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.	张利民,郭洪波,张百江,等.中段食管癌切除弓上机械吻合与颈部手工吻合的对比.全国食管癌诊断与治疗新技术研讨会论文集,2006.
12.	彭丛兄,周耀洪,吴旭辉,等.老年人中下段食管癌切除术两种吻合方式的临床疗效比较.中国基层医药,2014,21(11):1708-1709.
13.	胡晨虎,赵堂海,孙丽娟,等.中段食管癌切除后不同吻合部位的比较.中国癌症杂志,2000,10(6):572.
14.	金文波,张向华,祁彦君,等.中上段食管癌超胸项吻合与颈部吻合疗效对比分析.中国现代医学杂志,2003,13(16):117-118.
15.	王庆淮,吴勋宁,谭宁,等.107例食管癌手术治疗体会.海南医学,2010,21(19):74-76.
16.	王德昌.食管癌根治术42例临床分析.医药论坛杂志,2014,35(9):125-126.
17.	安丰山,黄金球,陈少湖,等.217例胸段食管癌淋巴结转移及其对预后影响的分析.癌症,2003,22(9):974-978.
18.	邵令方,高宗人,卫功铨,等.食管癌和贲门癌外科治疗进展——107例资料分析.中华胸心血管外科杂志,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刘彦中,李东峰.胸段食管癌切除食管胃胸内吻合与颈部吻合的临床分析.中国肿瘤临床与康复,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. 张利民,郭洪波,张百江,等.中段食管癌切除弓上机械吻合与颈部手工吻合的对比.全国食管癌诊断与治疗新技术研讨会论文集,2006.
12. 彭丛兄,周耀洪,吴旭辉,等.老年人中下段食管癌切除术两种吻合方式的临床疗效比较.中国基层医药,2014,21(11):1708-1709.
13. 胡晨虎,赵堂海,孙丽娟,等.中段食管癌切除后不同吻合部位的比较.中国癌症杂志,2000,10(6):572.
14. 金文波,张向华,祁彦君,等.中上段食管癌超胸项吻合与颈部吻合疗效对比分析.中国现代医学杂志,2003,13(16):117-118.
15. 王庆淮,吴勋宁,谭宁,等.107例食管癌手术治疗体会.海南医学,2010,21(19):74-76.
16. 王德昌.食管癌根治术42例临床分析.医药论坛杂志,2014,35(9):125-126.
17. 安丰山,黄金球,陈少湖,等.217例胸段食管癌淋巴结转移及其对预后影响的分析.癌症,2003,22(9):974-978.
18. 邵令方,高宗人,卫功铨,等.食管癌和贲门癌外科治疗进展——107例资料分析.中华胸心血管外科杂志,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刘彦中,李东峰.胸段食管癌切除食管胃胸内吻合与颈部吻合的临床分析.中国肿瘤临床与康复,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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