The stomach is a good alternative for patients with esophageal cancer undergoing esophagectomy. Traditionally, the accepted standard treatment for operable esophageal carcinoma is resection of the esophagus and lymph nodes with gastric pull up and constructing cervical or intrathoracic esophagogastric anastomosis (6, 10, 16). The main complications after esophagectomy and esophagogastric anastomosis are anastomotic leakage and stricture that may affect the patients’ quality of life and even threaten their lives (16). However, according to recent studies, the role of anastomotic leakage and the type of mechanical stapler device used is of great importance in developing anastomotic stricture (17, 18).
Our results showed that the overall rate of postoperative complications following gastroesophageal anastomosis decreased from 18–12.8% in the HS group compared to MMS group which decreased from 20.6–4.6% in over the 12-month follow-up. A retrospective study by Cook et al. Of 1133 patients undergoing esophagectomy followed by esophagogastric anastomosis showed a significant reduction in postoperative complications and the prevalence of problems in the construction of anastomosis using mechanical anastomosis (7).
According to literature, the rate of anastomotic leakage is approximately 3% following stapler anastomosis. (5, 19). However, in the present study, the prevalence of anastomotic leakage in patients undergoing MMS anastomosis was reported to be 4.6%, which may be related to different surgeons. Similarly to our results Mishra et al found that the rate of anastomotic leakage was significantly higher in patients undergoing HS anastomosis compared to patients underwent linear stapled anastomosis (20).
Laterza et.al compared manual and mechanical anastomosis and their results showed that patients with mechanical anastomosis had a high prevalence of anastomotic leakage and benign stricture (21). Further randomized controlled trials revealed higher anastomotic leakage and anastomosis stricture prevalence in the manual group suggesting the use of mechanical anastomosis to construct esophagogastric anastomosis (22–24). Even in intrathoracic esophagogastric anastomosis liner stapled technique significantly decreased anastomosis leakage and anastomosis stricture compared to HS technique (18).
Sugimora et al used a modified Collard technique, a linear stapler was applied to construct the posterior wall of the anastomosis and the anterior wall was closed using the linear stapler twice. The study showed that anastomosis leakage was less frequent in the modified Collard group compared to the HS group but the difference was not significant. Anastomosis stenosis was significantly less in modified Collard group and also the period between esophagectomy and the first time dilatation significantly was shorter in the HS group (25). Similarly to this technique, Ishibahi et al used a triple-stapled quadrilateral anastomosis for creation of an esophagogastric anastomosis and they reported no significant anastomosis leakage and anastomosis stricture (26).
Some reviews reported no significant difference between HS and mechanical stapled in the prevalence of anastomotic stricture, however, our results showed a decreasing pattern for the rate of anastomotic stricture during follow up period, in modified stapler group compared to the manual anastomosis. Similarly, Cooke et al showed significant decrease in the prevalence of postoperative complications and morbidity in patients using mechanical anastomosis (7).Price et al. Found that although the anastomotic site did not play an important role in predisposing postoperative complications such as anastomotic leakage and stenosis, patients with manual anastomosis experienced higher anastomotic leakage and stricture (24).
The present study was conducted on 409 patients undergoing esophagectomy by two methods of HS and MMS cervical esophagogastric anastomosis. The results of the current study significantly showed higher prevalence of cervical esophagogastric anastomosis leak following transhiatal esophagectomy with manual anastomosis. In addition, this study revealed that the prevalence of benign anastomotic stricture and regurgitation during the 12-month follow-up was significantly higher in the HS group compared to the MMS group. Therefore, we hypothesized that modified mechanical stapler plays an important role in reducing the incidence of postoperative complications.
In the present study, we demonstrated endoscopic interventions such as esophageal dilatation to relieve benign anastomotic stenosis and recurrent dysphagia over a 12-month follow-up. The results of statistical analysis showed that there was no significant difference between patients in both groups who required esophageal dilatation during 12 months follow-up which may reflect the fact that the severity of stenosis was not different in HS and MMS anastomosis patients.
In the study of Hsu, et.al, the operating time was compared between the manual and mechanical anastomosis groups. The results showed that the time of operation in the mechanical group patients was significantly shorter than the manual group (9). However, some studies including meta-analysis showed no significant difference in surgical time between manual and mechanical anastomosis techniques (15, 27). The results of the present study showed that the effective time of using a MMS technique for cervical esophageal anastomosis was significantly shorter than the manual procedure.
Our study has some limitations: first, this study was a retrospective study so we need a clinical trial to achieve acceptable results. Second, the follow-up period was 12 months, however, a longer period of follow-up may have different results. Third, three surgeons included in this study, although the surgical team had sufficient experience in esophageal surgery and all anastomoses were performed in the neck, may still have undesirable bias.
Overly in our study it was revealed that the operative time in the MMS group was significantly shorter and there was a significant decrease in the amount of anastomotic leakage, stenosis, and postoperative regurgitation. Therefore, the MMS technique can be used as a superior method for faster and more efficient esophageal anastomosis than HS procedure after esophagectomy.