Use Of Gastroesophageal Anastomosis Technique In Preventing Postoperative Complications After Oesophagectomy For Oesophageal Cancer

Esophagogastrostomy for oesophageal cancer is the standard surgical treatment. Despite the advances in surgical techniques, anastomotic complications including leakage, stricture formation and gastroesophageal reflux still contribute to a significant number of mortality and morbidity after operation, as well as the reduced quality of life. In order to reduce the anastomotic complications after esophagogastrostomy we designed several innovative surgical techniques including oesophageal flap valvuloplasty and wrapping suturing technique, and sleeve-wrapping of the pedicled omentum around esophagogastric anastomosis. The purpose of this study have three main objectives:(1) through a randomised control trial(RCT) to clarify the superiority of the oesophageal flap valvuloplasty and wrapping suturing technique in preventing postoperative complications after oesophagectomy for oesophageal cancer;(2) performed a retrospective study to observe the results of using sleeve-wrapping the pedicled omentum around esophagogastric anastomosis after esophagectomy for preventing and localizing anastomosis leakage;(3) to evaluate the outcomes of using the hand-sewn method compared with the stapler for the esophagogastric anastomosis after oesophagectomy we performed a Meta-analysis by pooled together all data from relevant randomized controlled trials(RCTs).Part 1. Use of oesophageal flap valvuloplasty and wrapping suturing technique in preventing postoperative complications after oesophagectomy for oesophageal cancerObjetive The purpose of this study is to clarify the superiority of the oesophageal flap valvuloplasty and wrapping suturing technique in preventing postoperative complications after oesophagectomy for oesophageal cancer. Methods: A prospective, randomised study was performed on 394 patients treated for esophageal cancer between January 2010 and June 2013. The trial registry number is ChiCTR-TRC-13003817 in the Chinese Clinical Trial Registry. Nine inoperable patients(2.3%) were excluded. Patients were randomly assigned to two groups with 191 patients in group A and 194 patients in group B. Patients in group A underwent esophagogastrostomy by esophageal flap valvuloplasty and wrapping suturing technique. Group B patients were used stapled technique.Results: Anastomotic leaks occurred in eight patients in group A(4.1%) and in seven patients in group B(3.6%) with no statistically significant difference(P=0.768). During the evaluation of benign stricture seven patients were excluded for hospital mortality(1.6% in group A and 2.1% in group B). Thirteen three patients in group A(6.9%) and 25 patients in group B(13.2%) occured anastomotic stricture respectively(P=0.044). Furthermore, reflux oesophagitis and Barrett’s epithelium were found in 105 patients(55.3%) of group B, and 54(28.7%) patients in group A(P <0.001). Conclusion: The oesophageal flap valvuloplasty and wrapping suturing technique decreased anastomotic leakage incidence and stricture rate thereby decreasing the morbidity and mortality. This procedure also prevented the occurrence of gastroesophageal reflux after esophagectomy.Part 2. Preventing and localizing anastomosis leakage by sleeve-wrapping of the pedicled omentum around esophagogastric anastomosisObjective: To develop a technique of sleeve-wrapping the pedicled omentum around esophagogastric anastomosis after esophagectomy for preventing and localizing anastomosis leakage. Methods: We summarized the data from 86 patients who were diagnosed with esophageal cancer and underwent the technique of sleeve-wrapping the pedicled omentum around esophagogastric anastomosis after esophagectomy between November 2011 and July 2013. The early complications which occurred during follow-up were analyzed. Results: Postoperative complications included pulmonary complications(15.1%, 13/86) and abdominal or thoracic wound infection(3.5%, 3/86). Complications that occurred during follow-up included one case of anastomosis leakage(limited by omentum; 1.2%) and five case of anastomosis stricture(5.8%). No deaths occurred. All complications were resolved through traditional treatment. No additional surgery was needed. Conclusion: Sleeve-wrapping of the pedicled omentum around esophagogastric anastomosis after esophagectomy is safe and effective in preventing and localizing anastomosis leakage.Part 3. Hand-Sewn Compared with Stapler in the Incidence of Anastomotic Leakage for the Esophagogastric Anastomosis after Oesophagectomy A Meta-AnalysisObjective: In this meta-analysis, to evaluate the outcomes of using the hand-sewn method compared with the stapler for the esophagogastric anastomosis after oesophagectomy we pooled together all data from relevant randomized controlled trials(RCTs) to gain a consensus in comparison of anastomotic leakage rate following the two esophagogastric anastomoses. Methods: A rigorous study protocol was established according to the recommendations of the Cochrane Collaboration. An electrical database search, hand search, and reference search were searched for all RCTs that compared hand-sewn versus mechanical anastomosis for esophagogastric anastomosis. Results: This study included fifteen RCTs with a total of 2337 patients. This study revealed the following important findings:(1) there was no significant difference in the incidence of anastomotic leakage [risk ratio(RR): 0.77, 95% confidence interval(CI): 0.57–1.04, P=0.09] but a subgroup analysis yielded a significant difference for the sutured layer and published year;(2) no significant difference in the incidence of postoperative mortality(RR: 1.52, 95% CI: 0.97–2.40, P=0.07) was found;(3) the anastomotic strictures rate in stapler group compared with hand-sewn group was increased(RR: 1.45, 95% CI: 1.11–1.91, P=0.007) in end-to-side subgroup, while decreased the incidence of anastomotic strictures(RR: 0.34, 95% CI: 0.16–0.76, P=0.008) in side-to-side subgroup. Conclusion: Currently, the stapler method contributed to reducing the anastomotic leakage rate compared with single layer hand-sewn method. In addition, although end-to-side stapler method contributed to increasing the risk of anastomotic strictures, side-to-side stapler was associated with a decreased rate.