To investigate the causes of anastomotic leak after reconstruction of the digestive tract using an anastomotic clutch during resection of pancreatic cancer in order to improve prevention and treatment. Methods A retrospective analysis was performed on 89 cases of pancreatic cancer resection with anastomosis for GI reconstruction between April 2001 and October 2004. Results Six cases (6.7%) of anastomotic leak occurred after surgery, four cases in men and two cases in women. The ages ranged from 32 to 68 years. Among them, 5 cases were abdominal anastomotic leak after transabdominal cardia resection and 1 case was intrathoracic anastomotic leak after transthoracic cardia resection, all of which were cured by treatment.
Conclusion Although anastomotic leak after pancreatic cancer gastrointestinal reconstruction is a serious complication that threatens the life of patients and has a high mortality rate, its incidence can be effectively reduced with active prevention and treatment.
Since the first anastomosis was used in China in the 1970s, mechanical suturing technology has been widely used in the field of surgery. From April 2001 to October 2004, 89 cases of pancreatic cancer were reconstructed by using anastomosis in our department, and 6 cases of anastomotic leakage occurred, without any death. The causes, prevention and treatment are summarized as follows
1. Information and methods
1.1 General information
All 89 cases in this group used WGW-2 tubular gastrointestinal anastomosis made in Changzhou to reconstruct the digestive tract. There were 6 cases of anastomotic leakage, including 4 male cases and 2 female cases, aged 32-68 years; 5 cases of abdominal anastomotic leakage after transabdominal esophagogastric anastomosis and 1 case of intrathoracic anastomotic leakage after left thoracic esophagogastric anastomosis; 5 cases were anastomosed with 26 mm anastomosis and 1 case with 28 mm anastomosis. The incidence of anastomotic leak was 6.7%, and the time of occurrence was from 3 to 10 days after surgery.
1.2 Anastomosis method
Open the safety and quickly close the handle with force to complete the cutting and anastomosis. After the anastomosis is completed, loosen the screws, withdraw the main body of the anastomosis and the central rod, routinely check the anastomosis, and close the lateral opening of the greater curvature of the residual stomach. Six cases of anastomotic leak occurred in this group, and the intraoperative anastomosis is shown in Table 1
1.3 Treatment methods and results
All 6 patients were treated with unobstructed and effective drainage, anti-infection, correction of water and electrolyte disorders, parenteral nutrition, enteral nutrition, etc. Among them, 2 cases underwent reoperation with drainage; 2 cases were treated with stent placement. All six patients were cured, and four of them had anastomotic stenosis, which was cured by balloon dilatation or internal stenting after ineffective dilatation. The shortest time from occurrence to cure of anastomotic leak was 28 d and the longest time was 40 d. The average time was 28.5 d.
2. Discussion
Anastomotic leak is one of the most common and serious postoperative complications of cardia cancer, and the mortality rate is as high as 50% once it occurs. There are many reasons for the occurrence of anastomotic leakage, except for the body’s own factors, anastomotic technique is one of the most important factors. According to 7 domestic groups reported 11327 cases of esophageal and cardia resection, the incidence of anastomotic leakage was 4.05%, and the mortality rate after leakage was 44.7%. Foreign reports of anastomotic leakage were 10% for manual anastomosis and 4% for instrumented anastomosis [3]. In our group, all anastomoses were mechanical, and the incidence of anastomotic leakage was 6.7%, which was slightly higher than that reported abroad.
Regarding the reasons for this, we believe it is mainly related to the following points.
(1) Insufficient familiarity with the use of the anastomosis at the initial stage, and forceful hard pulling out of the anastomosis when incomplete cutting was encountered after the strike, resulting in mucosal muscle tissue avulsion, in three cases in this group;
(2) The anastomotic sutures at both ends of the anastomosis were not tightly tied to the central rod in all layers, and too little tissue was retained outside the tied line, resulting in incomplete anastomosis, and there was one case in this group;
(3) Improper selection of the anastomosis type, the acne against the nail was too large, and it was difficult to put it into the hooded suture at the end of the esophagus;
(4) The gastric tube was stapled into the anastomosis without exiting at the time of striking, and the anastomosis was locally cut and manually sutured afterwards, and there was one case in this group.
In the above cases, although the sutures were made up by hand intraoperatively, there may be leakage of sutures due to the exposure of less trocar.
Therefore, in order to reduce the occurrence of anastomotic leakage, in addition to ensuring a good blood supply and no tension in the digestive tract to be anastomosed, we believe that the following points should be noted during the mechanical suturing process.
(1) The operator must be familiar with the mechanical properties of the anastomosis, and the instruments and components should be carefully checked before use;
(2) The surrounding tissues within 2 cm of the intestinal canal at both ends of the anastomosis should be excised to avoid incomplete anastomosis due to embedding;
(3) The suture must be tightly tied to the central bar in its entirety;
(4) When turning the anastomosis adjusting screw to bring the two ends of the anastomosis together, do not sandwich other tissues between the anastomosed tissues, and the distance between the pegging acne and the pegging plate should not be too tight to avoid incomplete anastomosis due to fracture of the plasma muscle layer;
(5) After the anastomosis is completed, the anastomosis should not be withdrawn immediately after releasing the anastomosis, but should be slowly withdrawn after gently rotating around and checking whether the resection circle is complete at both ends. In conclusion, if the anastomosis is incomplete or the resection circle is incomplete, the suture should be reinforced or coated with biologic adhesive, and drainage tubes should be routinely placed around the anastomosis.
Once anastomotic leak occurs, immediate treatment should include fasting, gastrointestinal decompression, adequate drainage, simultaneous maintenance of acid-base and water-electrolyte balance, infection control and nutritional support. If drainage is poor, early reoperation should be performed. The purpose of surgery is to effectively drain the leak and exudate from the abdominal or thoracic cavity, and any attempt to close the leak during surgery will only be contrary to what is desired. In addition, nutritional support is directly related to the course and prognosis of patients, while parenteral nutrition is costly and technically demanding, with the risk of complications of sepsis and impairment of intestinal immune function.
The indications for parenteral nutrition are basically the same as those for enteral nutrition, therefore, enteral nutrition should be used instead of parenteral nutrition when part of the digestive tract can still be used. Therefore, we routinely place an enteral nutrition tube through the anastomosis to the upper jejunum during pancreatic cancer resection, so that enteral nutrition can be given early after the recovery of intestinal function after surgery, avoiding the need for jejunostomy after the occurrence of anastomotic leak due to the problem of nutrition support.
In addition, endoprosthesis has been widely used in clinical practice for the treatment of esophageal stricture and esophageal fistula. The double flared nickel-titanium thermal memory alloy endoprosthesis with membrane has good histocompatibility and flexibility, which can close the leak with the esophageal wall and gastric wall after placement; it can also prevent gastric contents from entering the leak through the mesh of the stent; the length of the endoprosthesis should generally exceed the edge of the leak by 2 cm.
However, we believe that the timing of placement is more important, preferably 20 d after diagnosis to avoid further tearing and enlargement of the anastomosis during placement, and the two cases in this group were placed at 28 d and 31 d, respectively. For the stenosis complicated by anastomotic leak, we first treated it with balloon dilation, and then placed internal stent if the dilation treatment was ineffective.
In conclusion, the use of mechanical suture technique for GI reconstruction in pancreatic cancer resection has the advantages of simple operation, easy to grasp, safe and reliable, and so on. However, it is necessary to follow the principles of operating procedures, reducing trauma, careful hemostasis, no tension, and keeping the thickness of anastomotic tissue moderate, etc. If used improperly, it may still cause unnecessary trouble or even serious consequences. In addition, we still believe that a good manual anastomosis base is necessary to compensate for the failure of mechanical anastomosis.