We retrospectively analyzed the clinical data of 636 patients who were admitted to our hospital from August 2007 to October 2011 for middle and lower esophageal cancer surgery with instrumented anastomosis followed by sleeve suturing. Results In 636 consecutive patients with esophageal cancer who used instrumented anastomosis followed by sleeve-in suture, no anastomotic fistula occurred postoperatively. Conclusion The occurrence of anastomotic fistula after esophageal cancer surgery is the result of multiple factors, and the occurrence of anastomotic fistula can be significantly reduced by improving the anastomosis technique and actively preventing it.
Esophageal cancer is a common gastrointestinal malignancy in China, and surgery is an important treatment for esophageal cancer. Anastomotic fistula is a serious complication of esophageal cancer, with an incidence rate of 11.8% to 44.19% and a mortality rate of more than 50%[. In recent years, with the continuous improvement of anastomosis technology, the incidence of anastomotic fistula has decreased, but it is still 2.6% – 6.4%. Once an anastomotic fistula occurs, the opportunity for surgical repair is often lost, and only conventional conservative treatment is available, which has a long course and high cost, seriously affecting the quality of survival and comprehensive postoperative treatment of patients. From August 2007 to October 2011, 636 cases of lower middle esophageal cancer were treated surgically without anastomotic fistula. In this paper, we retrospectively analyzed the data of this group of patients and discussed the causes and prevention of postoperative anastomotic fistula, in order to further reduce the occurrence of postoperative anastomotic fistula in esophageal cancer, improve the survival quality of postoperative patients and reduce the hospitalization cost.
l. Materials and methods
1.1 General information
There were 636 cases in this group, 369 males and 267 females, aged 37-81 years old, with an average of 67 years old. Among them, 609 cases were radical resection and 27 cases were palliative resection. 14 cases were stage I, 319 cases were stage II, 297 cases were stage III, and 6 cases were stage IV. All staging was performed according to the postoperative pathological diagnosis.
1.2 Surgical method
In all cases, a left posterior lateral thoracic incision was made, and the intrathoracic esophagogastric was mechanically anastomosed with an anastomosis followed by interrupted full sutures, and then the anastomosis was sutured in a sleeve.
2. Results
In 636 consecutive cases of esophageal cancer patients with instrumented anastomosis followed by sleeve-in suture, no anastomotic fistula occurred after surgery, and all of them were discharged after treatment.
3.Discussion.
Surgical resection and reconstruction of the esophagus is the most effective means of treating esophageal cancer, and with the continuous improvement of technology and the application of anastomosis, the incidence of postoperative anastomotic fistula has decreased. The cervical anastomotic fistula has relatively small impact on patients because it is outside the thoracic cavity, and it heals faster and is not harmful after drainage and drug exchange treatment. However, intra-thoracic anastomotic fistula has serious consequences and a high morbidity and mortality rate. Active prevention during surgery, early diagnosis and active treatment after surgery are the keys to reduce the morbidity and mortality of anastomotic fistula. Therefore, it is especially important to prevent the occurrence of postoperative anastomotic fistula in esophageal cancer.
3.1 Causes of anastomotic fistula
At present, it is generally believed that the occurrence of anastomotic fistula is the result of a combination of factors, not only related to the level of operator’s technique and operation style, but also other factors play a significant role in the occurrence of anastomotic fistula.
(1) The esophagus is not covered by plasma membrane, and the muscle fibers are longitudinal and fragile, so the anastomosis is prone to tearing.
(2) During manual anastomosis, missed sutures or overly wide stitches tear the anastomosis when knotting, and the mucosa is poorly dovetailed; the anastomosis is squeezed to damage the gastric and esophageal walls or the anastomotic nail is not secure or missing.
(3) The gastric and esophageal freeing is too long or the blood flow at the anastomosis is poor due to misinjury of the trophoblastic vessels; the gastric and esophageal walls are damaged by rough handling during operation.
(4) Inadequate gastric freeing, oversized lesions, excessive tissue removal, resulting in excessive anastomotic tension.
(5) Poor postoperative drainage, fluid infection around the anastomosis, and immersion of the anastomosis in pus, which affects the healing of the anastomosis and increases the possibility of anastomotic fistula.
(6) Postoperative malnutrition, anemia, and hypoproteinemia lead to tissue edema and poor anastomotic healing, which is the cause of most mid- to late-stage fistulas.
(7) Poor gastrointestinal decompression or premature removal of the gastric tube, resulting in retention of gastric juice and excessive anastomotic tension.
(8) Intense postoperative nausea, vomiting, and coughing, which increase anastomotic tension.
(9) Lack of reliable tissue protection around the anastomosis and inappropriate use of pleura to reinforce the anastomosis.
(10) Preoperative radiotherapy and chemotherapy are also a risk factor for the occurrence of anastomotic fistula.
3.2 Treatment of anastomotic fistula
Anastomotic fistula after esophageal cancer surgery is a great headache for esophageal surgery, especially anastomotic fistula, once it occurs, its mortality rate can be as high as 50%. It is a great threat to the patient’s life and increases the economic burden. After surgery, the patient should be closely monitored for changes in temperature, blood and drainage fluid, and once an anastomotic fistula is determined to have occurred, it should be actively treated. The treatment of anastomotic fistula is mainly divided into two types: conservative treatment and surgical treatment. Studies have confirmed that most postoperative anastomotic fistulas in esophageal cancer can be cured by conservative treatment. For those intra-thoracic anastomotic fistulas with small fistulae and late occurrence, conservative treatment is also mostly adopted. Conservative treatment is based on adequate chest drainage, effective gastrointestinal decompression, promotion of pulmonary resuscitation, necessary antimicrobial application, long-term fasting, and effective and adequate systemic nutritional support. The occurrence of anastomotic fistula after esophageal cancer surgery is influenced by many factors, and active prevention can reduce the incidence of anastomotic fistula.
3.3 Prevention of anastomotic fistula after esophageal cancer surgery
It mainly relies on improving anastomosis method and surgical skills.
(1) Pay attention to protect the blood supply of the anastomosis during surgery, such as avoiding damage to the vascular arch on the side of the gastric greater curvature and not freeing the esophagus for too long.
(2) The application of esophageal anastomosis has simplified the difficulty of surgical operation, shortened the operation time, and provided reliable results. The operator should be familiar with the mechanical principles of the anastomosis, and check the number of anastomotic needles and the reliability of various connections before anastomosis. After the anastomosis, the whole layer of interrupted sutures is then sutured to encapsulate the pulpy muscle layer, so that the anastomosis is encapsulated by the gastric wall thus forming a protective sleeve, which can reduce the occurrence of anastomotic fistula.
(3) The choice of surgical method is also particularly important, as supra-arch and thoracic apex anastomosis have higher anastomotic tension and are difficult to operate, so the possibility of anastomotic fistula is high. In our hospital, we mostly use neck anastomosis for upper esophageal cancer, which is easy to handle and reduces the risk of fistula. Our hospital has reported 104 consecutive cases of left cervical anastomosis of esophagus and stomach without fistula.
(4) Intraoperative contamination of the anastomosis site should be reduced, and adequate suction and protection should be provided to prevent the spillage of gastric juice and esophageal secretions from contaminating the anastomosis, so as to avoid fistulas secondary to infection and reduce the occurrence of anastomotic stenosis and chest infection.
(5) Postoperative smooth drainage to avoid pleural fluid imbibition and promote healing.
(6) Keep the postoperative gastric tube unobstructed, the gastric cavity empty, and reduce tension.
(7) Strictly grasp the indications for surgery. For advanced patients with poor general condition and extensive lesion invasion, surgery should be taken with caution. Nutritional support before and after surgery, correction of anemia, prevention and control of hypoproteinemia, occurrence of tissue edema, and promotion of anastomotic healing.
Many clinical scholars have been devoted to reducing the incidence of fistula by improving the anastomosis method, for example, Dan et al. used a three-layer funnel-type esophagogastric anastomosis method has significantly reduced the incidence of postoperative anastomotic fistula. In our group, we used instrumentation anastomosis followed by full-layer interrupted suture of the anastomosis and then sleeve-in suture, so that the anastomosis was encapsulated by the gastric wall, and even if poor healing of the anastomosis occurred, its contents were less likely to leak into the pleural cavity and cause complications such as chest infection and pus-pneumothorax, which anatomically reduced the occurrence of anastomotic fistula, and after nearly 4 years of clinical observation, no anastomotic fistula occurred, which could effectively reduce the incidence of anastomotic fistula. Of course, its reliability remains to be further observed in a larger number of cases.