COMPARISON OF STAPLED AND HAND-SEWN ESOPHAGOGASTRIC ANASTOMOSES

BACKGROUND: Esophagogastric anastomotic leaks continue to be a major s ource of morbidity and mortality after esophagectomy. Leaks usually re sult from technical errors or occult ischemia of the mobilized gastric fundus, The introduction of stapled esophagogastric anastomoses was i nitially very promising; leak rates appeared to be reduced. DATA SOURC ES: The English language medical literature was searched for publicati ons comparing stapled and hand-sewn esophagogastric anastomoses, We re viewed data from four randomized trials and seven nonrandomized compar ative studies to determine if stapling was superior to hand suturing f or esophagogastric anastomoses, RESULTS: Pooled data from randomized t rials comparing stapled with hand-sewn esophagogastric anastomoses sho wed no significant difference for leaks (stapled 9%, hand-sewn 8%, P < 0.67), but a higher incidence of strictures in stapled anastomoses (s tapled 27%, hand-sewn 16%, P < 0.02). In nonrandomized studies, staple d 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 t he 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 t hese three studies showed no difference in anastomotic leak rate (stap led 4%, handsewn 6%, P < 0.28), CONCLUSIONS: Stapled and hand-sewn eso phagogastric anastomotic techniques have equivalent anastomotic leak r ates, but strictures are more common in stapled anastomoses, Irrespect ive of which technique is used, surgical experience and meticulous att ention to detail are required to prevent anastomotic complications. An astomotic technical modifications alone are unlikely to eliminate the problem of leaks, since they do not address the problem of gastric fun dal ischemia. (C) 1998 by Excerpta Medica, Inc.