Beitler A L, Urschel J D
Department of Thoracic Surgery, Roswell Park Cancer Institute, Buffalo, New York 14263-0001, USA.
Am J Surg. 1998 Apr;175(4):337-40. doi: 10.1016/s0002-9610(98)00002-6.
Esophagogastric anastomotic leaks continue to be a major source of morbidity and mortality after esophagectomy. Leaks usually result from technical errors or occult ischemia of the mobilized gastric fundus. The introduction of stapled esophagogastric anastomoses was initially very promising; leak rates appeared to be reduced.
The English language medical literature was searched for publications comparing stapled and hand-sewn esophagogastric anastomoses. We reviewed data from four randomized trials and seven nonrandomized comparative studies to determine if stapling was superior to hand suturing for esophagogastric anastomoses.
Pooled data from randomized trials comparing stapled with hand-sewn esophagogastric anastomoses showed no significant difference for leaks (stapled 9%, hand-sewn 8%, P <0.67), but a higher incidence of strictures in stapled anastomoses (stapled 27%, hand-sewn 16%, P < 0.02). In nonrandomized studies, stapled anastomoses had a lower leak rate (stapled 6%, hand-sewn 11%, P < 0.0001), but strictures were more frequent (stapled 31%, hand-sewn 16%, P < 0.0001). A major source of bias in the nonrandomized studies was the comparison of contemporary stapled experience and earlier hand-sewn experience. This bias was not present in three of seven nonrandomized studies that featured prospective data collection. Pooled data from these three studies showed no difference in anastomotic leak rate (stapled 4%, hand-sewn 6%, P < 0.28).
Stapled and hand-sewn esophagogastric anastomotic techniques have equivalent anastomotic leak rates, but strictures are more common in stapled anastomoses. Irrespective of which technique is used, surgical experience and meticulous attention to detail are required to prevent anastomotic complications. Anastomotic technical modifications alone are unlikely to eliminate the problem of leaks, since they do not address the problem of gastric fundal ischemia.
食管胃吻合口漏仍是食管切除术后发病和死亡的主要原因。漏通常源于技术失误或游离胃底的隐匿性缺血。吻合器食管胃吻合术的引入最初前景十分广阔；漏率似乎有所降低。
检索英文医学文献，查找比较吻合器食管胃吻合术和手工缝合食管胃吻合术的出版物。我们回顾了四项随机试验和七项非随机对照研究的数据，以确定吻合器吻合术在食管胃吻合方面是否优于手工缝合术。
比较吻合器食管胃吻合术和手工缝合食管胃吻合术的随机试验汇总数据显示，漏率无显著差异（吻合器吻合术为9%，手工缝合术为8%，P<0.67），但吻合器吻合术后狭窄发生率更高（吻合器吻合术为27%，手工缝合术为16%，P<0.02）。在非随机研究中，吻合器吻合术漏率较低（吻合器吻合术为6%，手工缝合术为11%，P<0.0001），但狭窄更常见（吻合器吻合术为31%，手工缝合术为16%，P<0.0001）。非随机研究中的一个主要偏倚来源是将当代吻合器吻合经验与早期手工缝合经验进行比较。在七项采用前瞻性数据收集的非随机研究中，有三项不存在这种偏倚。这三项研究的汇总数据显示吻合口漏率无差异（吻合器吻合术为,4%，手工缝合术为6%，P<0.28）。
吻合器食管胃吻合技术和手工缝合食管胃吻合技术的吻合口漏率相当，但吻合器吻合术后狭窄更常见。无论使用哪种技术，都需要手术经验并注重细节以预防吻合口并发症。仅靠吻合技术改良不太可能消除漏的问题，因为它们无法解决胃底缺血问题。
