title: Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis.
abstract: OBJECTIVE
  To compare the outcome of hand sewing and stapling for anastomotic leakage after esophagectomy.
  
  
  METHODS
  A rigorous study protocol was established according to the recommendations of the Cochrane Collaboration. An electronic database search, hand search, and reference search were used to retrieve all randomized controlled trials that compared hand-sewn and mechanical esophagogastric anastomoses.
  
  
  RESULTS
  This study included 15 randomized controlled trials with a total of 2337 patients. The results revealed that there was no significant difference in the incidence of anastomotic leakage between the methods [relative risk (RR) = 0.77, 95% confidence interval (CI): 0.57-1.04; P = 0.09], but a subgroup analysis yielded a significant difference for the sutured layer and year of publication (Ps < 0.05). There was also no significant difference in the incidence of postoperative mortality (RR = 1.52, 95%CI: 0.97-2.40; P = 0.07). However, the anastomotic strictures rate was increased in the stapler group compared with the hand-sewn group (RR = 1.45, 95%CI: 1.11-1.91; P < 0.01) in the end-to-side subgroup, while the incidence of anastomotic strictures was decreased (RR = 0.34, 95%CI: 0.16-0.76; P < 0.01) in the side-to-side subgroup.
  
  
  CONCLUSIONS
  The stapler reduces the anastomotic leakage rate compared with hand sewing. End-to-side stapling increases the risk of anastomotic strictures, but side-to-side stapling decreases the risk.
authors.affiliation: Quan-Xing Liu, Jia-Xin Min, Xu-Feng Deng, Ji-Gang Dai, Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
authors.forename: Quan-Xing
authors.initials: QX
authors.lastname: Liu
authors.affiliation: Quan-Xing Liu, Jia-Xin Min, Xu-Feng Deng, Ji-Gang Dai, Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
authors.forename: Jia-Xin
authors.initials: JX
authors.lastname: Min
authors.affiliation: Quan-Xing Liu, Jia-Xin Min, Xu-Feng Deng, Ji-Gang Dai, Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
authors.forename: Xu-Feng
authors.initials: XF
authors.lastname: Deng
authors.affiliation: Quan-Xing Liu, Jia-Xin Min, Xu-Feng Deng, Ji-Gang Dai, Department of Thoracic Surgery, Xinqiao Hospital, Third Military Medical University, Chongqing 400037, China.
authors.forename: Ji-Gang
authors.initials: JG
authors.lastname: Dai
mesh_terms: D057868:Anastomotic Leak / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control*; D016009:Chi-Square Distribution; D016629:Esophagectomy / Q000009:adverse effects*; D006801:Humans; D015994:Incidence; D016017:Odds Ratio; D012307:Risk Factors; D017792:Surgical Stapling / Q000009:adverse effects; D013536:Suture Techniques / Q000009:adverse effects; D016896:Treatment Outcome
keywords: Anastomotic leakage; Esophagectomy; Hand-sewn sutures; Mechanical sutures; Meta-analysis