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 interventions designed 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 was performed using random effects. Results: Two reviewers screened 441 abstracts and identified 17 RCTs eligible for inclusion; 11 studies were meta-analyzed. Omentoplasty reduced the risk of AL significantly by 78% [RR: 0.22; 95% CI: 0.10, 0.50] compared to no omentoplasty (3 studies, n=611 patients). Early removal of NG tube reduced AL risk significantly by 88% [RR: 0.12; 95% CI: 0.02, 0.65] compared to prolonged NG tube (2 studies, n=293 patients); Stapled (vs. hand-sewn) anastomosis did not significantly reduce AL risk [RR: 0.92; 95% CI: 0.45, 1.87] compared to hand-sewn (6 studies, n=1454 patients). The quality of evidence was high for omentoplasty (vs. no omentoplasty), moderate for early removal of NG tube (vs. conventional removal), and very low for stapled anastomosis (vs. hand-sewn). Conclusions: This is the first meta-analysis to summarize the graded quality of evidence for all RCT interventions designed to reduce AL following esophagectomy. Our findings demonstrated that omentoplasty reduced the risk of AL with a high quality of evidence. Although early nasogastric tube removal reduced AL risk, there is a need for further research to strengthen the quality of evidence. Evidence profiles presented in our review may help inform the development of clinical practice recommendations.Systematic review registration: CRD42019127181