Esophageal anastomosis: to oversew or to not oversew—is that the question?

Oesophagectomy for oesophageal cancer is one of the most challenging procedures performed by thoracic surgeons. Over the past decades, the transition from open surgery to minimally invasive approaches has promoted better postoperative outcomes, including long-term quality of life [1]. Observational studies, however, continue to show high rate of morbidity and mortality directly related to low surgical volume [2]. The oesophagogastric anastomosis, which some may consider an easy step of this operation, has the greatest long-term impact on proper swallowing after surgery. Meanwhile, debate continues regarding the best technique and whether the ideal location for performing the oesophagogastric anastomosis should be cervical versus thoracic. Recent data, at least, have shed some light in favour of a mechanical oesophagogastric anastomosis compared to the handsewn technique [3, 4]. In this issue of the European Journal of Cardio-Thoracic Surgery, Tu et al. [5] describe a large series of patients undergoing oesophagectomy for oesophageal cancer. They provide evidence that demonstrates by using an oversewing technique with interrupted sutures to reinforce the circular-stapled oesophagogastric anastomosis, one can achieve a leak rate that is significantly lower when compared to not using reinforcement. Out of the 1734 patients undergoing oesophagectomy during 2012–2019, 661 patients were included in each group (anastomotic unsewn versus anastomotic oversewn) based on propensity matching. In the multivariable analysis, patient tobacco use and unsewn anastomosis were significant independent risk factors for leak. The leak rate in the unsewn group was 10.3% compared to 4.7% in the oversewing group (P < 0.001). Increased risk based on unsewn anastomosis was significant in subgroups defined by age below 65 years, ASA II, tumour located in the middle segment of the oesophagus and cervical anastomosis. In addition, patients in the oversewn group resumed diet earlier and were discharged sooner than those in the unsewn group at the cost of a longer operative time and additional blood transfusions. Early and late anastomotic complications are relatively common with anastomotic leak rates of 10–15% in modern series [6–8]. While acute complications of an anastomotic leak are usually rapidly managed, this will often lead to a chronic stricture requiring regular dilations and ultimately reduce the patient’s quality of life. Tu et al. also demonstrated that the rate of anastomotic leakage from the cervical anastomosis, which has been shown to be higher [9], was similar when the McKeown technique was compared to the Ivor-Lewis technique in the oversewn group. Is this related to a decreased anastomotic tension with the oversew technique? An observational study can only explore this hypothesis keeping in mind that the oversewing technique was gradually introduced in the authors’ practice. In a much smaller cohort of patients, Caso et al. [10] also reported on a decrease oesophageal leak rate using the oversewing technique after circular stapler anastomosis when compared to the group without coverage of the anastomosis. As readers, we are left wondering if it is time for a randomized control trial to prospectively test this intervention. The study of Tu et al. provides a valuable detailed description of an added layer of protection to the oesophagogastric anastomosis, which clearly only enhances surgical outcomes and benefits the patients. We congratulate the authors on their work thus far and hope their findings will pave the way for more robust prospective studies on this vital matter to patients undergoing surgery for oesophageal cancer.

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