Interventions to prevent anastomotic leak after esophageal surgery: a systematic review and meta-analysis

Abstract

Background: Anastomotic leakage (AL) is a common and serious complication following esophagectomy. We aimed to provide an up-to-date review and critical appraisal of the efficacy and safety of all previous interventions aiming to reduce AL risk.

Methods: We searched MEDLINE and Embase from 1946 to January 2019 for randomized controlled trials (RCTs) evaluating interventions to minimize esophagogastric AL. Pooled risk ratios (RR) for AL were obtained using a random effects model.

Results: Two reviewers screened 441 abstracts and identified 17 RCTs eligible for inclusion; 11 studies were meta-analyzed. Omentoplasty significantly reduced the risk of AL by 78% [RR: 0.22; 95% CI: 0.10, 0.50] compared to conventional anastomosis (3 studies, n = 611 patients). Early removal of NG tube significantly reduced the risk of AL by 62% [RR: 0.38; 95% CI: 0.02, 0.65] compared to prolonged NG tube removal (2 studies, n = 293 patients); Stapled anastomosis did not significantly reduce the risk of AL [RR: 0.92; 95% CI: 0.45, 1.87] compared to hand-sewn anastomosis (6 studies, n = 1454 patients). The quality of evidence was high for omentoplasty (vs. conventional anastomosis), moderate for early NG tube removal (vs. prolonged NG tube removal), and very low for stapled anastomosis (vs. hand-sewn anastomosis).

Conclusions: This is the first meta-analysis to summarize the graded quality of evidence for all RCT interventions designed to reduce the risk of AL following esophagectomy. Our findings demonstrated that omentoplasty significantly reduced the risk of AL with a high quality of evidence. Although early NG tube removal significantly reduced AL risk, there is a need for further research to strengthen the quality of evidence for this finding. Evidence profiles presented in our review may help inform the development of future clinical practice recommendations. Systematic review registration: CRD42019127181.

Keywords: Adverse events; Anastomotic leakage; Cancer; Carcinoma; Esophagectomy; Intervention.

Fig. 1

PRISMA flow diagram summarizing screening and selection of eligible studies

Fig. 2

Pooled risk ratio for anastomotic leakage according to intervention type (11 meta-analyzed studies). Stapled anastomosis intervention compared to hand-sewn (a). Omentoplasty intervention compared conventional anastomosis (hand-sewn or stapled or hand-sewn anastomosis) (b). Early removal nasogastric tube (or no nasogastric tube) intervention compared to prolonged nasogastric tube removal (c). LCL, lower confidence limit; UCL, upper confidence limit; RR, risk ratio; POP, population size

Fig. 3

Pooled risk ratio for anastomotic stricture grouped according to intervention type (11 meta-analyzed studies). Stapled anastomosis intervention compared to hand-sewn (a). Omentoplasty intervention compared to conventional anastomosis (stapled or hand-sewn anastomosis) (b). LCL, lower confidence limit; UCL, upper confidence limit; RR, risk ratio; POP, population size

Fig. 4

Pooled risk ratio for mortality grouped according to intervention type (11 meta-analyzed studies). Anastomotic stricture grouped by intervention type. Stapled anastomosis intervention compared to hand-sewn (a). Omentoplasty intervention compared conventional anastomosis (hand-sewn or stapled or hand-sewn anastomosis) (b). Early  nasogastric tube removal (or no nasogastric tube) intervention compared to prolonged nasogastric tube removal (c). Overall mortality reported across studies except when marked (*) as 30-day mortality. LCL, lower confidence limit; UCL, upper confidence limit; RR, risk ratio; POP, population size

Fig. 5

Revised Cochrane risk of bias tool for randomized controlled trial studies included (11 meta-analyzed studies). Green, low risk of bias; yellow, unclear risk of bias; and red, high risk of bias