Skip to main content
NCBI home page
Springer logoLink to Springer
. 2025 Nov 21;78(1):95–106. doi: 10.1007/s13304-025-02464-y

Stapled vs. hand-sewn anastomosis during esophagectomy: a randomized trials systematic review and meta-analysis

Matteo Calì 1, Alberto Aiolfi 1,✉, Gianluca Bonitta 1, Michele Manara 1, Quan Wang 2, Antonio Biondi 3, Davide Bona 1, Luigi Bonavina 2; European Foregut Society (EFS) Collaborative Group
PMCID: PMC12909439  PMID: 41269649

Abstract

Introduction

Esophagogastric anastomosis during esophagectomy is a technically demanding step, carrying a high complication rate. Numerous techniques for anastomosis fashioning have been described, including hand-sewn (HS) and stapled (ST) anastomosis however, the optimal method remains uncertain.

Purpose

Analyse short-term outcomes for ST vs. HS anastomosis.

Methods

Systematic review and meta-analysis of randomized controlled trials (RCTs). PubMed, Scopus, Web of Science, Cochrane Central Library, and ClinicalTrials.gov were queried. Primary outcomes were anastomotic leak (AL) and stricture (AS).

Results

Twelve RCTs (2015 patients) were included. All trials were deemed to have an intermediate risk of bias. ST anastomosis was performed in 51.9%. The age of the patient population ranged from 37 to 88 years and 73% were males. Squamous cell carcinoma was diagnosed in 76.9% of patients. Neoadjuvant therapy was completed in 32.9%. Ivor-Lewis or McKeown esophagectomy were performed with thoracic (57.2%) or cervical (42.8%) anastomosis. No significant differences were found for ST vs. HS anastomosis for AL (RR 0.97; 95% CI 0.70–1.35) and AS (RR 1.47; 95% CI 0.96–2.23). Further, no differences were found for cardiovascular complications (RR 1.09; p = 0.59), pulmonary complication (RR 1.12; p = 0.28), length of stay (SMD 0.03; p = 0.69), and 30-day mortality (RR 1.30; p = 0.18). Operative time was shorter in ST anastomosis (SMD − 0.11; p = 0.002).

Conclusions

ST and HS esophagogastric anastomosis yield comparable rates of AL, AS, postoperative complications, and in-hospital mortality. The use of ST anastomosis may result in a shorter operative time. The choice of technique should be determined by the surgeon’s expertise and clinical scenario.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13304-025-02464-y.

Keywords: Esophageal cancer, Esophagectomy, Anastomotic leak, Anastomotic stenosis, Postoperative complications

Introduction

Esophageal cancer ranks as the sixth most prevalent malignancy globally and is the eighth leading cause of cancer-related mortality. Prognosis remains poor, with five-year overall survival rates between 15% and 20% [1]. The current gold standard for treatment involves esophagectomy, lymphadenectomy, and the restoration of gastrointestinal continuity via gastric conduit reconstruction [2, 3]. Esophagogastric anastomosis is regarded as the most technically demanding step, carrying a high complication rate. Anastomotic leak (AL) occurs in up to 10% of patients and is associated with a threefold increase in mortality, extended hospitalization, delayed initiation of oral intake, risk of reintervention, increased recurrence rates, and reduced overall as well as disease-free survival [4,70]. Anastomotic stricture (AS) has been reported in up to 30% of cases [5, 6], often requiring endoscopic dilation and negatively affecting postoperative recovery, nutritional status, and quality of life [7].

Numerous techniques for esophagogastric anastomosis have been described, including hand-sewn (HS) and stapled (ST) anastomosis, each presenting distinct advantages and limitations in both thoracic and cervical settings [8]. The optimal method for esophageal anastomosis remains uncertain, as existing studies offer conflicting evidence and no definitive conclusions regarding superior outcomes leaving the choice of technique on the surgeon’s expertise and personal preference [9]. In recent decades, there has been a gradual shift from HS to ST techniques, driven by advancements in stapling technology and efforts toward standardizing practices [10]. Nevertheless, the recent introduction of robotic platforms—offering enhanced visualization, precision, and dexterity—has led to renewed interest in the HS anastomosis technique [11, 12].

This systematic review and meta-analysis seek to provide updated insights into the comparative short-term outcomes of ST versus HS anastomosis in patients undergoing esophagectomy for resectable esophageal cancer in the setting of randomized controlled trials (RCTs).

Materials and methods

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [13]. Literature searches were performed using PubMed, Scopus, Web of Science, Cochrane Central Library, Google scholar, and ClinicalTrials.gov, with the final search date set as 10 January 2025. The search terms included “Esophagectomy,” “Esophageal,” “Esophagus,” “Cancer,” “Hand-sewn,” “Stapler,” “Anastomosis,” “Anastomotic,” and “Leak”. These were used in combination with the Boolean operators AND or OR. Details of the comprehensive literature search are provided in Appendix 1. Relevant studies reporting short-term outcomes after esophageal resection for cancer and comparing HS vs. ST anastomoses, were selected. All titles were screened, relevant abstracts were reviewed, and reference lists of each article were independently assessed by three authors (AA, MC, and MM). The review protocol was registered with PROSPERO CRD420250654558.

Eligibility criteria

Inclusion criteria: (a) RCTs evaluating short-term outcomes following esophagectomy for cancer in adult patients (≥ 18 years), comparing ST) versus HS anastomosis; (b) articles written in English; (c) when two or more papers were published by the same institution, study group, or used the same data-set, articles with the longest follow-up or the largest sample size; (d) in case of duplicate studies with accumulating numbers of patients, only the most complete reports were included for quantitative analysis. Exclusion criteria: (a) non-English written; (b) conference abstracts, review articles, and case reports; (c) studies that doesn’t report a comparison between previously mentioned anastomotic techniques; (d) non RCTs study.

Data extraction

The following data were extracted: authors, year of publication, demographic characteristic of the included patients, tumor location, perioperative therapy, tumor histology, pathologic tumor stage, surgical radicality and surgical approach, operative time (minutes), hospital stay, short-term outcomes, and in-hospital mortality.

Outcome of interest and definitions

The primary outcome assessed was AL. Secondary outcomes included AS, mortality, cardiopulmonary complications, hospital length of stay and operative time. AL was defined as evidence of contrast extravasation at postoperative swallow study and/or CT-scan, or endoscopic visualization of anastomotic dehiscence/fistula, or visible loss of digestive secretions through surgical drains combined with clinical signs. AS was defined based on the need for endoscopic dilatation or evidence of reduced anastomosis diameter at postoperative endoscopic or swallow studies assessment. Cardiovascular complication was defined as postoperative myocardial infarction, stroke, peripheral limb ischemia, thrombotic events, and pulmonary embolism. Pulmonary complication was defined as pneumonia, pleural effusion with lung atelectasis, acute respiratory distress syndrome (ARDS), and respiratory failure requiring reintubation. Esophageal cancer was defined as any primary histopathologically verified neoplasm situated in the cervical, thoracic, and distal esophagus or gastroesophageal junction (Siewert I–II).

Quality assessment

Three authors (AA, MC, GB) independently assessed the methodological quality of the selected trials by using the Cochrane risk of bias tool II [14]. This tool evaluates five domains: (1) bias of randomization; (2) allocation concealment; (3) bias due to missing outcomes; (4) bias in the measurements of outcomes; and (5) bias in selection of the reported results. Thus, each RCT was graded as having low, moderate, or high risk of bias [15]. Disagreements were solved by discussion.

Statistical analysis

The results of the systematic review were summarized quantitatively into frequentist random effect meta-analysis of pooled risk ratio (RR) and standardized mean difference (SMD). An inverse-variance method and DerSimonian–Laird estimator for the variance of the true effect size (τ2) were performed [16]. Heterogeneity among studies was evaluated by the I2 index and Cochran’s Q test. Statistical heterogeneity (I2) was stratified as low (< 25%), moderate (25–75%), or high and significant when p < 0.10 [17, 18]. The Wald-type 95% confidence interval (CI) was computed for pooled measurements; otherwise, the 95% CI for the I² index was calculated according to Higgins and Thompson [18]. The prediction interval for the treatment effect of a new study was calculated according to Borenstein et al. [17]. As the sample size was not the same in all studies, we performed a sensitivity analysis by excluding one study each time and rerunning the analysis to verify the robustness of the overall results. The publication bias was also investigated with the trim and fill funnel plot and Egger test. A two-sided p value was considered statistically significant when p < 0.05. All analyses and figures were carried out using the R software program, version 3.2.2 [19].

Results

Literature search

The PRISMA flow chart is reported in Fig. 1. Overall, 5443 publications were identified. After duplicates removal, 5438 titles were screened. After title and abstract evaluation 18 articles were found possibly relevant for full-text assessment. After full-text analysis, 12 [20–31] studies meet the inclusion/exclusion criteria and were encompassed in the quantitative synthesis.

Fig. 1.

Fig. 1

Open in a new tab

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram

Risk of bias assessment

The quality of included RCTs is reported in Supplementary Table 1. All RCTs had a single-center design. Randomization methods were specified in nine RCTs [20–22, 24, 25, 27, 28, 30, 31], while details on the blinding of perioperative outcomes were provided in one study [31]. Power analysis was clarified in five RCTs [20, 28–31]. Three RCTs provide specific data regarding the operating surgeon proficiency [20, 23, 31] whereas none reported specific details regarding the surgical quality control. Given all these limitations regarding randomization, power analysis, blinding, outcomes assessment and lack of quality controls all the included trials were deemed to have an intermediate risk of bias (Supplementary Fig. 1).

Systematic review

Overall, 2015 patients that underwent esophagectomy for cancer were included (Table 1 [20–31]). Of those 1045 (51.9%) underwent ST while 970 (48.1%) underwent HS anastomosis. The age of the patient population ranged from 37 to 88 years, the majority (72.7%) were males. The preoperative BMI was not reported in any of the included trials and the ASA score was reported in one study [31]. Tumor histology was specified in 6 studies [21, 23–25, 29, 31]; squamous cell carcinoma and adenocarcinoma were diagnosed in 76.9% and 20.7% of patients, respectively. Pathological tumor staging according to the 7th edition of the American Joint Committee on Cancer (AJCC) and 6th Union for Internation Cancer control (UICC) was detailed in 8 studies [21, 24–26, 29–31] (stage 0–I: 16.8%, stage II: 39.7%, stage III: 43.2%, and stage IV: 0.3%). The tumor was located in the upper (5.6%), middle (57.5%), and lower (36.9%) esophagus. Neoadjuvant chemotherapy or chemoradiation therapy was defined in 5 studies [23, 24, 28, 30, 31] (891 patients) and completed in 32.9% of patients with heterogeneous strategies (i.e. protocols, regimens, dosages, radiation fractioning, etc.). Open Ivor-Lewis or McKeown esophagectomy were performed depending on operating surgeon preference, tumor location, and histology, all procedures and anastomoses were performed with open technique. Cervical and intrathoracic anastomosis were fashioned in 42.8% and 57.2% of patients, respectively. The technique for anastomosis was detailed in all studies; HS anastomosis was performed with one layer in six studies and two layers in five studies with both absorbable and non-absorbable sutures as per operating surgeon preference. Circular stapled end-to-end or end-to-side anastomosis with diverse stapling devices and size was described in 10 studies [20–27, 29, 30]. Linear stapled anastomosis was labeled in 2 studies [28, 31] both performing cervical Orringer or Collard side-to-side anastomosis (Supplementary Table 2).

Table 1.

Demographic and clinical characteristics of patients undergoing hand-sewn (HS) or stapled (ST) anastomosis. Tumour location (T Location); neoadjuvant therapy (NADJ); histology (Squamous cell carcinoma SCC – Adenocarcinoma ADK – Other); hospital length of stay (HLOS), cardiovascular complication (CV), pulmonary complication (P). Data are reported as numbers, mean ± standard deviation, median (range)

Author, country, year Period Anastomotic technique No.
pts		 Age (yrs) M/F Tumor location
(U-M-L)		 NADJ Histology
SCC-ADK-Other		 Stage
0-I		 Stage
IIa		 Stage
IIb		 Stage III Stage IV
Valverde, France, 1996 20 1991–1994 HS 74 59 ± 9 67/7 0-39-35 nr nr nr nr nr nr nr
SA 78 59 ± 10 71/7 0-42-36 nr nr nr nr nr nr nr
Law, Hong Kong, 1997 21 1989–1995 HS 61 64 ± 1,2 54/7 0-50-11 nr 61-0-0 3 9 5 44 0
SA 61 63 ± 1 53/8 0-51-10 nr 61-0-0 2 6 2 51 0
Laterza, Italy, 1999 22 1993–1996 HS 21 50,9 4/17 6-12-3 nr nr nr nr nr nr nr
SA 20 51,9 3/17 4-12-4 nr nr nr nr nr nr nr
Walther, Sweden, 2003 23 1990–1996 HS 41 68 ± 8,25 28/13 3-20-16 0 25-14-2 7 5 27 0
SA 42 66 ± 10 29/13 1-10-24 0 17-18-7 6 6 23 0
Hsu, Taiwan, 2004 24 1996–1999 HS 32 63 ± 10 27/5 10-10-12 17 32-0-0 2 6 7 17 0
SA 31 61 ± 12 30/1 6-16-9 16 31-0-0 1 5 7 18 0
Okuyama, Japan, 2007 25 1996–1999 HS 18 64,3 ± 6,75 16/2 0-13-5 nr 17-0-1 6 1 7 4 0
SA 14 63,6 ± 3,75 13/1 0-10-4 nr 13-0-1 4 1 2 7 0
Luechakiettisak, Thailand, 2008 26 2000–2005 HS 59 63.6 ± 7,25 50/9 0-31-28 nr nr 1 12 46 0
SA 58 62 ± 7,25 48/10 0-26-32 nr nr 2 14 42 0
Zhang, China, 2010 27 2002–2007 HS 244 60 ± 1.3 142/102 125 *- 119 ** nr nr nr nr nr nr nr
SA 272 59 ± 1.2 158/114 134 *- 138 ** nr nr nr nr nr nr nr
Saluja, India, 2012 28 2004–2010 HS 87 50.9 ± 14 54/33 0-45-35 51 nr nr nr nr nr nr
SA 87 51.4 ± 12 61/26 0-39-45 56 nr nr nr nr nr nr
Wang, China, 2013 29 2007–2008 HS 52 58.9 ± 7.3 40/12 0-43-9 nr 131 -12-1 6 19 3 22 2
SA 92 61.4 ±7.7 82/10 0-65-27 nr 10 28 6 48 0
Liu, China, 2015 30 2009–2011 HS 237 61 ± 9 176/61 42-138-57 29 nr 26 65 80 66 nr
SA 241 62 ± 8 183/58 40-145-56 35 nr 28 70 79 64 nr
Nederlof, Netherlands, 2020 31 2011–2014 HS 44 65 ± 23 40/4 34 * − 10 ** 39 7-36-1 23 3 6 12 0
SA 49 64 ± 19 36/13 38 * − 11 ** 46 18-31-0 20 6 5 16 2
Open in a new tab

Meta-analysis – primary outcomes

AL was reported in all studies (2015 patients). The cumulative incidence of AL was similar between ST and HS anastomosis (6.9% vs. 7.5%). No significant differences were found for ST vs. HS (RR 0.97; 95% CI 0.70–1.35; p = 0.857) (Fig. 2A). The prediction lower and upper limits were 0.60 and 1.56, respectively. The heterogeneity was 21% (I2 = 21%) and τ2 = 0.01. The funnel plot (Fig. 2B) and the Egger test (p = 0.95) did not show evidence of publication bias. The sensitivity analysis showed the robustness of these findings in terms of point estimation, relative confidence intervals, and heterogeneity. No differences were found for ST vs. HS after stratification for cervical (4 studies) (RR 1.30; 95% CI 0.87–1.92; p = 0.727; I2 = 0.0%) and thoracic anastomosis (3 studies) (RR 1.76; 95% CI 0.39–7.99; p = 0.182 I2 = 41.2%).

Fig. 2.

Fig. 2

Fig. 2

Open in a new tab

Anastomotic leak. Forrest A and Funnel B plot. RR: Risk ratio; 95% CI: Confidence Interval

AS was reported in all studies and for 1863 patients (considering lost at follow-up). The cumulative incidence of AS was similar between HS and ST anastomosis (4.7% vs. 7.3%). No significant differences were found for ST vs. HS (RR 1.47; 95% CI 0.96–2.23; p = 0.073) (Fig. 3A). The prediction lower and upper limits were 0.42 and 5.17, respectively. The heterogeneity was moderate (I2 = 54.7%) and τ2 = 0.28. The funnel plot (Fig. 3B) and Egger’s test (p = 0.04) suggest potential asymmetry, which may indicate the presence of publication bias. Nevertheless, sensitivity analyses confirmed the robustness of the findings in terms of point estimates, confidence intervals, and heterogeneity. No differences were found for ST vs. HS after stratification for cervical (4 studies) (RR 1.53; 95% CI 0.75–3.11; p = 0.451; I2 = 72.2%) and thoracic anastomosis (3 studies) (RR 1.61; 95% CI 0.49–4.27; p = 0.197 I2 = 38.4%).

Fig. 3.

Fig. 3

Fig. 3

Open in a new tab

Anastomotic stricture. Forrest A and Funnel B plot. RR: Risk ratio; 95% CI: Confidence Interval

Meta-analysis – secondary outcomes

No significant differences were found for ST vs. HS anastomosis when considering cardiovascular complications (RR 1.09; p = 0.59), pulmonary complication (RR 1.12; p = 0.28), HLOS (SMD 0.03; p = 0.69), and 30-day mortality (RR 1.30; p = 0.18) (Table 2). OT was significantly shorted in ST vs. HS anastomosis (SMD − 0.11; 95% CI -0.21, -0.03; p = 0.002).

Table 2.

Summary of the analysis of the categorical and continuous outcomes comparing HS vs. ST

Outcomes No. Studies No. pts Heterogeneity
I2 (%) 95% CI
Mortality 11 1871 1.30 (0.88; 1.93) ♦ 0 0–60
Cardiovascular complications 7 1502 1.09 (0.80; 1.49) ♦ 0 0–71
Pulmonary complications 9 1656 1.12 (0.91; 1.37) ♦ 0 0–65
Operative time (min) 10 1890 -0.11 (-0.21; -0.03) * 0 0–62
HLOS (day) 5 891 0.03 (-0.10; 0.16) * 0 0–79
Open in a new tab

♦ Risk ratio, * Standardized mean difference, (95% Confidence Interval), I2 Heterogeneity

Discussion

This meta-analysis indicates that ST and HS esophagogastric anastomosis yield comparable rates of AL, AS, postoperative complications, and in-hospital mortality. The use of ST anastomosis may result in a shorter operative time.

Esophagogastric anastomosis is regarded as the most technically demanding step of esophagectomy [32]. AL is a major complication, with reported incidence rates between 10% and 20% [1]. This complication is associated with increased postoperative morbidity, elevated mortality rates, prolonged hospitalizations, and higher healthcare costs [4, 5, 33, 34]. Moreover, AL has been shown to negatively affect long-term quality of life and oncological outcomes [4, 7]. Several factors may contribute to anastomotic failure, including the absence of a serosal layer and longitudinal orientation of muscle fibers, tension at the anastomotic site, anatomical location (cervical vs. thoracic), insufficient blood supply to the gastric conduit, surgical approach, malnutrition, and patient comorbidities [35–37]. Additionally, emerging evidence suggests that the gut microbiome may influence suture line healing and potentially contribute to anastomotic breakdown [38]. The specific technique employed for esophagogastric anastomosis has also been examined in prior studies as a variable that may affect leakage and stenosis [39]. ST and HS anastomosis are widely utilized globally, with selection often guided by the operating surgeon’s preference. However, despite a recent gradual shift toward ST anastomosis, definitive evidence favoring one technique over the other remains to be established. In our study, the estimated incidence of AL for HS and ST anastomosis was 7.5% and 6.9%, respectively. No significant differences were found in the quantitative analysis (RR 0.97) with a low related heterogeneity (I2 = 21%). Our findings are similar to what previously reported by Markar et al. [40] who concluded similar postoperative odds for AL comparing HS vs. ST (OR 1.06, 95% CI = 0.62–1.80, p = 0.83). Similar results were found by Honda et al. [41] that concluded equivalent AL rates for ST vs. HS anastomosis (RR 1.02, 95% CI: 0.66–1.59). In contrast Järvinen et al. [42] concluded higher leak rates for HS compared to ST anastomosis (OR 2.02; 95% CI 1.48–2.75). Since our findings indicate no significant difference in postoperative AL rates between HS and ST anastomosis techniques, we can argue that the choice of technique to fashion the anastomosis has minimal effect on the risk of postoperative AL.

In current literature, AS has been documented in up to 30% of cases, frequently necessitating endoscopic dilation. This complication may adversely impact postoperative recovery, nutritional status, and overall quality of life. In the present study, we observed a comparable postoperative AS risk between ST and HS anastomoses (RR 1.47). The heterogeneity among studies was moderate (I²=54%) however, the sensitivity analysis confirmed the robustness of the point estimate and 95% confidence intervals. Notably, the point estimate was above 1 thus suggesting a potential clinical trend toward an increased risk of AS following ST as compared to HS anastomoses. This effect may be influenced by the prevalent use of circular stapled anastomoses rather than linear stapled techniques in the included RCTs. According to previous studies, the use of circular staplers for esophagogastric anastomosis might be associated with an increased risk of postoperative stenosis compared to linear and HS anastomosis [43]. This effect is attributed to a reduced anastomotic diameter, greater incidence of staple line scarring/fibrosis, and a lack of mucosa-to-mucosa apposition. Further, the circular stapled technique produces an inverted anastomosis in which the esophageal and gastric mucosal margins are separated by muscle layers, potentially resulting in higher rates of stricture formation. Our findings seem to align with those reported by Markar et al. [40] (OR 1.76; 95% CI, 1.09–2.86; p = 0.02) and Honda et al. [41] (RR 1.67; 95% CI 1.16–2.42), both demonstrating a higher risk of AS following ST in comparison to HS anastomosis. Although heterogeneity was low to moderate, our findings should be interpreted with caution due to potential confounding factors. These include tensions-free visceral approximation with visceral size matching, adequate blood supply at the apex of the gastric conduit [44], patient age and comorbidities, steroid administration, body morphometrics with poor nutritional status, medical history (i.e. diabetes, peripheral vasculopathy), intraoperative variables (i.e. blood transfusion, intraoperative hypotension), variations in anesthesia protocols, epidural catheter utilization, neoadjuvant therapy, and tumor characteristics (i.e. R0). Further, it is important to carefully assess the absence of standardized anastomotic techniques, as inter-operator differences exist (e.g., single-layer versus dual-layer), along with variability in circular stapler sizes (21 mm, 25 mm, 28 mm, and 31 mm), types of stapling devices (such as purse-string suture, EEATM, OrvilTM), and incidence of postoperative leaks [45, 46]. The anastomosis location is a significant factor influencing the incidence of postoperative AL and AS, with cervical anastomoses demonstrating a higher susceptibility to such complications [47–51]. Importantly, subgroup analysis based on anastomosis site (cervical versus thoracic) yielded comparable outcomes. The selection of cervical versus thoracic anastomosis in the referenced studies was not randomized but determined by tumor characteristics/location, and surgeon preference with a risk for selection bias. Notably, other than oncological considerations, some technical issue should be considered when choosing the anastomotic technique in relation to the anatomical location and some clinical considerations [52]. For instance, circular staplers are advantageous for constructing anastomoses at the apex of the thorax (cupula pleuralis) however the anastomotic lumen is dependent on the original esophageal diameter with problems related to possible size mismatch [53]. Conversely, HS and linear stapled anastomoses generate larger luminal diameters thus minimizing possible issues related to visceral mismatch. However, these techniques necessitate a longer esophageal remnant, posing challenges to the creation of a well-aligned, high intra-thoracic tension-free anastomosis due to spatial constraints. The choice of surgical approach can impact the anastomotic technique. Evidence indicates that both circular and linear stapled anastomoses are generally preferred for transthoracic minimally invasive esophagogastric procedures due to the complexity of suturing within a rigid anatomical compartment using non-articulated instruments [43, 54]. Conversely, the robotic transthoracic approach offers enhanced surgical stability, allowing for greater precision and instrument dexterity, which facilitates direct suturing [55, 56].

No differences were found in term of postoperative cardiovascular and pulmonary complications with equivalent hospital length of stay and in-hospital mortality rates. However, we observed a significantly shorter OT for ST compared to HS anastomosis (SMD − 0.11; p = 0.002). This finding might reflect the reduced time to complete the anastomosis in a stapled fashion as described by Walther [23] and colleagues that concluded a significantly longer time to perform a manual single-layer compared to a stapled anastomosis (28 vs. 15 min; p < 0.001). Also Saluja et al. [28] concluded a significantly reduce time to complete a stapled compared to a double-layer manual anastomosis (27 vs. 25 min; p = 0.02). Our findings are in accordance with Honda et al. [41], who reported a notably reduced OT for ST versus HS anastomosis (mean difference: − 15.3 min; range: − 28.1 to − 2.39). Also Markar et al. concluded significantly reduced OT for ST vs. HS anastomosis (weighted mean difference − 1.56; p = 0.04). The decreased operative time likely reflects less tissue manipulation and a more standardized approach associated with ST anastomosis compared to the HS technique.

It is important to recognize that both AL and AS are influenced not only by the anastomotic technique itself but also by factors such as surgeon proficiency, the learning curve, structured training or mentorship programs, and hospital case volumes [57–59]. Achieving optimal surgical outcomes following esophagectomy depends significantly on surgical volume and the expertise of the operating surgeon. Evidence indicates that centralizing cases in high-volume centers contributes to lower mortality rates and may enhance overall outcomes [60, 61]. Notably, studies have shown that during the learning curve, AL rates decrease from 18% in the initial phase to 4.5% after 119 cases [62]. These observations underscore that AL and AS metrics do not exclusively reflect technical choices but are substantially affected by the learning curve and the surgeon’s experience. Furthermore, advancements such as fluorescence imaging with indocyanine green for gastric conduit perfusion assessment [63–65] and the implementation of robot-assisted esophagectomy [66, 67] could provide additional improvements in patient outcomes.

The study was conducted in accordance with PRISMA guidelines, following the comprehensive methodology established by the PROSPERO protocol. This process included thorough outcome measures and quality assessments at the study level, specifically addressing risk of bias for each included RTC. The selection criteria led to a relatively homogenous population for primary outcomes, as indicated by low to moderate heterogeneity. Nonetheless, certain limitations warrant consideration. First, variations in surgeon proficiency may influence postoperative complication rates. Second, potential confounders—such as inconsistencies in surgical approaches (e.g., Ivor Lewis versus McKeown), anastomosis location (cervical or intrathoracic), and standardized postoperative management protocols—could impact some of the assessed outcomes. Importantly, as all included trials reported outcomes exclusively for open esophagectomy, our findings should be interpreted with caution in the context of minimally invasive settings. Third, substantial technical variability existed in anastomotic techniques due to individual surgeon preferences. Fourth, differences in the definitions and reporting of outcomes among the included studies were observed and might introduce publication bias. Fifth, the effects of neoadjuvant therapies on short-term postoperative outcomes remain uncertain and require further investigation [68, 69]. Furthermore, there is a potential for temporal bias since the included studies encompass more than thirty years, which may result in heterogeneity related to chemoradiation protocols as well as intraoperative and postoperative management approaches. Lastly, because the majority of studies were conducted in Eastern countries, the applicability of these findings to other populations may be limited.

Conclusions

This meta-analysis indicates that ST and HS esophagogastric anastomosis yield comparable rates of AL, AS, postoperative complications, and in-hospital mortality. The use of ST anastomosis may result in a shorter operative time. Ultimately, the choice of technique should be determined by the surgeon’s expertise and clinical scenario, as both ST and HS anastomosis demonstrate safety and efficacy when performed appropriately.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Material 1 (207.5KB, docx)
Supplementary Material 2 (14.3KB, docx)

Acknowledgements

European Foregut Society (EFS) Collaborative Group: Yves Borbely, Moustafa Elshafei , Suzanne Gisberz, Christian Gutschow, Mark Ivo van Berge Henegouwen, Sheraz Markar, Calin Popa, Diana Schlanger, Sebastian Schoppmann, Aleksandar Simić, Ognjan Skrobic, Dimitrios Theodorou.

Funding

Open access funding provided by Università degli Studi di Milano within the CRUI-CARE Agreement.

Declarations

Conflict of interest

All the authors declare no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with human participants or animals performed by any of the authors.

Informed consent

Informed consent does not apply.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Alberto Aiolfi, Email: alberto.aiolfi86@gmail.com.

European Foregut Society (EFS) Collaborative Group:

Yves Borbely, Moustafa Elshafei, Suzanne Gisberz, Christian Gutschow, Mark Ivo van Berge Henegouwen, Sheraz Markar, Calin Popa, Diana Schlanger, Sebastian Schoppmann, Aleksandar Simić, Ognjan Skrobic, and Dimitrios Theodorou

References

  • 1.Then EO, Lopez M, Saleem S, Gayam V, Sunkara T, Culliford A, Gaduputi V (2020) Esophageal cancer: an updated surveillance epidemiology and end results database analysis. World J Oncol 11:55–64. 10.14740/WJON1254 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Obermannová R, Alsina M, Cervantes A, Leong T, Lordick F, Nilsson M, van Grieken NCT, Vogel A, Smyth EC (2022) Oesophageal cancer: ESMO clinical practice guideline for Diagnosis, treatment and Follow-Up. Ann Oncol 33:992–1004. 10.1016/j.annonc.2022.07.003 [DOI] [PubMed] [Google Scholar]
  • 3.Aiolfi A, Cammarata F, Bonitta G, Bona D, Bonavina LOPEN, Hybrid (2025) Minimally Invasive, and Robotic-Assisted transthoracic esophagectomy for cancer A network Meta-Analysis of randomized trials. Int J Surg. 10.1097/js9.0000000000002985 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Turrentine FE, Denlinger CE, Simpson VB, Garwood RA, Guerlain S, Agrawal A, Friel CM, Lapar DJ, Stukenborg GJ, Jones RS, Morbidity (2015) Mortality, Cost, and survival estimates of Gastrointestinal anastomotic leaks. J Am Coll Surg 220:195–206. 10.1016/j.jamcollsurg.2014.11.002 [DOI] [PubMed] [Google Scholar]
  • 5.Zhong Y, Sun R, Li W, Wang W, Che J, Ji L, Guo B, Zhai C (2024) Risk Factors for Esophageal Anastomotic Stricture after Esophagectomy: A Meta-Analysis. BMC Cancer 24 [DOI] [PMC free article] [PubMed]
  • 6.Na B, Kang CH, Na KJ, Park S, Park IK, Kim YT (2023) Risk factors of anastomosis stricture after esophagectomy and the impact of anastomosis technique. Ann Thorac Surg 115:1257–1264. 10.1016/j.athoracsur.2023.01.026 [DOI] [PubMed] [Google Scholar]
  • 7.Dell’Anna G, Fanizza J, Mandarino FV, Barchi A, Fasulo E, Vespa E, Fanti L, Azzolini F, Battaglia S, Puccetti F et al (2025) The endoscopic management of anastomotic strictures after esophagogastric surgery: A comprehensive review of emerging approaches beyond endoscopic dilation. J Pers Med 15 [DOI] [PMC free article] [PubMed]
  • 8.Bundred JR, Kamarajah SK, Siaw-Acheampong K, Nepogodiev D, Jefferies B, Singh P, Evans R, Griffiths EA, Alderson D, Gossage J et al (2019) International variation in surgical practices in units performing oesophagectomy for oesophageal cancer: A unit survey from the Oesophago-Gastric anastomosis audit (OGAA). World J Surg 43:2874–2884. 10.1007/s00268-019-05080-1 [DOI] [PubMed] [Google Scholar]
  • 9.Kim RH, Takabe K (2010) Methods of esophagogastric anastomoses following esophagectomy for cancer: A systematic review. J Surg Oncol 101:527–533 [DOI] [PubMed] [Google Scholar]
  • 10.Kamarajah SK, Bundred JR, Singh P, Pasquali S, Griffiths EA (2020) Anastomotic techniques for oesophagectomy for malignancy: systematic review and network Meta-Analysis. BJS Open 4:563–576 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Milone M, Kooij CD, Manigrasso M, Goense L, van Det MJ, Kouwenhoven EA, Gisbertz SS, Müller BP, Lingohr P, Fujita T et al (2025) Anastomotic leakage following Robot-Assisted minimally invasive esophagectomy (RAMIE): which anastomosis should be preferred? Surg Endosc 39:5604–5612. 10.1007/s00464-025-11977-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Kooij CD, de Jongh C, Kingma BF, van Berge Henegouwen MI, Gisbertz SS, Chao YK, Chiu PW, Rouanet P, Mourregot A, Immanuel A et al (2025) The current state of Robot-Assisted minimally invasive esophagectomy (RAMIE): outcomes from the upper GI international robotic association (UGIRA) esophageal registry. Ann Surg Oncol 32:823–833. 10.1245/s10434-024-16364-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE et al (2021) The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews. The BMJ 372 [DOI] [PMC free article] [PubMed]
  • 14.Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, Savović J, Schulz KF, Weeks L, Sterne JAC (2011) The Cochrane collaboration’s tool for assessing risk of bias in randomised trials. BMJ (Online) 343. 10.1136/bmj.d5928 [DOI] [PMC free article] [PubMed]
  • 15.McGuinness LA, Higgins JPT (2021) Risk-of-Bias VISualization (Robvis): An R Package and Shiny Web App for Visualizing Risk-of-Bias Assessments. In Proceedings of the Research Synthesis Methods; John Wiley and Sons Ltd, January 1 ; Vol. 12, pp. 55–61 [DOI] [PubMed]
  • 16.Dersimonian R, Laird N Meta-Analysis in Clinical Trials* [DOI] [PubMed]
  • 17.Borenstein M, Hedges LV, Higgins JPT, Rothstein HR (2010) A basic introduction to Fixed-Effect and Random-Effects models for Meta-Analysis. Res Synth Methods 1:97–111. 10.1002/jrsm.12 [DOI] [PubMed] [Google Scholar]
  • 18.Higgins JPT, Thompson SG, Deeks JJ, Altman DG Measuring Inconsistency in Meta-Analyses Testing for Heterogeneity [DOI] [PMC free article] [PubMed]
  • 19.R Core Team R (2023) A Language and Environment for Statistical Computing; R Foundation for Statistical Computing
  • 20.Valverde A, Hay J-M, Fingerhut A, Elhadad A (1996) Manual versus Mechanical Esophagogastric Anastomosis after Resection for Carcinoma: A Controlled Trial [DOI] [PubMed]
  • 21.Law S, Fok M, Chu K-M, Wong J (1997) Comparison of Hand-Sewn and Stapled Esophagogastric Anastomosis After Esophageal Resection for Cancer A Prospective Randomized Controlled Trial; ; Vol. 226 [DOI] [PMC free article] [PubMed]
  • 22.Laterza E, De’ Manzoni G, Franco Veraldi G, Guglielmi A, Tedesco P, Cordiano C Manual Compared with Mechanical Cervical Oesophagogastric Anastomosis: A Randomised Trial [DOI] [PubMed]
  • 23.Walther B, Johansson J, Johnsson F, Von Holstein CS, Zilling T, Peracchia A, Lerut T (2003) Cervical or Thoracic Anastomosis after Esophageal Resection and Gastric Tube Reconstruction: A Prospective Randomized Trial Comparing Sutured Neck Anastomosis with Stapled Intrathoracic Anastomosis. In Proceedings of the Annals of Surgery; Lippincott Williams and Wilkins, ; Vol. 238, pp. 803–814 [DOI] [PMC free article] [PubMed]
  • 24.Hsu HH, Chen JS, Huang PM, Lee JM, Lee YC (2004) Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: A prospective randomized controlled trial. Eur J Cardiothorac Surg 25:1097–1101. 10.1016/j.ejcts.2004.02.026 [DOI] [PubMed] [Google Scholar]
  • 25.Okuyama M, Motoyama S, Suzuki H, Saito R, Maruyama K, Ogawa JI (2007) Hand-Sewn cervical anastomosis versus stapled intrathoracic anastomosis after esophagectomy for middle or lower thoracic esophageal cancer: A prospective randomized controlled study. Surg Today 37:947–952. 10.1007/s00595-007-3541-5 [DOI] [PubMed] [Google Scholar]
  • 26.Luechakiettisak P, Kasetsunthorn S (2008) Comparison of Hand-Sewn and Stapled in Esophagogastric Anastomosis after Esophageal Cancer Resection: A Prospective Randomized Study; ; Vol. 91 [PubMed]
  • 27.Zhang YS, Gao BR, Wang HJ, Su YF, Yang YZ, Zhang JH, Wang C (2010) Comparison Anastomotic Leakage Stricture Formation Following Layer Stapler Oesophagogastric Anastomosis Cancer: Prospective Randomized Controlled Trial ; ; Vol. 38 [DOI] [PubMed]
  • 28.Saluja SS, Ray S, Pal S, Sanyal S, Agrawal N, Dash NR, Sahni P, Chattopadhyay TK (2012) Randomized trial comparing Side-to-Side stapled and Hand-Sewn esophagogastric anastomosis in neck. J Gastrointest Surg 16:1287–1295. 10.1007/s11605-012-1885-7 [DOI] [PubMed] [Google Scholar]
  • 29.Wang WP, Gao Q, Wang KN, Shi H, Chen LQ (2013) A prospective randomized controlled trial of Semi-Mechanical versus Hand-Sewn or circular stapled esophagogastrostomy for prevention of anastomotic stricture. World J Surg 37:1043–1050. 10.1007/s00268-013-1932-x [DOI] [PubMed] [Google Scholar]
  • 30.Liu QX, Qiu Y, Deng XF, Min JX, Dai JG (2015) Comparison of outcomes following End-to-End Hand-Sewn and mechanical oesophagogastric anastomosis after oesophagectomy for carcinoma: A prospective randomized controlled trial. Eur J Cardiothorac Surg 47:e118–e123. 10.1093/ejcts/ezu457 [DOI] [PubMed] [Google Scholar]
  • 31.Nederlof N, Tilanus HW, de Vringer T, van Lanschot JJB, Willemsen SP, Hop WCJ, Wijnhoven BPL (2020) A single blinded randomized controlled trial comparing Semi-Mechanical with Hand-Sewn cervical anastomosis after esophagectomy for cancer (SHARE-Study). J Surg Oncol 122:1616–1623. 10.1002/jso.26209 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 32.Anastomotic Leak Following Oesophagectomy (2021) Research priorities from an international Delphi consensus study. Br J Surg 108. 10.1093/bjs/znaa034 [DOI] [PubMed]
  • 33.Ubels S, Klarenbeek B, Verstegen M, Bouwense S, Griffiths EA, van Workum F, Rosman C, Hannink G (2023) Predicting mortality in patients with anastomotic leak after esophagectomy: development of a prediction model using data from the TENTACLE—Esophagus study. Dis Esophagus 36:1–9. 10.1093/dote/doac081 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 34.Aiolfi A, Asti E, Rausa E, Bonavina G, Bonitta G, Bonavina L (2018) Use of C-Reactive protein for the early prediction of anastomotic leak after esophagectomy: systematic review and bayesian Meta-Analysis. PLoS ONE 13. 10.1371/journal.pone.0209272 [DOI] [PMC free article] [PubMed]
  • 35.Dewar L, Gelfand G, Finley RJ, Evans K, Columbia B, InCUlt R, Nelems B Factors Affecting Cervical Anastomotic Leak and Stricture Formation Following Esophagogastrectomy and Gastric Tube Interposition [DOI] [PubMed]
  • 36.Bonavina L (2021) Progress in the esophagogastric anastomosis and the challenges of minimally invasive thoracoscopic surgery. Ann Transl Med 9:907–907. 10.21037/atm.2020.03.66 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Kamarajah SK, Evans RPT, Nepogodiev D, Hodson J, Bundred JR, Gockel I, Gossage JA, Isik A, Kidane B, Mahendran HA et al (2022) The influence of anastomotic techniques on postoperative anastomotic complications: results of the Oesophago-Gastric anastomosis audit. J Thorac Cardiovasc Surg 164(e5):674–684. 10.1016/j.jtcvs.2022.01.033 [DOI] [PubMed] [Google Scholar]
  • 38.Russ AJ, Casillas MA (2016) Gut microbiota and colorectal surgery: impact on postoperative complications. Clin Colon Rectal Surg 29:253–257. 10.1055/s-0036-1584502 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 39.Davey MG, Donlon NE, Elliott JA, Robb WB, Bolger JC (2025) Optimal Oesophagogastric Anastomosis Techniques for Oesophageal Cancer Surgery – A Systematic Review and Network Meta-Analysis of Randomised Clinical Trials. European Journal of Surgical Oncology 51 [DOI] [PubMed]
  • 40.Markar SR, Karthikesalingam A, Vyas S, Hashemi M, Winslet M (2011) Hand-Sewn versus stapled Oesophago-Gastric anastomosis: systematic review and Meta-Analysis. J Gastrointest Surg 15:876–884 [DOI] [PubMed] [Google Scholar]
  • 41.Honda M, Kuriyama A, Noma H, Nunobe S, Furukawa TA (2013) Hand-Sewn versus mechanical esophagogastric anastomosis after esophagectomy: A systematic review and Meta-Analysis. Ann Surg 257:238–248 [DOI] [PubMed] [Google Scholar]
  • 42.Järvinen T, Cools-Lartigue J, Robinson E, Räsänen J, Ilonen I (2021) Hand-Sewn versus stapled anastomoses for esophagectomy: we will probably never know which is better. JTCVS Open 7:338–352. 10.1016/j.xjon.2021.07.021 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Aiolfi A, Sozzi A, Bonitta G, Lombardo F, Cavalli M, Cirri S, Campanelli G, Danelli P, Bona D (2022) Linear- versus Circular-Stapled esophagogastric anastomosis during esophagectomy: systematic review and Meta-Analysis. Langenbecks Arch Surg 407:3297–3309 [DOI] [PubMed] [Google Scholar]
  • 44.Aiolfi A, Bona D, Bonitta G, Bonavina L, Cayre L, Guerrazzi G, Gutschow CA, Lipham J, Manara M, Popa C et al (2024) Short-Term outcomes of different techniques for gastric ischemic preconditioning before esophagectomy: A network Meta-Analysis. Ann Surg 279:410–418. 10.1097/SLA.0000000000006124 [DOI] [PubMed] [Google Scholar]
  • 45.Uzun E, d’Amore A, Berlth F, Mann C, Tagkalos E, Hadzijusufovic E, Lang H, Grimminger PP (2024) Anterior gastric wall anastomosis May lead to lower rate of delayed gastric emptying after minimally invasive Ivor Lewis esophagectomy: A retrospective cohort study. Surg Endosc 38:1950–1957. 10.1007/s00464-024-10696-z [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Ubels S, Verstegen M, Bouwense S, Hannink G, Siersema P, Klarenbeek B, Van Workum F, Rosman C (2022) 124: DETERMINING SEVERITY OF ESOPHAGEAL ANASTOMOTIC LEAK IN PATIENTS AFTER ESOPHAGECTOMY: DEVELOPMENT OF THE SEAL SCORE. Dis Esophagus 35. 10.1093/dote/doac015.124
  • 47.Bonavina L, Scolari F, Aiolfi A, Bonitta G, Sironi A, Saino G, Asti E (2016) Early outcome of thoracoscopic and hybrid esophagectomy: Propensity-Matched comparative analysis. Surg (United States) 159:1073–1081. 10.1016/j.surg.2015.08.019 [DOI] [PubMed] [Google Scholar]
  • 48.You J, Zhang H, Li W, Dai N, Lu B, Ji Z, Zhuang H, Zheng Z (2022) Intrathoracic versus cervical anastomosis in esophagectomy for esophageal cancer: A Meta-Analysis of randomized controlled trials. Surg (United States) 172:575–583. 10.1016/j.surg.2022.03.006 [DOI] [PubMed] [Google Scholar]
  • 49.Van Workum F, Verstegen MHP, Klarenbeek BR, Bouwense SAW, Van Berge Henegouwen MI, Daams F, Gisbertz SS, Hannink G, Haveman JW, Heisterkamp J et al (2021) Intrathoracic vs cervical anastomosis after totally or hybrid minimally invasive esophagectomy for esophageal cancer: A randomized clinical trial. JAMA Surg 156:601–610. 10.1001/jamasurg.2021.1555 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Jamasurgery_merritt_2021_ic_210019_1625867453.38507
  • 51.Carr RA, Molena D (2021) Minimally invasive esophagectomy: anastomotic techniques. Annals Esophagus 3
  • 52.Bonavina L, Asti E, Sironi A, Bernardi D, Aiolfi A (2017) Hybrid and total minimally invasive esophagectomy: how I do it. J Thorac Dis 9:S761–S772 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Jung JO, de Groot EM, Kingma BF, Babic B, Ruurda JP, Grimminger PP, Hölzen JP, Chao YK, Haveman JW, van Det MJ et al (2023) Hybrid laparoscopic versus fully Robot-Assisted minimally invasive esophagectomy: an international Propensity-Score matched analysis of perioperative outcome. Surg Endosc 37:4466–4477. 10.1007/s00464-023-09911-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Schröder W, Raptis DA, Schmidt HM, Gisbertz SS, Moons J, Asti E, Luyer MDP, Hölscher AH, Schneider PM, Van Berge Henegouwen MI et al (2019) Anastomotic techniques and associated morbidity in total minimally invasive transthoracic esophagectomy: results from the EsoBenchmark database. Ann Surg 270:820–826. 10.1097/SLA.0000000000003538 [DOI] [PubMed] [Google Scholar]
  • 55.van der Sluis PC, Babic B, Uzun E, Tagkalos E, Berlth F, Hadzijusufovic E, Lang H, Gockel I, van Hillegersberg R, Grimminger PP (2022) Robot-Assisted and conventional minimally invasive esophagectomy are associated with better postoperative results compared to hybrid and open transthoracic esophagectomy. Eur J Surg Oncol 48:776–782. 10.1016/j.ejso.2021.11.121 [DOI] [PubMed] [Google Scholar]
  • 56.Mann C, Jezycki T, Berlth F, Hadzijusufovic E, Uzun E, Mähringer-Kunz A, Lang H, Klöckner R, Grimminger PP (2023) Effect of thoracic cage width on surgery time and postoperative outcome in minimally invasive esophagectomy. Surg Endosc 37:8301–8308. 10.1007/s00464-023-10340-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 57.Schlottmann F, Strassle PD, Charles AG, Patti MG (2018) Esophageal cancer surgery: spontaneous centralization in the US contributed to reduce mortality without causing health disparities. Ann Surg Oncol 25:1580–1587. 10.1245/s10434-018-6339-3 [DOI] [PubMed] [Google Scholar]
  • 58.Aiolfi A, Bona D, De Bernardi S, Bonitta G, Wang Q, Biondi A, Bonavina L (2025) Impact of centralizing esophageal cancer surgery at High-Volume centers on Long-Term survival: individual patient data Meta-Analysis. Ann Surg Oncol. 10.1245/s10434-025-17823-7 [DOI] [PubMed] [Google Scholar]
  • 59.Van Jan B, Lanschot J, Hulscher JBF, Buskens CJ, Tilanus HW, Ten Kate FJW, Obertop H (2001) Hospital volume and hospital mortality for esophagectomy. Cancer 91:1574–1578. 10.1002/1097-0142(20010415)91:8<1574::AID-CNCR1168>3.0.CO;2-2 [DOI] [PubMed] [Google Scholar]
  • 60.Ohn J, Irkmeyer DB, Ndrea A, Iewers ES, Mily E, Inlayson VAF, Tukel HAS, Ee FL, Ucas L, Da I et al (2002) Special Article 1128 · ; ; Vol. 346
  • 61.Chang AC (2018) Centralizing esophagectomy to improve outcomes and enhance clinical research: invited expert review. Ann Thorac Surg 106:916–923 [DOI] [PubMed] [Google Scholar]
  • 62.Claassen L, van Workum F, Rosman C (2019) Learning curve and postoperative outcomes of minimally invasive esophagectomy. J Thorac Dis 11:S777–S785 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 63.Sozzi A, Bona D, Yeow M, Habeeb TAAM, Bonitta G, Manara M, Sangiorgio G, Biondi A, Bonavina L, Aiolfi A (2024) Does Indocyanine Green Utilization during Esophagectomy Prevent Anastomotic Leaks? Systematic Review and Meta-Analysis. J Clin Med 13 [DOI] [PMC free article] [PubMed]
  • 64.de Groot EM, Kuiper GM, van der Veen A, Fourie L, Goense L, van der Horst S, van den Berg JW, van Hillegersberg R, Ruurda JP (2023) Indocyanine green fluorescence in Robot-Assisted minimally invasive esophagectomy with intrathoracic anastomosis: A prospective study. Updates Surg 75:409–418. 10.1007/s13304-022-01329-y [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Pather K, Deladisma AM, Guerrier C, Kriley IR, Awad ZT (2022) Indocyanine green perfusion assessment of the gastric conduit in minimally invasive Ivor Lewis esophagectomy. Surg Endosc 36:896–903. 10.1007/s00464-021-08346-9 [DOI] [PubMed] [Google Scholar]
  • 66.Kersebaum JN, Möller T, Becker T, Egberts JH (2021) Robotic resection for esophageal cancer. Eur Surg - Acta Chir Austriaca 53:133–141. 10.1007/s10353-020-00675-8 [Google Scholar]
  • 67.Gritsiuta AI, Esper CJ, Parikh K, Parupudi S, Petrov RV (2025) Anastomotic Leak After Esophagectomy: Modern Approaches to Prevention and Diagnosis. Cureus10.7759/cureus.80091 [DOI] [PMC free article] [PubMed]
  • 68.Steering Committee, Alderson D, Bundred J, Rpt E, Gossage J, Griffiths EA, Jefferies B, Kamarajah SK, McKay S, Mohamed et al (2023) Postoperative and pathological outcomes of CROSS and FLOT as neoadjuvant therapy for esophageal and junctional adenocarcinoma: an international cohort study from the oesophagogastric anastomosis audit (OGAA). Ann Surg 277:E1026–E1034. 10.1097/SLA.0000000000005394 [DOI] [PubMed] [Google Scholar]
  • 69.Hoeppner J, Brunner T, Schmoor C, Bronsert P, Kulemann B, Claus R, Utzolino S, Izbicki JR, Gockel I, Gerdes B et al (2025) Perioperative chemotherapy or preoperative chemoradiotherapy in esophageal cancer. N Engl J Med 392:323–335. 10.1056/nejmoa2409408 [DOI] [PubMed] [Google Scholar]
  • 70.Alberto, Aiolfi Ewen A., Griffiths Andrea, Sozzi Michele, Manara Gianluca, Bonitta Luigi, Bonavina Davide, Bona (2023) Effect of Anastomotic Leak on Long-Term Survival After Esophagectomy: Multivariate Meta-analysis and Restricted Mean Survival Times Examination Annals of Surgical Oncology 30(9) 5564-5572 10.1245/s10434-023-13670-6 [DOI] [PubMed]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplementary Material 1 (207.5KB, docx)
Supplementary Material 2 (14.3KB, docx)

Articles from Updates in Surgery are provided here courtesy of Springer

RESOURCES