# Comparison of anastomotic stricture rates between 23- and 25-mm powered circular staplers in cervical esophagogastric anastomosis: a propensity-matched study

## TL;DR

This study compared 23- and 25-mm staplers for esophageal surgery and found similar stricture rates, suggesting the 23-mm stapler is a viable alternative when the 25-mm is hard to use.

## Contribution

The study introduces the 23-mm stapler as a practical alternative in cervical anastomosis when 25-mm stapler use is difficult.

## Key findings

- Anastomotic stricture rates were 18.0% for 23-mm and 12.8% for 25-mm staplers, with no significant difference.
- The 23-mm stapler showed potential equivalence in stricture risk and easier anvil insertion in challenging cases.
- Anastomotic leakage rates and locations were not significantly different between the two stapler sizes.

## Abstract

Circular stapler (CS) anastomosis is widely used in McKeown esophagectomy; however, anastomotic stenosis remains a significant concern. This study aimed to compare stenosis rates between newly introduced 23- and 25-mm powered CSs in cervical esophagogastric anastomosis.

From May 2022 to February 2024, 126 patients who underwent thoracoscopic McKeown esophagectomy with retrosternal gastric conduit reconstruction were retrospectively analyzed. They were categorized into the 23-mm (n = 52) and 25-mm (n = 74) CS groups. The primary endpoint was the comparison of anastomotic stricture rates. Propensity score matching was performed to adjust for potential confounders.

After propensity score matching, 39 pairs were selected. The incidence of anastomotic stricture was 18.0% (7 cases) and 12.8% (5 cases) in the 23- and 25-mm CS groups, respectively (p = not significant [NS]). The incidence of anastomotic leakage and the leakage location revealed no significant differences between the two groups. A two one-sided test for equivalence was performed to compare the risk difference in stricture rates between the groups, resulting in a risk difference of 5.1% with a 90% confidence interval of − 0.087 to 0.191 and a p value of 0.041, suggesting potential equivalence.

In this study, 23- and 25-mm powered CSs achieved comparable anastomotic stricture rates in cervical esophagogastric anastomosis during McKeown esophagectomy. The newly introduced 23-mm powered CS can be a useful option, considering its easier anvil insertion into the residual esophagus when insertion of the 25-mm CS anvil is technically challenging.