


Department of Surgical Oncology, Dr. Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India

Date of Web Publication30-Dec-2019

Correspondence Address:
Dr. Hemish H Kania
House No. 29, First Floor, Indira Gandhi Path, Santipur, Bhalarumukh, Guwahati 781009, Assam.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jco.jco_14_19

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  Abstract 

Anastomotic leak from cervical esophagogastric anastomoses is a serious problem after esophagectomy. We explored the efficacy of partial or total mechanical anastomoses accomplished with the endoscopic linear cutting and stapling device as an alternative to hand-sewn anastomotic techniques. Along that we compared various clinical outcomes associated with the same.

Keywords: Cervical esophagogastric anastomosis, hand sewn, linear stapled


How to cite this article:
Purkayastha J, Kania HH, Talukdar A, Das G, Pegu N, Kalita D. Hand-sewn versus stapled cervical esophagogastric anastomosis for esophageal carcinoma: A study of postoperative clinical outcomes from a high-incidence center of northeast India. J Curr Oncol 2019;2:61-6

How to cite this URL:
Purkayastha J, Kania HH, Talukdar A, Das G, Pegu N, Kalita D. Hand-sewn versus stapled cervical esophagogastric anastomosis for esophageal carcinoma: A study of postoperative clinical outcomes from a high-incidence center of northeast India. J Curr Oncol [serial online] 2019 [cited 2020 Jun 2];2:61-6. Available from: http://www.journalofcurrentoncology.org/text.asp?2019/2/2/61/274299




  Introduction Top


Esophageal carcinoma (EC) is a multifaceted and complex disease of rapidly rising incidence that exerts an increasing social and financial burden on global health-care systems.[1],[2],[3] It has marked geographical variations, and the northeast part of India is one of the highest incidence areas. Approximately 800 new patients with EC attend our institute every year. Radical total esophagectomy is the standard treatment for EC. The most important factor of a successful surgery is a well-healed anastomosis without complications. Transthoracic esophagectomy (TTE) with gastric pull-up and neck anastomosis is the procedure followed in most high-volume centers. The technique of esophagogastric anastomosis (EGA) at the neck following esophagectomy is demanding and is closely correlated with the patient’s outcome because early complications, such as leakage, and late complications, such as stricture, cause significant morbidity and mortality.[4] EGA can be carried out either manually by sutures or by using surgical staplers. We hereby present our experience of 60 cases of EGA at neck for esophageal cancer comparing our recent experience of stapler anastomosis with retrospective hand-sewn (HS) anastomosis.


  Patients and Methods Top


All patients undergoing total esophagectomy with neck anastomosis between January 2013 and March 2019, were included in this study of surgical oncology at Dr. Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India, and they were evaluated from the retrospectively maintained database.

Operative technique

After preoperative preparation and planning, surgery was performed either through a transhiatal esophagectomy (THE) approach or through a right posteriolateral TTE [Table 1].
Table 1: Comparison of demographic and clinical preoperative profile in both groups

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The stomach was mobilized through midline abdominal incision, and gastric conduit was prepared based on the right gastroepiploic and right gastric vessels using linear cutter staplers. The esophagus was mobilized, isolated, and divided in the left lower neck. The stomach conduit was brought up into the neck through the posterior mediastinal route. The EGA was performed in the left lower neck by either HS with suture or linear cutter stapler.

Cervical esophagogastric anastomosis

Hand-sewn anastomosis

An end-to-side EGA was performed using single-layer full-thickness interrupted 3-0 absorbable polyglycolic acid suture. A Ryle’s tube was passed into the gastric conduit for decompression of the conduit. Appropriate site was selected on the anterior wall of the gastric conduit away from the stapled line and approximately 3cm below the highest point of the organ to ensure good vascularity.

Stapled anastomosis

A side-to-side anastomosis was performed in the neck using endo linear cutter stapler of 45 mm size blue cartridge. An opening was made in the posterior wall of the pulled up stomach conduit 2cm away from the suture line. The two limbs of linear cutter stapler were placed inside this opening in stomach and inside the cut open proximal remnant esophagus, and the posterior layer of anastomosis was conducted longitudinally by firing the stapler [Figure 1]. A Ryle’s tube was then passed inside the stomach conduit for postoperative stomach decompression. The anterior layer of anastomosis was performed by firing similar linear cutter stapler transversely, thus opposing the stomach and esophagus [Figure 2]. The anterior staple line was buried by placing a few seromuscular sutures.
Figure 1: Vertical limb anastomosis stapled anastomosis

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Figure 2: (A) Vercical limb of stapled anastomosis (end to end) (B) Alining the tissue (C) Horizontal limb (D) After anastomosis

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Postoperative management

All the patients could be extubated immediately after surgery, and they were managed in the postoperative recovery room. Jejunostomy feeding was started 6h after surgery and was well tolerated in all the patients. If the patients recovered well with proper wound healing and no evidence of any leak then oral liquids were started from the seventh postoperative day. Oral feeding was gradually increased, whereas jejunostomy feeding was decreased till the patient was on full oral feeding by the third postoperative week. If there was evidence of any leak then the cervical wound was opened for external drainage, and jejunostomy feeding was continued till the leak closed.

Outcome measures

The primary outcome measure was anastomotic leak. The secondary outcome measures included operative time, anastomotic time, blood loss, occurrence of anastomotic stricture, and other parameters related to postoperative management such as mean intensive care unit (ICU) stay, day of ambulation, removal of intercostal drainage tubes, day of starting of feeding jejunostomy and oral feeds, and mean hospital stay. Leaks were labeled “minor” when the leak was minimal, healed spontaneously without stoppage of oral feeding, and without prolonging the hospital stay beyond 14 days. All leaks causing neck wound dehiscence, copious discharge of saliva or refluxed bile, requiring stoppage of oral feeding, and prolongation of hospital stay beyond 14 days were labeled “major.” Anastomotic stricture was defined as anastomotic narrowing, requiring dilatation to relieve postoperative dysphagia, or failure to pass the esophagoscope through the anastomosis.

Statistical analysis

Continuous variables were reported as mean with standard deviation. Categorical variables were reported as proportions. Student’s t test and Fisher exact test were used, where appropriate, for comparison between groups. A P value of 0.05 or less was regarded as significant. All calculations were performed with the Statistical Package for the Social Sciences (SPSS, Chicago, Illinois) program.


  Results Top


Seventy patients were operated for esophagectomy from January 2013 to May 2018, at Dr. Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, India. Of these 70 patients, four underwent Ivor Lewis type of esophagectomy, three were inoperable, and three underwent esophagectomy with total gastrectomy with esophagojejunostomy. Hence, these 10 patients were excluded from the study.

Remaining 60 patients underwent cervical esophagogastric anastomosis (CEGA); 45 patients of these 60 underwent HS anastomosis (Group A) and 15 underwent linear stapled (LS) type of anastomosis (Group B) (we introduced this method after January 2016). The two groups were comparable in terms of demographic and preoperative clinical profile as per [Table 1].

[Table 2] shows various clinical outcomes in tabulated form and [Table 3] shows the adjuvant treatment given.
Table 2: Assessment of various postoperative outcomes

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Table 3: Adjuvant treatment

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Operative time

The overall mean operative time in HS and LS groups was 285 and 330min, respectively. P value was 0.227, which was statistically not significant.

Anastomotic time

Anastomotic time in HS and LS groups was 34.3 and 15.4min, respectively. P value was statistically significant at <0.0001.

Blood loss

Blood loss in HS and LS groups was 362 and 360mL, respectively. P value was not statistically significant at 0.924.

Intercostal drainage tube removal time

The mean removal time of left intercostal drainage tube (ITCD) in HS and LS groups was 8.52 and 7.13 days, respectively, with a statistically significant P value of 0.037.

The mean removal time of right ITCD in HS and LS groups was 9.90 and 9.46 days, respectively, with P value statistically not significant at 0.672.

Time of first ambulation

The mean time in HS and LS groups came out to be 4.35 and 3.2 days, with a statistically significant P value of 0.047.

Intensive care unit stay

The mean ICU stay in HS and LS groups was 4.25 and 2.8 days, with a statistically significant P value of 0.041.

Time of starting postoperative feeds

The mean time of starting postoperative FJ feed in HS and LS groups was 2.84 and 2.13 days, which was statistically significant at a P value of 0.045.

The mean time of starting oral feed in HS and LS groups was 11.16 and 8.07 days, which was statistically significant at a P value of 0.047. It may be because in HS group, there were eight cases of anastomotic leak, which caused the delay in starting oral feed, whereas there was no case of anastomotic leak in LS group.

Anastomotic leak

There were eight cases of anastomotic leak in HS group (six were minor that were managed conservatively and two were major). Both patients with major leak had serobilliary discharge from ITCD and developed mediastinitis for which they were treated but patients succumbed on post operative day (POD)7 and POD9, respectively. No cases of leak in LS group were observed. P value was 0.042, which was statistically significant.

Anastomotic stricture

One of 14 patients in LS group and 8 of 42 patients in HS group developed stricture. P value was 0.043, which was statistically significant.

Mean hospital stay

In HS group, the mean hospital stay was 23.1 days, and in LS group, it was 16.6 days, with a statistically significant P value of 0.007.

Mean postoperative stay

In HS group, the mean postoperative stay was 17.5 days, and in LS group, it was 12.9 days, with a statistically significant P value of 0.004.

Cost

Average of six polydioxanone sutures was used for anastomosis in HS group with average cost of around 1500 INR to patient. In LS group with two Endo GIA, 45 cartridges were used, the cost was between 12,000 and 14,000 INR.

Morbidity

In HS group, six patients had minor leak, one had burst abdomen, four had neck wound dehiscence, two had prolonged nausea and vomiting, eight had hoarseness in voice, and eight had anastomotic stricture (n = 6).

In LS group, two patients had hoarseness, one with neck wound dehiscence, two with midline wound discharge, and one patient had anastomotic stricture (n = 4).

Mortality

Four patients in HS group succumbed, one patient with major leak developed mediastinitis and died on POD7, two patients with respiratory distress, who were given intensive support and ventilated, died on POD8 and POD9, respectively. One patient who developed hemorrhagic shock 2 months after discharge from hospital and who was on adjuvant treatment succumbed.

One patient in LS group died of respiratory distress on POD8.

Recurrence

Four patients in HS group developed anastomotic site recurrence 1 year after treatment completion for which they were given palliative treatment, whereas one patient developed left-sided neck recurrence 4 months after surgery for which radical neck dissection was carried out.


  Discussion Top


A well-healed anastomosis is the mainstay of the successful outcome of esophageal surgery. HS anastomosis has been the standard of care since the inception of esophageal surgery. Many different techniques of HS anastomosis have been described. Problems of anastomotic leaks and strictures were the main complications of esophageal surgery. As anastomosis technology progressed, the success rate increased, and when LS was developed, the success rates were even higher. LS anastomosis was first described by Collard et al.[5] in 1998 and modified by Orringer et al.,[6] who performed side-to-side EGA with a small linear stapler LS anastomosis or with a side-to-side orientation, which improved the postoperative outcomes after EGA.

The aim of this study was to compare the main clinical outcomes following LS and HS EGA, including the rates of anastomotic leakage and stricture. Many local and systemic factors, such as the absence of serosa and longitudinal orientation of muscle fibers, influence the process of wound healing and incidence of anastomotic leakage. Among these factors, the surgical anastomotic technique remains an important variable that can be modified.

Compared with HS, LS EGA has a lower rate of anastomosis leakage for several possible reasons: (1) the stapled anastomoses are considered to be more expedient and less traumatic to tissues, (2) the lateral stay sutures allow for reduced tension on the anastomosis without compromising gastric conduit microcirculation, and (3) LS provides triple-layered staple construction that is less traumatic and more watertight than HS. It has been reported that the incidence of EGA leakage with the LS technique in cervical anastomosis varies between 15% and 25%, which is more frequent than that in thoracic anastomosis.[7],[8]] Therefore, the superiority of the LS technique in reducing the rate of leakage is more substantial in cervical anastomosis than that in thoracic anastomosis.

The reasons why stricture rate was more common with the stapled method in previous literature include the following: (1) lack of accurate mucosa‑to‑mucosa apposition when performing anastomosis; (2) tissue necrosis beyond the stapled line, inflammation, and delayed epithelialization may predispose to excessive fibrosis and stricture formation; and (3) circumferentially placed absorbable metal staples do not allow the lumen to dilate beyond the size obtained originally.

Urschel[9] compared manual anastomoses with mechanical anastomoses in a meta‑analysis and found that the risks for anastomotic leakage were comparable but that mechanical EGA caused more stenosis than manual anastomosis. Esophageal anastomotic leak is among the leading causes of perioperative morbidity and mortality after an esophagectomy.

In 1984, Steichen[10] reviewed the varieties of stapled esophageal anastomoses available at the time. He suggested the use of a GIA stapler for an end‑to‑side anastomosis either in the chest or lower neck. This technique, however, did not gain widespread popularity. Therefore, it is necessary to develop a new anastomotic technique.

A new partially stapled anastomosis was described by Collard and modified by Orringer. It has the advantages of reducing the incidence of leaks and stenosis.

Orringer et al. performed a side‑to‑side stapled CEGA in 114 patients with EC; the rate of anastomotic leakage was 2.7% and the rate of anastomotic stricture was 12%.

In terms of anastomotic stricture, as per their literature, LS is superior to HS (relative risk = 0.54, 95% confidence interval (CI): 0.47–0.63; P < 0.00001). This trend was consistent in all subgroup analyses, and the between-study heterogeneity was found to be less. Such results are possible because LS anastomosis provides a larger cross-sectional area of esophagogastrostomy, which could reduce strictures and the subsequent need for later dilatation.

It is believed that subsequent gastroesophageal reflux is decreased if the end of cervical esophagus is anastomosed to gastric wall in neck, several centimeters below the tip of stomach, as an end-to-side anastomosis.

Our study also has shown less rate of anastomotic stricture (one case as opposed to eight cases in HS) (7.14% as opposed to 17.74%), and no cases of anastomotic leak were observed in LS group.

Limitations of the technique

The LS anastomosis has some drawbacks. This technique needs a longer esophageal remnant. Therefore, patients with tumor located at the upper third of the esophagus might not be appropriate for this technique. This limitation is also applicable in other stapling techniques using LS.

Limitations of the study

This study also had some limitations including inadequate follow‑up; six patients had a follow‑up of 6–9 months. We recognized that the strength of the study would be improved with a longer follow‑up. However, we considered that most dysphagia and anastomotic strictures related to the anastomotic technique would occur within the initial 3 months after the operation. By that time, we might obtain an effective comparison. After 3 months, other influencing factors such as adjuvant radiation might play a role and impair the comparison, more patients would be lost to follow‑up, some patients would undergo postoperative radio or chemotherapy, whereas some may die. Therefore, unbiased long-term comparison is difficult.


  Conclusion Top


  • LS anastomotic technique for esophagogastric anastomoses in esophagectomy for cancer indicates that the new technique lowers anastomotic leakage and stricture rates compared to traditionally used HS techniques.

  • Furthermore, the application of the LS technique is usually easy and standardized such that the incidence of technical errors is minimized.


  • Use of staplers decreased the mean anastomotic time.

  • The incidence of anastomotic leakage and stricture decreased, which indirectly reduced the mean ICU stay, hospital stay, and early supplementation of feeding to the patient, which decreased the overall morbidity of the patient.


  • The use of stapler, however, has shown no decrease or increase in blood loss and surgical time, but decreased the anastomotic, pulmonary complications, and mortality.


  • The LS EGA is a safe and effective anastomotic technique, which can decrease the rate of leak and postoperative dysphagia.


  • In contrast, the HS method requires surgical expertise and may not be practical everywhere; therefore, we should preferentially use LS over the HS method.

    Declaration of patient consent

    The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

    Financial support and sponsorship

    Nil.

    Conflicts of interest

    There are no conflicts of interest.



     
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    Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg 2000;119:277-88.  Back to cited text no. 6
        
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    Markar SR, Karthikesalingam A, Vyas S, Hashemi M, Winslet M. Hand-sewn versus stapled oesophago-gastric anastomosis: Systematic review and meta-analysis. J Gastrointest Surg 2011;15:876-84.  Back to cited text no. 7
        
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    Rizk NP, Bach PB, Schrag D, Bains MS, Turnbull AD, Karpeh M, et al. The impact of complications on outcomes after resection for esophageal and gastroesophageal junction carcinoma. J Am Coll Surg 2004;198:42-50.  Back to cited text no. 8
        
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        Figures

      [Figure 1], [Figure 2]
     
     
        Tables

      [Table 1], [Table 2], [Table 3]



     

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