Stapled vs. hand-sewn anastomosis during esophagectomy: a randomized trials systematic review and meta-analysis

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INTRODUCTION: Esophagogastric anastomosis during esophagectomy is a technically demanding step, carrying a high complication rate. Numerous techniques for anastomosis fashioning have been described, including hand-sewn (HS) and stapled (ST) anastomosis however, the optimal method remains uncertain. PURPOSE: Analyse short-term outcomes for ST vs. HS anastomosis. METHODS: Systematic review and meta-analysis of randomized controlled trials (RCTs). PubMed, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcomes were anastomotic leak (AL) and stricture (AS). RESULTS: Twelve RCTs (2015 patients) were included. All trials were deemed to have an intermediate risk of bias. ST anastomosis was performed in 51.9%. The age of the patient population ranged from 37 to 88 years and 73% were males. Squamous cell carcinoma was diagnosed in 76.9% of patients. Neoadjuvant therapy was completed in 32.9%. Ivor-Lewis or McKeown esophagectomy were performed with thoracic (57.2%) or cervical (42.8%) anastomosis. No significant differences were found for ST vs. HS anastomosis for AL (RR 0.97; 95% CI 0.70-1.35) and AS (RR 1.47; 95% CI 0.96-2.23). Further, no differences were found for cardiovascular complications (RR 1.09; p = 0.59), pulmonary complication (RR 1.12; p = 0.28), length of stay (SMD 0.03; p = 0.69), and 30-day mortality (RR 1.30; p = 0.18). Operative time was shorter in ST anastomosis (SMD - 0.11; p = 0.002). CONCLUSIONS: ST and HS esophagogastric anastomosis yield comparable rates of AL, AS, postoperative complications, and in-hospital mortality. The use of ST anastomosis may result in a shorter operative time. The choice of technique should be determined by the surgeon's expertise and clinical scenario.