Perioperative Outcomes
Among the 433 consecutive patients with esophageal cancer, 271 (62.5%) belonged to the hand-sewn anastomosis group, and 162 (37.4%) were assigned to the stapled anastomosis group. Of the subjects, 248 (57.3%) were male, and 185 (42.7%) were female. The demographic data and clinical characteristics of the patients are presented in Table 1.
The groups showed no significant differences in terms of age, gender, and preoperative clinical signs and symptoms. Despite the high incidence of squamous cell carcinoma in both groups, the rate of esophageal adenocarcinoma was significantly higher in the stapled anastomosis group (P = 0.004). Although the groups significantly differed in tumor stage at the time of operation (P = 0.01), the post hoc analysis revealed no difference in this respect between the hand-sewn and stapled anastomosis patients.
Table 2 shows the durations of operation, ICU and hospital stays, and postoperative morbidity and mortality rates of the patients. Compared with the hand-sewn anastomosis group, the stapled anastomosis group had significantly shorter operation times (P = 0.028). Nevertheless, no significant differences in ICU and hospital stays and perioperative complications other than anastomotic leakage were found between the groups. All the patients were evaluated for postoperative anastomotic leakage by water-soluble esophagogram or neck CT with oral contrast. The incidence of anastomotic leakage in the hand-sewn and stapled anastomosis groups were seen in 38 (14.02%) and eight (4.93%) cases, respectively. The incidence was significantly lower in the stapled group (P = 0.002). Overall, 44 (10.1%) patients had minor leaks and received conservative management, which consisted of delays in oral intake (usually one week), cervical wound drainage, enteral nutrition via a jejunostomy tube, and selective antibiotic administration. Among the nine patients who underwent reoperation, four (1.5%) were in the hand-sewn anastomosis group, and five (3%) belonged to the stapled anastomosis group. Two (0.41%) patients with considerable leakage and subsequent conduit necrosis had revisional surgery, which included a resection of the gastric conduit and construction of cervical esophagostomy.
Hospital mortality rates were 2.58% (n = 7) and 2.46% (n = 4) in the hand-sewn and stapled anastomosis groups, respectively (P = 0.60). Of 2 patients who died in 30-day after hospital discharge, one (0.56%) received hand-sewn esophago-gastrostomy and the other (0.061%) underwent stapled cervical esophagogastric anastomosis (P = 0.57). Two (0.73%) patients belonging to the hand-sewn esophago-gastrostomy group died within 90 days after the operation (P = 0.48). One death due to anastomotic leakage occurred in each group.
Postoperative Outcomes
Among the 433 cases, 24 were excluded from the 12-month follow-up evaluation period because of postoperative mortality, anastomotic recurrence, and positive esophageal proximal resection margin (Table 2). This left 409 patients for assessment as regards postoperative complications, including reflux symptoms, benign anastomotic stricture, and the need for anastomotic dilatation at the 12th month of follow-up. All the patients underwent serial clinical examinations and appropriate workup during the second week, as well as in the fourth, eighth, and 12th months after operation.
The prevalence of reflux symptoms (heartburn and regurgitation) during the follow-up is depicted in Figure 2. These symptoms occurred less frequently in patients with stapled anastomosis (P = 0.001), but pattern decreased in both groups at the final steps of the follow-up period. Changes in reflux prevalence were higher in the hand-sewn anastomosis group during the early stages of the follow-up (P = 0.004), but prevalence was significantly eliminated within the one-year follow-up (P = 0.02).
Upper gastrointestinal barium swallow and subsequent upper gastrointestinal endoscopy were performed to investigate anastomotic stricture in the patients with complaints of dysphagia, odynophagia, and retrosternal pain. Data on the prevalence of anastomotic stricture during the follow-up period are summarized in Table 3. During the follow-up, the groups were compared in terms of different time points via Cochran’s Q test, which revealed that the prevalence of anastomotic stricture was significantly higher in the hand-sewn anastomosis group than in their stapled anastomosis counterparts (P = 0.004 vs 0.263). The mixed model test demonstrated that changes in such prevalence were significantly fewer in the stapled group than the hand-sewn group (P = 0.029).
The prevalence pattern of anastomotic dilatation is illustrated in Table 4. All the patients with symptomatic anastomotic stricture underwent esophageal dilatation guided by Savary–Gilliard bougie dilators during rigid esophagostomy performed under general anesthesia. The patients who were subjected to hand-sewn anastomosis required significantly more dilatation than did the stapled anastomosis group at different time points during the follow-up period (P = 0.048 vs 0.273). Compared with the hand-sewn anastomosis group, the stapled anastomosis group required fewer changes for intervention, as determined in the mixed model test conducted during the follow-up period (P = 0.021).