Efficacy and Safety of Intrathoracic Anastomosis vs. Cervical Anastomosis after Esophagectomy Using Gastric Tube: A Meta-Analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 QIANKun-jie , LIDe-sheng , JULAITIAiniwaer , YOUZhao-lei , YILIYAERXiaheding ,  ZHANGLi-wei

Department of Thoracic Surgery, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;

Corresponding?author：

ZHANGLi-wei, Email: zhangliwei@medmail.com.cn

Keywords：

Esophageal; Cervical anastomosis; Intrathoracic anastomosis; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.20150143

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Objective To systematically review the efficacy and safety between intrathoracic anastomosis (IA) and cervical anastomosis (CA) after esophagectomy using gastric tube. Methods We electronically searched databases including PubMed, EMbase, The Cochrane Library (Issue 11, 2014), Web of Knowledge, CNKI, CBM, and WanFang Data for randomized controlled trials (RCTs) of IA vs. CA after esophagectomy using gastric tube from inception to Nov, 2014. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed by RevMan 5.2 software. Results A total of 10 RCTs involving 1 138 patients were included, of which, 570 patients were in the IA group and the other 568 patients were in the CA group. The results of meta-analysis showed that the incidences of anastomotic leak (RR=2.72, 95%CI 1.67 to 4.45, P<0.05) and injury of recurrent laryngeal nerve (RR=5.64, 95%CI 2.41 to 13.18, P<0.05) in the IA group were significantly lower than those in the CA group, but the IA group had a higher rate of positive margins (RR=0.25, 95%CI 0.09 to 0.67, P<0.05). There were no significant differences between two groups in postoperative anastomotic stricture (RR=1.12, 95%CI 0.73 to 1.74), pulmonary complications (RR=1.10, 95%CI 0.60 to 2.01), operation mortality (RR=1.03, 95%CI 0.55 to 1.94), tumor recurrence (RR=1.57, 95%CI 0.72 to 3.44) and chylothorax (RR=0.76, 95%CI 0.24 to 2.36). Conclusion IA after esophagectomy using gastric tube has lower rates of anastomotic leak and injury of recurrent laryngeal nerve than CA but with a higher rate of positive margins. There are no significant differences between the two surgical operations in operation mortality, postoperative anastomotic stricture and pulmonary complications. IA could reduce the incidence of postoperative complications and is an effective and safe surgical operation for digestive tract reconstruction after esophagectomy. Due to limited quality and quantity of included studies, more high quality studies are needed to verify the conclusion for long-term efficacy and the quality of life.

Citation： QIANKun-jie, LIDe-sheng, JULAITIAiniwaer, YOUZhao-lei, YILIYAERXiaheding, ZHANGLi-wei. Efficacy and Safety of Intrathoracic Anastomosis vs. Cervical Anastomosis after Esophagectomy Using Gastric Tube: A Meta-Analysis. Chinese Journal of Evidence-Based Medicine, 2015, 15(7): 847-854. doi: 10.7507/1672-2531.20150143 Copy

1.	Enzinger PC,Mayer RJ.Esophageal cancer.N Engl Med,2003,349(23):2241-2252.
2.	Wu PC,Posner MC.The role of surgery in the management of oesophageal cancer.Lancet Oncol,2003,4(8):481-488.
3.	Urschel JD.Esophagogastrostomy anastomotic leaks complicating esophagectomy:a review.Am J Surg,1995,169(6):634-640.
4.	Lam TC,Fok M,Cheng SW,et al.Anastomotic complications after esophagectomy for cancer.A comparison of neck and chest anastomoses.J Thorac CardiovascSurg,1992,104(2):395-400.
5.	Muller JM,Erasmi H,Stelzner M,et al.Surgical therapy of oesophageal carcinoma.Br J Surg,1990,77(8):845-857.
6.	Patil PK,Patel SG,Mistry RC,et al.Cancer of the esophagus:esophagogastric anastomotic leak--a retrospective study of predisposing factors.J Surg Oncol,1992,49(3):163-167.
7.	Walther B,Johansson J,Johnsson 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):803-812.
8.	Ribet M,Debrueres B,Lecomte-Houcke M.Resection for advanced cancer of the thoracic esophagus:cervical or thoracic anastomosis? Late results of a prospective randomized study.J Thorac Cardiovasc Surg,1992,103(4):784-789.
9.	Okuyama M,Motoyama S,Suzuki H,et al.Hand-sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer:a prospective randomized controlled study.Surg Today,2007,37(11):947-952.
10.	Chasseray VM,Kiroff GK,et al.Cervical or thoracic anastomosis for esophagectomy for carcinoma.Surg Gynecol Obstet,1989,169(1):55-62.
11.	張利民,郭洪波,張百江,等.中段食管癌切除弓上機械吻合與頸部手工吻合的對比.全國食管癌診斷與治療新技術研討會論文集,2006.
12.	彭叢兄,周耀洪,吳旭輝,等.老年人中下段食管癌切除術兩種吻合方式的臨床療效比較.中國基層醫藥,2014,21(11):1708-1709.
13.	胡晨虎,趙堂海,孫麗娟,等.中段食管癌切除后不同吻合部位的比較.中國癌癥雜志,2000,10(6):572.
14.	金文波,張向華,祁彥君,等.中上段食管癌超胸項吻合與頸部吻合療效對比分析.中國現代醫學雜志,2003,13(16):117-118.
15.	王慶淮,吳勛寧,譚寧,等.107例食管癌手術治療體會.海南醫學,2010,21(19):74-76.
16.	王德昌.食管癌根治術42例臨床分析.醫藥論壇雜志,2014,35(9):125-126.
17.	安豐山,黃金球,陳少湖,等.217例胸段食管癌淋巴結轉移及其對預后影響的分析.癌癥,2003,22(9):974-978.
18.	邵令方,高宗人,衛功銓,等.食管癌和賁門癌外科治療進展——107例資料分析.中華胸心血管外科雜志,1994,10(1):41-43.
19.	Dewar L,Gelfand G,Finley RJ,et al.Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition.Am J Surg,1992,163(5):484-489.
20.	Fok M,Law S,Stipa F,et al.A comparison of transhiatal and transthoracic resection for oesophageal carcinoma.Endoscopy,1993,25(9):660-663.
21.	Blewett CJ,Miller JD,Young JE,et al.Anastomotic leaks after esophagectomy for esophageal cancer:a comparison of thoracic and cervical anastomoses.Ann Thorac Cardiovasc Surg,2001,7(2):75-78.
22.	22劉彥中,李東峰.胸段食管癌切除食管胃胸內吻合與頸部吻合的臨床分析.中國腫瘤臨床與康復,2010,4(17):137-139.
23.	Vigneswaran WT,Trastek VF,Pairolero PC,et al.Transhiatal esophagectomy for carcinoma of the esophagus.Ann Thorac Surg,1993,56(4):838-844;discussion 844-846.
24.	Reavis KM.The esophageal anastomosis:how improving blood supply affects leak rate.J Gastrointest Surg,2009,13(9):1558-1560.
25.	Pierie JPEN,de Graaf PW,Vroonhoven TJ,et al.Impaired healing of extraperitoneal intestinal anastomoses.Br J Surg,1999,86(5):680-684.
26.	Cooke DT,Lin GC,Lau CL,et al.Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy:risk factors,presentation,and detection.Ann Thorac Surg,2009,88(1):177-84;discussion 184-185.
27.	Hulscher JBF,van Sandick JW,Devriese PP,et al.Vocal cord paralysis after subtotal oesophagectomy.Br J Surg,1999,86(12):1583-1587.
28.	Charles TB,Thomas F,Tolutope O,et al.Impact of the surgical technique on pulmonary morbidity after esophagectomy.Ann Thorac Surg,2012,93(1):221-227.
29.	Dresner SM,Lamb PJ,Wayman J,et al.Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy:risk factors and management.Br J Surg,2000,87(3):362-373.
30.	Honkoop P,Siersema PD,Tilanus HW,et al.Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy:risk factors and management.J Thorac Cardiovasc Surg,1996,111(6):1141-1146.
31.	Rice TW.Anastomotic stricture complicating esophagectomy.Thorac Surg Clin,2006,16(1):63-73.
32.	Neil H,Aditya G,Christy M,et al.Esophagectomies with thoracic incisions carry increased pulmonary morbidity.JAMA Surgery,2013,148(8):733-739.

1. Enzinger PC,Mayer RJ.Esophageal cancer.N Engl Med,2003,349(23):2241-2252.
2. Wu PC,Posner MC.The role of surgery in the management of oesophageal cancer.Lancet Oncol,2003,4(8):481-488.
3. Urschel JD.Esophagogastrostomy anastomotic leaks complicating esophagectomy:a review.Am J Surg,1995,169(6):634-640.
4. Lam TC,Fok M,Cheng SW,et al.Anastomotic complications after esophagectomy for cancer.A comparison of neck and chest anastomoses.J Thorac CardiovascSurg,1992,104(2):395-400.
5. Muller JM,Erasmi H,Stelzner M,et al.Surgical therapy of oesophageal carcinoma.Br J Surg,1990,77(8):845-857.
6. Patil PK,Patel SG,Mistry RC,et al.Cancer of the esophagus:esophagogastric anastomotic leak--a retrospective study of predisposing factors.J Surg Oncol,1992,49(3):163-167.
7. Walther B,Johansson J,Johnsson 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):803-812.
8. Ribet M,Debrueres B,Lecomte-Houcke M.Resection for advanced cancer of the thoracic esophagus:cervical or thoracic anastomosis? Late results of a prospective randomized study.J Thorac Cardiovasc Surg,1992,103(4):784-789.
9. Okuyama M,Motoyama S,Suzuki H,et al.Hand-sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer:a prospective randomized controlled study.Surg Today,2007,37(11):947-952.
10. Chasseray VM,Kiroff GK,et al.Cervical or thoracic anastomosis for esophagectomy for carcinoma.Surg Gynecol Obstet,1989,169(1):55-62.
11. 張利民,郭洪波,張百江,等.中段食管癌切除弓上機械吻合與頸部手工吻合的對比.全國食管癌診斷與治療新技術研討會論文集,2006.
12. 彭叢兄,周耀洪,吳旭輝,等.老年人中下段食管癌切除術兩種吻合方式的臨床療效比較.中國基層醫藥,2014,21(11):1708-1709.
13. 胡晨虎,趙堂海,孫麗娟,等.中段食管癌切除后不同吻合部位的比較.中國癌癥雜志,2000,10(6):572.
14. 金文波,張向華,祁彥君,等.中上段食管癌超胸項吻合與頸部吻合療效對比分析.中國現代醫學雜志,2003,13(16):117-118.
15. 王慶淮,吳勛寧,譚寧,等.107例食管癌手術治療體會.海南醫學,2010,21(19):74-76.
16. 王德昌.食管癌根治術42例臨床分析.醫藥論壇雜志,2014,35(9):125-126.
17. 安豐山,黃金球,陳少湖,等.217例胸段食管癌淋巴結轉移及其對預后影響的分析.癌癥,2003,22(9):974-978.
18. 邵令方,高宗人,衛功銓,等.食管癌和賁門癌外科治療進展——107例資料分析.中華胸心血管外科雜志,1994,10(1):41-43.
19. Dewar L,Gelfand G,Finley RJ,et al.Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition.Am J Surg,1992,163(5):484-489.
20. Fok M,Law S,Stipa F,et al.A comparison of transhiatal and transthoracic resection for oesophageal carcinoma.Endoscopy,1993,25(9):660-663.
21. Blewett CJ,Miller JD,Young JE,et al.Anastomotic leaks after esophagectomy for esophageal cancer:a comparison of thoracic and cervical anastomoses.Ann Thorac Cardiovasc Surg,2001,7(2):75-78.
22. 22劉彥中,李東峰.胸段食管癌切除食管胃胸內吻合與頸部吻合的臨床分析.中國腫瘤臨床與康復,2010,4(17):137-139.
23. Vigneswaran WT,Trastek VF,Pairolero PC,et al.Transhiatal esophagectomy for carcinoma of the esophagus.Ann Thorac Surg,1993,56(4):838-844;discussion 844-846.
24. Reavis KM.The esophageal anastomosis:how improving blood supply affects leak rate.J Gastrointest Surg,2009,13(9):1558-1560.
25. Pierie JPEN,de Graaf PW,Vroonhoven TJ,et al.Impaired healing of extraperitoneal intestinal anastomoses.Br J Surg,1999,86(5):680-684.
26. Cooke DT,Lin GC,Lau CL,et al.Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy:risk factors,presentation,and detection.Ann Thorac Surg,2009,88(1):177-84;discussion 184-185.
27. Hulscher JBF,van Sandick JW,Devriese PP,et al.Vocal cord paralysis after subtotal oesophagectomy.Br J Surg,1999,86(12):1583-1587.
28. Charles TB,Thomas F,Tolutope O,et al.Impact of the surgical technique on pulmonary morbidity after esophagectomy.Ann Thorac Surg,2012,93(1):221-227.
29. Dresner SM,Lamb PJ,Wayman J,et al.Benign anastomotic stricture following transthoracic subtotal oesophagectomy and stapled oesophago-gastrostomy:risk factors and management.Br J Surg,2000,87(3):362-373.
30. Honkoop P,Siersema PD,Tilanus HW,et al.Benign anastomotic strictures after transhiatal esophagectomy and cervical esophagogastrostomy:risk factors and management.J Thorac Cardiovasc Surg,1996,111(6):1141-1146.
31. Rice TW.Anastomotic stricture complicating esophagectomy.Thorac Surg Clin,2006,16(1):63-73.
32. Neil H,Aditya G,Christy M,et al.Esophagectomies with thoracic incisions carry increased pulmonary morbidity.JAMA Surgery,2013,148(8):733-739.

Chinese Journal of Evidence-Based Medicine

Efficacy and Safety of Intrathoracic Anastomosis vs. Cervical Anastomosis after Esophagectomy Using Gastric Tube: A Meta-Analysis

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