Table 1:
Best evidence papers
| Author, date, journal and country Study type (level of evidence) | Patient group | Outcomes | Key results | Comments |
|---|---|---|---|---|
| Chasseray et al. (1989), Surg Gynaecol Obstet, France [2] Prospective randomized trial (level 2) |
Prospective randomized study (n = 123) comparing cervical (n = 43) and intrathoracic (n = 49) anastomoses following oesophagectomy for squamous cell carcinoma In total 31 patients excluded because of noncompliance with randomization Cervical anastomosis group treated with three-stage approach (n = 35) or transhiatal approach (n = 8). Intrathoracic anastomosis performed with two-stage approach (n = 49) The groups were comparable with respect to smoking, alcohol abuse, pre-existing pulmonary disease, serum albumin concentration and weight loss |
Length of operation (h) [median (range)] Transfusion requirements (ml) [median (range)] Length of macroscopically normal oesophagus above tumour (cm) [median (range)] Length of hospital stay (days) [median (range)] Median survival (months) [median (range)] 30-day mortality rate (%) Fistula formation (%) Stricture formation (%) Respiratory complications (%) Chylothorax Other (cardiac failure, myocardial infarction, septicaemia, acute cholecystitis, pulmonary embolus) |
Cervical vs intrathoracic 7 (4.5–10.0) vs 7 (3.5–10) 1250 (0–8500) vs 1250 (0–5000) 4 (0.2–9.0) vs 1.5 (0.2–9.5), P < 0.05 19.5 (3–71) vs 18 (2–122) 23 (1–52) vs 20 (1–48) 4 (9.3%) vs 7 (14.2), P = NS 11 (26%) vs 2 (4%), P < 0.02 23 (53%) vs 14 (29%), P = NS 7 (16%) vs 15 (29%), P = NS 2 (5%) vs 4 (8%), P = NS 6 (14%) vs 6 (12%), P = NS |
Cervical anastomosis associated with significantly increased risk of anastomotic leak Authors attribute increased incidence of anastomotic leak in cervical anastomosis to excessive mobilization of oesophagus and increased tension on conduit promoting ischaemia at anastomotic site No significant difference between groups with respect to cardiorespiratory complications, post-operative mortality or length of hospital stay Limitations: Methodology not standardized with respect to approach for cervical anastomosis, positioning of gastric tubes and pyloroplasty procedure. Operative technique may have promoted selection bias |
| Okuyama et al. (2007), Surg Today, Japan [3] Prospective randomized trial (level 2) |
Prospective randomized study comparing hand-sewn cervical anastomosis (n = 18) and stapled intrathoracic (n = 14) anastomosis following oesophagectomy for middle or lower thoracic oesophageal cancer Cervical anastomosis performed through three-stage approach and intrathoracic anastomosis performed with two-stage approach All patients underwent routine post-operative bronchoscopy and water-soluble contrast medium. Patients with metastases excluded from study |
Operating time (min) (mean ± SD) Blood loss (ml) (mean ± SD) Number of dissected lymph nodes (mean ± SD) Anastomotic leaks Recurrent laryngeal nerve palsy Pneumonia Hospital mortality Diameter of anastomosis (mm) (mean ± SD) Anastomotic stricture |
Cervical vs intrathoracic 547 ± 95 vs 593 ± 57, P = NS 537 ± 281 vs 702 ± 252, P = NS 53 ± 21 vs 48 ± 17, P = NS 3 (16.7%) vs 1 (7.1%), P = NS 8 (38.8%) vs 1 (7.1%), P < 0.05 2 (11.1%) vs 5 (35.7%), P = NS 0 vs 0, P = NS 14 ± 6 vs 15 ± 5, P = NS 0 vs 2 (14.2%), P = NS |
No significant difference between the two groups with respect to the rate of anastomotic leak, stricture formation, recurrent laryngeal nerve injury (RLN) or symptoms 6 months after surgery Increased incidence of RLN injury and greater proximal resection margins with cervical anastomosis did not impact on post-operative symptoms and survival Limitations: small sample size, variations in anastomotic approach and technique |
| Ribet et al. (1992), J Thoracic Cardiovasc Surg, France [4] Prospective randomized trial (level 2) |
Prospective randomized trial comparing clinical and pathological outcomes in oesophagectomy with cervical (n = 30) and intrathoracic anastomosis (n = 28) Tumours staged pre-operatively (UICC 1987): Stage I, n = 2; Stage II, n = 19; Stage III, n = 9; Stage IV, n = 30; and were almost equally distributed amongst the two groups Intrathoracic anastomosis performed with the two-stage approach and cervical anastomosis with the three-stage approach. Hand-sutured two-layer anastomosis in all cases Radiotherapy started 5–6 weeks post-operatively (cervical, n = 23; intrathoracic n = 27) |
Mean operation time (min) Mean hospital stay (days) Brochopulmonary infection Vocal cord palsy—Temp Vocal cord palsy—Perm Median survival Mean supratumor margin (cm) (shrunken tissue) Mean tumour length (cm) |
Cervical vs intrathoracic 405 vs 375 24.2 vs 16.6 21 (70%) vs 11 (29.3%), P = 0.01 3 (10%) vs 0 (0%), P = NS 3 (10%) vs 1 (3.6%), P = NS 9 months vs 12 months, P = NS 5.01 vs 2.83 5.08 vs 5.3 |
Respiratory complications significantly more common in cervical than intrathoracic anastomosis. Authors comment that this may be secondary to more extensive dissection and vocal cord damage in the cervical group No significant difference between groups with respect to risk of anastomotic leak or mortality Cervical anastomosis improved resection of undetected supratumour lesions and lymph node harvesting. This did not correlate with any difference in long-term survival between groups Limitations: patients not matched for neoadjuvant therapy, limited data on other post-operative complications and large variation in extra-oesophageal resections at time of surgery |
| Walther et al. (2003), Ann Surg, Sweden [5] Prospective randomized study (level 2) |
Prospective randomized trial comparing hand-sewn cervical (n = 41) with stapled intrathoracic anastomoses (n = 42) To evaluate selection bias, non-randomized patients undergoing oesophagectomy over same time period (n = 29) were followed and results were compared with those randomized (n = 83) Measurements of anastomotic level and diameter were assessed with an endoscope and balloon catheter 3, 6, and 12 months after surgery |
Operating time [median (range)] Blood loss (ml) [median (range)] Anastomotic stricture formation (%) Chest drainage (days) [median (range)] Anastomotic leak (%) Airway complication (%) Cardiac complication (%) Vocal cord palsy (%) Reoperation (%) Hospital stay (days) [median (range)] Uncomplicated (%) Hospital mortality (%) |
Cervical vs intrathoracic vs non-randomised 555 (382–850) vs 553 (290–750) vs 615 (459–886), P = 0.0018 950 (250–3000) vs 950 (200–4000) vs 1300 (400–3000), P = NS 8/41 (19.5) vs 12/42 (28.6%), P = 0/443 7 (5–65) vs 7 (0–55) vs 7 (4–71), P = NS 1 (2.4) vs 0 (0) vs 1 (3.4), P = NS 2 (4.9) vs 4 (9.5) vs 2 (6.9), P = NS 4 (9.8) vs 4 (9.5)vs 0 (0), P = NS 1 (2.4) vs 0 (0) vs 2 (6.9), P = NS 3 (7.3) vs 2 (4.8) vs 3 (10.3), P = NS 14 (8–68) vs 14 (0–83) vs 15 (10–75), P = NS 28 (68) vs 29 (69) vs 19 (66), P = NS 1 (2.4) vs 1 (2.4) vs 0 (0), P = NS |
No significant difference between the groups with respect to cardiorespiratory complications, anastomotic leak or mortality High incidence of stricture formation in intrathoracic anastomosis attributed to increased stapling of anastomosis in this group. No difference in anastomotic diameter between groups at 3, 6 and 12 months following surgery Only significant factor affecting the survival was disease stage Limitations: variation in the use of stapled and sutured anastomosis at each site. Low incidence of anastomotic leak making correlation to site and severity difficult |
| Lam et al. (1992), J Thoracic Cardiovasc Surg, Hong Kong [6] Prospective non-randomized study (level 3) |
Prospective non-randomised study comparing cervical (n = 294) and intrathoracic (n = 117) anastomosis post-oesophagectomy Patients grouped according to the location of tumour in relation to aortic arch and preoperative respiratory function. Groups comparable except palliative resections more frequent in cervical group Anastomosis formed between residual proximal area of oesophagus and stomach, jejunum or colon |
Anastomotic leak: hand-sewn Anastomotic leak: stapled Anastomotic leak: whole stomach substitution Anastomotic leak: distal stomach substitution Anastomotic leak: jejunum substitution Anastomotic leak: colon substitution Anastomotic stricture: hand-sewn Anastomotic stricture: stapled |
Cervical vs intrathoracic 4/75 (5.3%) vs 5/106 (4.7%) 7/219 (3.2%) vs 0/11 (0.0%) 8/240 (3.3%) vs 4/91 (4.4%) 2/49 (4.1%) vs 0/8 (0.0%) 0/3 (0.0%) vs 0/0 Half (50%) vs 1/18 (5.5%) 6/62 (9.7%) vs 6/78 (7.7%) 36/158 (22.8%) vs 2/11 (18.2%) |
No significant difference between the groups with respect to anastomotic leak rate or mortality Increased incidence of benign stricture formation with intrathoracic anastomosis attributed to increased use of stapling device in this group Limitations: study not randomized, variations in approaches for cervical anastomosis and use of substitutes and limited data on other post-operative complications |
| Johansson et al. (1999), J Thoracic Cardiovasc Surg, Sweden [7] Prospective non-randomized study (level 3) |
Prospective study comparing pharyngeal reflux after gastric pull-up oesophagectomy between cervical (n = 20) and intrathoracic anastomoses (n = 27) Intrathoracic anastomoses formed using the two-stage approach and intrathoracic anastomoses created using the three-stage approach Placement of pH probes proximal and distal to oesophageal remnant for 24 h. Acid exposure in the gastric pull expressed as total percentage of time pH <4 during a 24-h period. This was also measured at 3, 6 and 12 months post-operatively |
pH levels: 3 vs 6 vs 12 months [mean (95%CI)] Anastomotic height from incisors (cm) [mean (95% CI)] Dilated for anastomotic stricture at 3 months Oesophagitis after 3 months |
In general: 46% (29–63%: n = 14) vs 32% (14–50%: n = 13) vs 31% (9–53%: n = 11) 21.2 (19.4–21.3) vs 24.8 (23.8–25.3) 3 (15%) vs 5 (18.5%) 2 (10%) vs 7 (25.9%) |
Acid exposure to the pharynx and oesophageal remnant increased during the first year with cervical anastomosis but not with intrathoracic anastomosis. This did not increase oesophagitis or subsequent stricture formation Authors attributed increased reflux with cervical anastomosis to extensive neck dissection impairing swallowing Limitations: very limited data on other post-operative complications. Comorbidities affecting reflux not accounted for and significant variation in the formation of gastric tubes |
| Nguyen et al. (2008), Ann Surg, USA [8] Prospective non-randomized study (level 3) |
Prospective study evaluating the outcomes of 104 minimally invasive oesophagectomy (MIE) procedures for the treatment of benign and malignant disease Indications for surgery included oesophageal cancer (n = 80), Barrett oesophagus (n = 8), gastrointestinal stromal tumour (n = 3) and gastric cardia cancer (n = 7) Conversion rate to laparotomy 3/104 (2.9%) Overall mortality 2/104 (1.9%) |
Operative time (min) Estimated blood loss (ml) Length of hospital stay (days) Length of ICU stay (days) Major complications (%) Anastomotic stricture (%) Anastmotic leaks (%) |
MIE with cervical vs MIE with intrathoracic anastomosis 333 ± 75 vs 249 ± 72 263 ± 179 vs 146 ± 117 12.1 ± 12.2 vs 9.7 ± 8.1 4.8 ± 9.1 vs 2.9 ± 4.4 12.8 vs 11.8 23.4 vs 27.5 6.4 × 9.8 |
No significant difference between MIE with cervical and intrathoracic anastomosis with respect to post-operative outcomes or mortality Overall, the authors report MIE associated with low conversion rate, acceptable morbidity and low mortality Limitations: varying approaches for anastomotic formation, data includes surgery for non-malignant disease and patients not matched for neo-adjuvant therapy |
| Blewett et al. (2001), Ann Thoracic Cardiovasc Surg, Canada [9] Retrospective cohort study (level 3) |
Retrospective cohort study comparing histological and clinical outcomes between cervical (n = 19) and intrathoracic anastomoses (n = 55) Cervical anastomoses formed through three-stage (n = 16) or transhiatal approach (n = 3). All intrathoracic anastomoses formed using two-stage approach No significant difference between the two groups with respect to age, gender, histology, stage, adjuvant therapy and overall survival |
Anastomotic leaks Mortality due to leak Operative mortality (all cases) Medial survival (months) Positive resection margins |
Cervical vs intrathoracic anastomosis 1/19 (5%) vs 9/55 (16%), P = 0.21 0/19 (0%) vs 1/55 (2%), P = 0.90 0/19 (0%) vs 3/55 (5%), P = 0.40 13.9 vs 13.5, P = 0.55 2/19 (11%) vs 9/55 (16%), P = 0.42 |
Anastomotic site not related to risk of anastomotic leak or post-operative mortality Comment in conclusion suggests that anastomotic wound healing is multifactorial. Surgical experience, technique and adequacy of gastric conduit vascularity highlighted as critical determinants of anastomotic wound healing Limitations: retrospective study with low incidence of anastomotic leaks, lack of data on other post-operative complications and varying approaches for cervical anastomosis |
| Egberts et al. (2008), Ann Surg Oncol, Germany [10] Prospective longitudinal study type (level 3) |
Prospective longitudinal study (n = 105) comparing QOL following cervical (n = 33) and intrathoracic anastomosis (n = 72) post-oesophagectomy QOL assessed using cancer-specific questionnaire (EORTC QLQ-C30) with an oesophagus-specific module that assessed functional, symptomatic and global health of patients QOL assessed preoperatively, at discharge, 3, 6, 12 and 24 months following surgery |
Cumulative morbidity Anastomotic leakage Peritonitis Oesophagotracheal fistula Haemorrhage Damage of the recurrent laryngeal nerve Wound complication Cardiac complications Pneumonia Renal failure 30-day mortality Hospital mortality |
Cervical vs intrathoracic 23 (69.7%) vs 39 (54.2%), P = 0.133 11 (33.3%) vs 13 (18.1%), P = 0.083 0 (0%) vs 1 (1.4%), P = 0.496 0 (0%) vs 3 (4.2%), P = 0.234 2 (6.1%) vs 2 (2.8%), P = 0.415 1 (3.0%) vs 1 (1.4%), P = 0.568 2 (6.1%) vs 3 (4.2%), P = 0.672 4 (12.1%) vs 14 (19.4%), P = 0.355 11 (33.3%) vs 20 (27.8%), P = 0.562 1 (3.0%) vs 3 (4.2%), P = 0.778 1 (3.0%) vs 2 (2.8%), P = 0.943 2 (6.1%) vs 5 (6.9%), P = 0.866 |
No significant difference between cervical and intrathoracic anastomosis with respect to cardiorespiratory or wound complications, anastomotic leak, or hospital mortality Post-operative pain significantly greater following intrathoracic anastomosis than cervical anastomosis. This was attributed to additional thoracotomy procedure in intrathoracic group. Difference between groups resolved within 24 months Limitations: missing patient data due to death, disease progression and poor compliance. Limited data on the site of pain and analgesia used. Poor standardization of approach for cervical anastomosis. Patients not matched for neo-adjuvant therapy |