Application of goal-directed fluid therapy combined with modified hand-sewn layered anastomosis (H Anastomosis) in thoracoscopic esophagectomy for esophageal cancer: an exploratory propensity score-matched study

Anastomotic leakage remains a major complication with substantial prognostic impact after esophagectomy. Goal-directed fluid therapy (GDFT) can optimize tissue perfusion, yet its benefit in esophageal cancer surgery remains limited when used alone. Hand-sewn layered anastomosis avoids tissue compression injury caused by staplers, but it is technically demanding. Whether combining these two approaches yields potentially complementary effects is unclear. This study aimed to preliminarily evaluate the feasibility, safety, and potential clinical value of GDFT combined with modified hand-sewn layered anastomosis in thoracoscopic esophagectomy. This was a single-center, retrospective, controlled, exploratory study. The experimental group included 26 patients (GDFT + H group) who underwent thoracoscopic esophagectomy with GDFT and modified hand-sewn layered anastomosis between November 2025 and April 2026. The control group comprised historical cases from the same surgical team. These patients underwent surgery between August 2024 and October 2025 and received conventional fluid therapy with stapled anastomosis. After 1:2 propensity score matching, 52 patients were included (VM group). Matching variables included age, sex, BMI, tumor location, TNM stage, ASA grade, and preoperative albumin. The primary endpoint was anastomotic leakage rate. Secondary endpoints included perioperative anesthesia and tissue perfusion parameters, postoperative recovery, complications, and hospital costs. Firth penalized logistic regression was used to assess the association between the combined protocol and major complications. Baseline characteristics were well balanced after matching, with most SMDs < 0.2 (sex SMD = 0.285). The GDFT + H group had significantly lower intraoperative total fluid volume (1500 vs. 2000 mL, P < 0.001), lower peak arterial lactate (1.02 vs. 1.59 mmol/L, P < 0.001), shorter extubation time (0.50 vs. 0.75 h, P < 0.001), and better oxygenation index at 15 min post-extubation (290 vs. 267.5 mmHg, P < 0.001). The anastomotic leakage rate was 0% (0/26) in the GDFT + H group versus 28.85% (15/52) in the VM group ( P = 0.002). Major complications (Grade ≥ III) occurred in 7.69% versus 50.00% ( P < 0.001). Pulmonary-related complications occurred in 3.85% versus 46.15% ( P < 0.001). Stapler-related costs were significantly lower in the GDFT + H group ( P < 0.001). Postoperative hospital stay was significantly shorter (12 vs. 18 d, P < 0.001). The adjusted odds ratios for anastomotic leakage and major complications were 0.057 (95% CI: <0.001 to 0.423) and 0.121 (95% CI: 0.023 to 0.410), respectively. Our preliminary findings suggest that the combination of GDFT and modified hand-sewn layered anastomosis may be safe and feasible in thoracoscopic esophagectomy, and was associated with significantly lower rates of anastomotic leakage and major complications, faster recovery, and reduced stapler costs compared with conventional protocols. However, given the two-intervention design of this study, the specific contribution of each component cannot be determined. The hypothesis of complementary effects between GDFT and H anastomosis requires formal testing in a future 2 × 2 factorial trial (GDFT vs. conventional fluid × H anastomosis vs. stapled anastomosis). These findings are hypothesis-generating and warrant cautious interpretation. Larger prospective studies are needed to validate these observations.