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Hand-Sewn Versus Mechanical Esophagogastric Anastomosis After Esophagectomy: A Systematic Review and Meta-Analysis

Honda, Michitaka MD*,§; Kuriyama, Akira MD; Noma, Hisashi PhD; Nunobe, Souya MD, PhD§; Furukawa, Toshi A MD, PhD

doi: 10.1097/SLA.0b013e31826d4723

Objective: To evaluate the risks and benefits of using a circular stapler (CS) compared with the hand-sewn (HS) method for the esophagogastric anastomosis after esophageal resection.

Background Data: Previous randomized controlled trials (RCTs) indicated that the use of a CS might prevent anastomotic leakage, whereas it was more likely to lead to anastomotic strictures. The relative efficacy of this intervention in comparison with the HS method has not been conclusively determined.

Methods: A systematic review and meta-analysis of all RCTs that compared HS versus mechanical anastomosis using a CS was conducted regarding the leakage, strictures, operative time, and mortality. The study protocol was established a priori according to the recommendations of the Cochrane Collaboration.

Results: Twelve RCTs were included with a total of 1407 patients. The use of a CS, compared with the HS method, (1) led to no significant difference in the incidence of anastomotic leakage [risk ratio (RR): 1.02, 95% confidence interval (CI): 0.66–1.59] or postoperative mortality (RR: 1.64, 95% CI: 0.95–2.83), (2) increased the incidence of anastomotic strictures (RR: 1.67, 95% CI: 1.16–2.42), and (3) reduced the length of the operation time (mean: −15.3 minutes, range: −28.1 to −2.39). For these results, a subgroup analysis and a meta-regression analysis yielded no significant differences for the anastomotic site, diameter of the CS, layer, or configuration.

Conclusion: The use of a CS contributed to reducing the length of the operation, but was associated with an increased risk of anastomotic strictures. Both the CS and the HS method are viable alternatives in the reconstruction after esophagectomy.

The use of a circular stapler for esophagogastric anastomosis was more likely to induce anastomotic strictures than the hand-sewn method, although the former reduced the operative time. There was no significant difference in the risk of leakage. These trends were consistent in all of the subgroup analyses.

*Department of Bioartificial Organs, Institute for Frontier Medical Science, Kyoto University, Kyoto, Japan

Department of General Medicine, Kurashiki Central Hospital, Okayama Japan

Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan

§Department of Gastroenterological Surgery, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan

Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan.

Reprints: Michitaka Honda, MD, Department of Bioartificial Organs, Institute for Frontier Medical Science, Kyoto University, 53 Kawahara cho, Sakyo-ku, Kyoto 606-8507, Japan. E-mail:

Disclosure: The authors declare no conflicts of interest.

© 2013 Lippincott Williams & Wilkins, Inc.