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Esophagogastrectomy: The Influence of Stapled vs. Hand-Sewn Anastomosis on Outcome
Abdollah Behzadi, Francis C. Nichols, Stephen D. Cassivi, Claude Deschamps, Mark S. Allen, Peter C. Pairolero, Mayo Clinic College of Medicine, Rochester, MN

Successful anastomosis is crucial for success of esophagogastrectomy (EG). Before July 2002 almost all esophagogastric anastomoses at our institution were hand-sewn (HSA). We then began utilizing a linear stapled anastomotic technique (LSA). This review compares the outcomes of patients with HSA and LSA following EG.

Two-hundred eighty consecutive patients with EG and gastric reconstruction from July 2001 to June 2004 were reviewed.

There were 235 men, 45 women. Median age: 65 years (range 22 - 95 years). Indications were malignancy in 244 patients, high-grade dysplasia in 22, benign conditions in 14. Ivor Lewis EG was performed in 196 patients (70%), transhiatal 70 (25%), left thoracoabdominal 10 (4%), and extended esophagectomy in 4 (1%). Anastomosis was intrathoracic in 206 patients (74%) and cervical in 74. HSAs was performed in 205 patients (73%) and LSAs in 75 (27%). LSA was intrathoracic in 33 patients (16%) and cervical in 42 (57%). One-hundred seventeen patients (42%) received neoadjuvant therapy. Five patients died (mortality, 1.8%). Anastomotic leaks occurred in 30 patients (11%): cervical in 11 (15.1%) and intrathoracic in 19 (9.2%) (p=0.013). Leaks were asymptomatic in 17 patients (57%). Thirteen patients (4.6%) had symptomatic leaks requiring re-operation. Other major complications occurred in 40 patients (14.3%). Median hospitalization: 10 days (range 6 - 98 days). Median follow-up: 9 months (range 0.25 - 38 months). Overall, 81 patients required dilatation (median 2; range 1 to 14); 70 (34%) had HSA and 11 (14.6%) LSA (p=0.001). HSAs were more likely to leak and require dilatation; odds ratios and 95% confidence intervals were 5.35 (1.67-19.27) and 3.58 (1.66-8.34) respectively.

A linear stapled esophagogastric anastomosis (LSA) is safe and associated with significantly lower leak rate and need for dilatation than hand-sewn anastomosis (HSA). This non-randomized series suggests that LSA is the preferred anastomotic technique regardless of surgical approach.

Comparison of Hand-sewn and Linear stapled anastomoses

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