title: Anastomotic leak and stricture after hand-sewn versus linear-stapled intrathoracic oesophagogastric anastomosis: single-centre analysis of 415 oesophagectomies.
abstract: OBJECTIVE
  There seems to be a decreased anastomotic leak rate and a late stricture formation after linear-stapled (LS) cervical oesophagogastric anastomosis compared with hand-sewn (HS) technique. The aim of our study was to compare the surgical outcomes of intrathoracic side-to-side LS and end-to-end HS anastomosis after transthoracic oesophagectomy.
  
  
  METHODS
  We conducted a retrospective review of all patients undergoing Ivor Lewis oesophagectomy with LS or HS anastomosis for neoplasia at our institution from 2005 to 2012. Anastomotic leak was radiologically and clinically graded as minor or major. End-points included overall and major leak rate, morbidity, mortality, length of hospital stay and endoscopically identified late anastomotic stricture. A propensity score-matched analysis was done to compensate for the differences in baseline characteristics between HS and LS groups. Multivariable analyses of the associations of anastomotic technique and other preoperative and pathological variables with anastomotic leak and stricture were performed.
  
  
  RESULTS
  There were 415 patients, 134 with HS and 281 with LS anastomoses. Anastomotic leak occurred in 56 patients (13.5%), significantly more after HS than LS technique (20.9 vs 10.0%; P = 0.002). Major leak rate was not significantly different (9.0 vs 5.7%; P = 0.216, respectively). Overall morbidity (54.7%), in-hospital mortality (3.9%) and length of hospital stay (median 12 days) were not affected by the anastomotic technique. A follow-up endoscopic evaluation was available in 248 patients (59.8%). An anastomotic stricture was detected in 24 patients (9.7%), significantly more after HS than LS technique (20.3 vs 6.3%; P = 0.002). The propensity score-matched analysis of 105 patient pairs confirmed a significantly decreased overall leak rate (11.4 vs 22.9%; P = 0.045) and stricture formation (7.5 vs 18.2%; P = 0.041) in LS technique compared with HS technique. The multivariable analyses found obesity and HS anastomotic technique associated with an increased overall leak rate, chronic hepatopathy and diabetes associated with major leak and HS technique, female sex and the absence of arterial hypertension associated with increased stricture formation.
  
  
  CONCLUSIONS
  Our non-randomized study showed that side-to-side LS technique is the preferred method of intrathoracic oesophagogastric anastomosis due to a decreased overall anastomotic leak rate and anastomotic stricture formation compared with HS technique.
authors.affiliation: 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic tomas.harustiak@fnmotol.cz.
authors.forename: Tomas
authors.initials: T
authors.lastname: Harustiak
authors.affiliation: 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic.
authors.forename: Alexandr
authors.initials: A
authors.lastname: Pazdro
authors.affiliation: 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic.
authors.forename: Martin
authors.initials: M
authors.lastname: Snajdauf
authors.affiliation: 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic.
authors.forename: Alan
authors.initials: A
authors.lastname: Stolz
authors.affiliation: 3rd Department of Surgery, First Faculty of Medicine of Charles University in Prague and University Hospital Motol, Prague, Czech Republic.
authors.forename: Robert
authors.initials: R
authors.lastname: Lischke
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000714:Anastomosis, Surgical / Q000379:methods; D057868:Anastomotic Leak / Q000209:etiology*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery; D016629:Esophagectomy / Q000379:methods*; D004947:Esophagus / Q000601:surgery*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D012189:Retrospective Studies; D013270:Stomach / Q000601:surgery*; D017792:Surgical Stapling; D013536:Suture Techniques; D016896:Treatment Outcome
keywords: Hand-sewn; Intrathoracic oesophagogastric anastomosis; Linear-stapled