The Comparison Between Stapler And Manual Lingual Mucosal Flap In Application Of Cervical Anastomosis For Esophageal Cancer

Background Esophageal cancer (EC) is one of most common malignancies that remains a big health challenge. The morbidity and mortality of EC are very high in some developing countries. The morbidity of EC clearly shows regional difference. In China, North of Henan province and Ci xian in Hebei province nearby Taihang Mountains are high risk areas of EC. Surgery is the first line treatment for EC. The surgical resection requires remove esophagus at maximal extent because of multiple origin of foci usually distributed in a scattered fashion. The surgery of cervical esophagogastric anastomosis can remove the majority of esophagus, and thus minimizes the local recurrence at anastomotic foci. Therefore, it is widely adopted in the surgical treatment of EC. However, the incidence of complications in cervical anastomosis is high. Among these, the anastomotic leakage and stenosis are the two most common complications of esophageal cervical anastomosis. To decrease the incidence of cervical anastomotic leakage and other related complications, a variety of different anastomosis methods including tunnel anastomosis, whole layer anastomosis, side to side anastomosis, and mechanical anastomosis, have been undertaking in different hospitals. Nevertheless, circular stapler and manual lingual mucosal flap are the two main cervical esophagogastric anastomosis in our hospital. To compare the advantage and limits of these two methods,189 patients of esophageal cancer including 99 patients of stapler, and 90 patients of lingual mucosal flap were retrospectively analyzed. A series of parameters including the surgery time, hospitalization time, the costs of surgery and hospitalization, the incidence and extent of esophageal anastomotic leakage and anastomotic stenosis, and the extent of regurgitation were analyzed after the surgery in order to provide a reference for choosing the proper method in cervical esophageal anastomosis.Objective To compare the postoperative effect between stapler and manual lingual mucosal flap stapler for cervical anastomosis in order to provide a reference for choosing the proper method in cervical esophageal anastomosis.Methods One-hundred nine patients of esophageal cancer underwent transthoracic esophagectomy with two-field lymph node dissection and tube stapled esophagogastric anastomosis. Among them,99 patients received anastomosis stapler and the other 90 manual lingual mucosal flap. After surgery, the surgery time, blood loss, hospitalization time, the costs of surgery and hospitalization, the incidence and extent of esophageal anastomotic leakage and anastomotic stenosis, and the extent of regurgitation between two groups were compared.Results1.Four patients in stapler group occurred anastomotic leakage (4.0%, n=99) and 11 patients in manual lingual mucosal flap group anastomotic leakage (12.2%, n=90). The difference of anastomotic leakage between these two groups was statistically significant (P<0.05, x2=4.32).2.Seven patients in stapler group occurred anastomotic stenosis (7.1%, n=99) and 8 patients in manual lingual mucosal flap group anastomotic stenosis (8.9%, n=90). The difference of anastomotic stenosis between these two groups was statistically significant (P>0.05, x2=0.24).3. The rate of reflux in stapler group (35.4%, n=99) was higher than that in manual lingual mucosal flap group (21.1%, n=90) with a statistically significant difference(P <0.05, x2=4.69).4. The average hospital cost in stapler group (13356.8±60.7yuan) was higher than that in manual lingual mucosal flap group (12147.6±62.5yuan) with a statistically significant difference (P<0.01,t=134.86).5. The average hospital stay in stapler group (19±1.5d) was lower than that in manual lingual mucosal flap group (21±1.8d) with a statistically significant difference (P<0.01, t=8.33).6. The average surgery time in stapler group(181.3±5.7min) and that in manual lingual mucosal flap group(180.6±6.2min) was no statistical difference(P> 0.05, t=0.81).7. The average blood loss in stapler group(239±76ml) and that in manual lingual mucosal flap group(242±72ml) was no statistical difference(P> 0.05, t=0.28).Conclusions The protocol of circular stapler is easier for beginner in surgery than manual lingual mucosal flap. The incidence of anastomotic leakage is lower and the hospitalization time of circular stapler is shorter, while the incidence of reflux and the hospital cost are higher. The incidence of anastomotic leakag is higher and the hospitalization time is longer in manual lingual mucosal flap group, but the incidence of reflux and the hospital cost are lower. There is no statistical difference in comparing surgery time and blood loss between these two modalities. Thus either method has its own limits and advantages and the practioner needs to select the appropriate modality according to the disease severity, economic status and performance status.