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Ann Thorac Surg 2006;82:1862
© 2006 The Society of Thoracic Surgeons
Department of Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China
(Email: yimap{at}cuhk.edu.hk).
The article by Bhat and colleagues [1] entails a prospective, randomized trial aimed to investigate the efficacy of omental wrap in preventing anastomotic leak after esophagectomy. All anastomoses in the study were hand sewn in a single layer of silk, in comparison with those in the treatment arm augmented by a patch of gastric omentum. The authors managed to show a significant reduction in anastomotic leak in favor of treatment (3.7% vs 14.3%). However, mortality rates in the two groups of patients were not significantly different.
Anastomotic leak contributes significantly to early postoperative morbidity and mortality after esophagectomy. For many years, surgeons have tried hard to avoid such complication. Although several reports advocated reinforcing the esophagogastric anastomosis with viable autologous tissues, we believe that a truly randomized trial like this one has not been undertaken before, and for that the authors are to be congratulated. Having said that, however, the interpretation and application of findings in this study to clinical practice should be taken with a little caution. Meticulous skill in fashioning the anastomosis can not be replaced by the omental wrap. An adequately perfused gastric conduit, a tension free anastomosis, and the circumferential incorporation of mucosa into the anastomosis are probably more important than any autologous tissue.
While this study may be of value to institutes where hand-sewn anastomosis is still being practiced, the current trend in esophageal surgery is toward stapling techniques. Most series using mechanical stapling devices in esophagogastrostomy report a leak rate of around 4%, in contrast to the hand-sewn technique, which could result in leakage exceeding 10% (similar to that of the control arm in this study). Earlier criticism of the stapling technique citing an increased risk of stricture formation is no longer valid due to improved design in and increased experience with the new stapling devices currently in use.
Also, braided suture materials like silk are known to increase the risk of infection because of potential bacterial harboring in the interstices. If a hand-sewn esophagogastrostomy is being contemplated, a monofilament, delayed-absorbable suture would be a better choice than silk.
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