J Thorac Cardiovasc Surg. 2022 Sep;164(3):674-684.e5. doi: 10.1016/j.jtcvs.2022.01.033. Epub 2022 Feb 3.
The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.
This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.
Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.
Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.
目前尚不清楚哪种食管切除术吻合技术能最大程度地降低吻合口漏和吻合口瘘的发生率。本研究旨在评估国际食管胃吻合口审计队列中，吻合技术是否与食管切除术后吻合口失败有关。
这是一项前瞻性观察性多中心队列研究，纳入了 2018 年 9 个月期间接受食管癌切除术的患者。主要暴露因素是吻合技术，分为手工吻合、线性吻合和圆形吻合。主要结局是吻合口失败，即吻合口漏和吻合口瘘的复合结局，定义为食管并发症共识小组。多变量逻辑回归模型用于调整混杂因素后，确定吻合技术与吻合口失败之间的关联。
在 2238 例食管切除术患者中，27.1%的患者行手工吻合，21.0%的患者行线性吻合，51.9%的患者行圆形吻合。吻合技术在吻合部位上差异有统计学意义（P<.001），颈部吻合以手工吻合为主（69.9%），而大多数胸部吻合采用吻合器（66.3%为圆形吻合器，19.3%为线性吻合器）。不同吻合技术的吻合口失败率差异有统计学意义（P<.001），手工吻合为 19.3%，线性吻合为 14.0%，圆形吻合为 12.1%。多变量分析调整混杂因素后，这种效果仍然显著，圆形吻合与手工吻合相比，比值比为 0.63（95%可信区间，0.46-0.86；P=.004）。然而，吻合部位的亚组分析表明，这种效果主要存在于颈部吻合，颈部吻合的吻合口失败率分别为手工吻合 23.2%、线性吻合 14.6%、圆形吻合 5.9%，而胸部吻合的吻合口失败率分别为 13.7%、13.8%、12.2%。
与吻合器吻合相比，手工吻合似乎与更高的吻合口失败率独立相关。然而，这种效果似乎主要局限于颈部吻合，胸部吻合中各种技术之间的差异很小。进一步研究吻合技术的标准化可能会进一步改善结果。
