Optimal oesophagogastric anastomosis techniques for oesophageal cancer surgery - A systematic review and network meta-analysis of randomised clinical trials

Background: The optimal oesophagogastric anastomosis technique for oesophageal cancer surgery remains unclear. The aim of this study was to perform a network meta-analysis (NMA) of randomised clinical trials (RCTs) to compare oesophagogastric anastomosis techniques for oesophageal cancer surgery. Methods: A systematic review and NMA were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines-NMA extension. Statistical analyses were performed using R and Shiny. Results: Overall, 16 RCTs were included (14 provided data eligible for NMA). These included 2520 patients and 4 different anastomosis techniques: 1055 (41.9 %) patients underwent circular stapled (CS), 1232 (48.9 %) underwent handsewn (HS), 100 (3.9 %) underwent triangulated stapled (TS) and 133 (5.3 %) underwent linear stapled (LS). Fourteen studies reported on open surgery, while one reported on both open and minimally invasive techniques. At NMA, no significant difference was observed regarding anastomotic leak rates among all techniques, while HS significantly reduced anastomotic leaks following cervical technique (odds ratio (OR): 0.32, 95 % confidence interval (CI): 0.13-0.78). Moreover, HS (OR: 0.58, 95 % CI: 0.38-0.90) and LS (OR: 0.21, 95%CI: 0.06-0.71) significantly reduced anastomotic stricture rates, while LS significantly reduced anastomotic strictures following intrathoracic anastomotic technique (OR: 0.17, 95%CI: 0.06-0.90). Conclusion: HS reduced anastomotic leaks following cervical anastomoses, while HS and LS reduced overall anastomotic strictures (with LS significantly reducing strictures following intrathoracic anastomoses). Importantly, institutional and surgeon expertise should be considered prior to adopting these results into contemporary practice for open oesphagectomy, with a call for the harmonisation of trials to align with contemporary, minimally invasive approaches.