Can intraoperative endoscopy prevent esophagojejunal anastomotic leakage after total gastrectomy?

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RESEARCH ARTICLE

Hippokratia 2021, 25(3): 108-112

Alemdar A, Eğin S, Yılmaz İ, Kamalı S, Duman MG 

Department of General Surgery, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi, İstanbul, Turkey

Abstract

Background: Esophagojejunostomy (EJ) is frequently performed after total gastrectomy for proximal gastric tumors. Despite evolving surgical techniques and improving perioperative care, the EJ leak is one of the most severe life-threatening complications. This study investigated the preventability of postoperative anastomotic complications by performing intraoperative endoscopy.

Methods: We included 86 patients who underwent total gastrectomy and Roux-en-Y esophagojejunostomy anastomosis in the study. Patients were divided into two groups and analyzed retrospectively. Group 1 consisted of 43 patients who did not undergo intraoperative endoscopy between 2017 and 2019, and Group 2 included 43 patients who underwent intraoperative endoscopy between 2019 and 2020.

Results: Esophagojejunostomy anastomotic leak (EAL) was observed in 2.3 % of patients in Group 1 but not in Group 2. Anastomosis-related abnormal findings (anastomotic defect, bleeding, air leak, mucosal separation) were recorded in seven patients of Group 2 during endoscopy. When such findings were observed, additional full-thickness sutures were placed on the anastomosis line and strengthened. Complication related to anastomosis was not observed in the postoperative period in Group 2.

Discussion: After a total gastrectomy, the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage. Most of these complications are induced by technical errors not noticed during surgery. The crucial advantage of performing intraoperative endoscopy is the technically detailed evaluation of anastomosis.

Conclusion: Intraoperative endoscopy is a safe method to evaluate the strength of anastomosis. This procedure provides detailed information regarding anastomotic integrity. HIPPOKRATIA 2021, 25 (3):108-112.

Keywords: Perioperative endoscopy, gastric cancer, total gastrectomy, esophagojejunostomy, anastomotic leakage

Corresponding Author: Ali Alemdar, General Surgery Specialist, Department of General Surgery, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi Şişli-İstanbul Turkey, tel: +905327170755, fax: +902164214265, e-mail: alemdarali@gmail.com

Introduction

Gastric cancer is currently the fifth most common malignancy and the world’s third leading cause of cancer-related deaths among all cancers1. Curative treatment in gastric cancer is surgical resection and adequate lymph node dissection2.

Although subtotal resection is sufficient for distal gastric cancers, total gastrectomy is required in proximal gastric cancers. Esophagojejunostomy anastomotic leak (EAL) after total gastrectomy is one of the most severe, life-threatening surgical complications3. Despite the development of surgical techniques, surgical instruments (stapler, etc.), and perioperative care, EAL rates after gastric cancer surgery have been reported to be 2.1 % to 14.7 %3-6. The presence of EAL increases mortality and morbidity and negatively affects the prognosis. It prolongs the length of hospital stay and causes an increase in patient care costs3,7,8.

The most important concern of surgeons after gastric resection is the safety of esophagojejunostomy (EJ) anastomosis. None of the tests performed to evaluate the integrity of the anastomosis, like the air leak test, methylene blue leak test, and integrity of stapler rings is entirely safe9,10. Intraoperative endoscopy (IOE) provides a more detailed examination of the anastomosis (Figure 1). Anastomotic integrity, air leak, bleeding, and anastomotic stenosis are evaluated with IOE (Figure 2), and any problem detected during endoscopy can be corrected during the procedure.

Figure 1: Intraoperative endoscopy image showing anastomotic integrity.

Figure 2: Intraoperative endoscopy image showing bleeding at the site of the anastomosis.

IOE is widely used in colorectal and bariatric surgery11-16. Limited studies evaluate the safety and durability of the anastomosis with IOE after gastric cancer surgery17-19. Our aim in this study was to investigate the safety of the IOE procedure and its impact on postoperative anastomosis-related complications.

Methods

Ethical approval was obtained from the University of Health Sciences Okmeydanı Training and Research Hospital ethics committee in 2020. Eighty-six patients who underwent total gastrectomy Roux-en-Y esophagojejunostomy anastomosis for gastric cancer between July 2017 and September 2020 at Cemil Taşçıoğlu City Hospital General Surgery Clinic were analyzed retrospectively. Patients were divided into two groups. Group 1 consisted of 43 patients operated on between July 2017 and July 2019 who did not have IOE. Group 2 consisted of 43 patients operated on between July 2019 and September 2020 who had IOE. All patients included in the study were diagnosed with proximal gastric adenocarcinoma. All patients underwent curative intent total gastrectomy and D2 lymph node dissection performed by the same surgical team. EJ anastomoses were performed as an end-to-side Roux-en-Y esophagojejunostomy with a circular stapler (ILS 25 mm Ethicon endosurgery Inc., USA; and ILS 28 mm Covidien, USA).

In the IOE group, after completion of the anastomosis, the distal jejunal part was clamped. The operation field was filled with saline, with the remaining anastomosis in water. A gastroscope was inserted from the mouth, and the anastomosis was visualized. The air-water test was performed by insufflating air. The anastomosis was evaluated under direct vision for bleeding, stenosis, anastomotic and mucosal integrity.

Once an abnormal finding was detected (air leak, mucosal bleeding, mucosal detachment), additional full-thickness sutures (3/0 vicryl) or endoscopic intervention to the bleeding (cautery, injection, etc.) was performed. The effectiveness of the intervention was controlled by repeating endoscopy after the procedure. No additional procedure was required for patients with normal endoscopic findings.

Postoperative hospital stay, complications related to the anastomosis, and all complications, including re-operation, were analyzed. Postoperative complications were classified according to Clavien-Dindo (CD)20. CD 1-2 was considered mild, while three and above as severe complications. Tumor staging was done according to TNM 8th edition21.

Statistical Analysis

We used for statistical analyses the SPSS Statistics for Windows, Version 18.0. (SPSS Inc. Chicago, IL, USA).  Continuous variables are expressed as mean ± standard deviation. We compared the postoperative complications among groups using the Chi-square test and means using the Mann-Whitney U test. All tests are 2-sided, and we assessed statistical significance at a p <0.05 level.

Results

Patients’ demographic findings are shown in Table 1. The mean age, gender distribution, body mass index (BMI), comorbidities, operation times, and pathological stages of the two groups were similar (p >0.05). The most common comorbidities among patients were hypertension, diabetes mellitus, and chronic obstructive pulmonary disease. The distribution of patients who received neoadjuvant therapy was similar. There was no significant difference present between groups according to pathological TNM staging. Mean operation time didn’t show a significant difference between the two groups.

Postoperative complications are shown in Table 2. Three of four patients with severe complications, according to CD, were in the group of non-IOE. Two of these were intra-abdominal bleeding, one was an anastomotic leak, and the other was a pancreatic fistula. There was no significant difference present between the two groups concerning general complications. In one of two patients with intra-abdominal bleeding, bleeding was controlled with re-operation, while blood transfusion was performed to the other without additional surgical procedures. One patient with an anastomotic leak was re-operated due to abdominal sepsis, while the patient with a pancreatic fistula recovered with conservative treatment.

Postoperative severe complications were observed in three (7 %) patients in the non-IOE group while in one (2.3 %) patient in the IOE group (p =0.616). The most common complication recorded in the patients was superficial surgical site infection. Superficial surgical site infection was more common in the group without IOE (p =0.011). Regarding the length of hospital stay, there was no significant difference between the two groups (p =0.964). No postoperative mortality was recorded in any group.

Doughnut control was evaluated as normal in both groups. IOE detected abnormal findings that would negatively affect the anastomosis in seven patients. Of these, two patients had air leaks, four had mucosal bleeding, and one had mucosal detachment. Abnormal findings were controlled by suture ligation in four and endoscopic intervention in three of these seven patients. The mean duration of the IOE was eight minutes in patients with normal findings and 16 minutes in patients with abnormal findings with additional intervention. No postoperative complications were seen after the additional intervention. The clinical course of these intervened patients is shown in Table 3. 

Discussion

Among the complications of anastomosis (intraluminal bleeding, leakage, anastomotic stricture), the most severe complication affecting mortality, morbidity, and consequently the cost of the disease is esophagojejunal anastomotic leakage (EAL)4-6. EAL rates are reported between 2.1 and 14.7 % in literature4-6. In our study, we detected EAL in one patient (2.3 %), which was compatible with the literature.  Most EAL is caused by technical errors not detected during surgery22,23. With the widespread use of staplers, the rates of anastomotic leaks have decreased3,22,24. Once an anastomotic leak is observed, the mortality rate increases4. Evaluation of doughnuts alone may not be sufficient after an EJ anastomosis. In this study, the integrity of the doughnuts was complete in both groups, but we detected abnormal findings with IOE in seven patients and fixed the problem intraoperatively. After the additional intervention, supporting sutures, or endoscopic control, no postoperative anastomosis-related complications were observed in those patients.

IOE has been carried out for many years to evaluate tumor localization and anastomosis in colon surgery11-14. IOE is frequently used in bariatric surgery to evaluate gastric conduit and anastomosis15,16. There are limited studies about the control of anastomosis with IOE in gastric cancer surgery17-19. Studies evaluating the anastomosis after gastric cancer surgery in the literature are air insufflation with a nasogastric tube, methylene blue leak test, or endoscopic assessment9,10,17-19. In three of these studies, anastomosis was evaluated in detail by endoscopy. Evaluation by endoscopy reduces the complication rates associated with anastomosis19. Our study did not observe an anastomotic leak in the IOE group.

After EAL develops, treatment can be carried out by different methods. Regardless of the technique used for treatment, the length of hospital stay and the number of re-operations will increase, and It will be necessary to struggle with life-threatening complications23,25,26. There was a patient with an anastomotic leak in the non-IOE group. The hospitalization period of this patient was 152 days, and he was operated on six times during this period. IOE may help to prevent such complications by detailed evaluation of anastomosis and intervention. No complication related to the endoscopic procedure was seen in the previous studies13,15,17-19. Similarly, there was no complication related to endoscopy in the current study.

It is known that prolonged operation time adversely affects post-op complications6. The average endoscopic intervention time was 16 minutes in patients who had an abnormal finding related to the anastomosis. The mean procedure time was eight minutes in patients of the IOE group with no intervention. There was no significant difference between the total operation times in both groups (Table 1).

We were not performing routine endoscopies before July 2019. After this time, we are currently routinely performing endoscopy after EJ anastomosis. Our study’s limitation is the lack of randomization. Postoperative complications are one of the main reasons for the high cost of cancer surgery8. IOE may help to decrease anastomosis-related complication rates and thus cost. Another limitation is that cost calculation was not made in our study.

The comorbidities and patient’s nutritional status should be determined preoperatively, and necessary precautions should be taken. Improving perioperative patient care can reduce complications associated with anastomosis by accelerating wound healing27-30.

In conclusion, IOE is a safe method for evaluating EJ anastomosis after total gastrectomy. It can reduce complications associated with anastomosis. However, we couldn’t observe a significant difference in our study. The small number of enrolled patients and single-center retrospective nature are the main limitations of the current study. Multi-centered prospective randomized controlled trials with a large number of patients are required to evaluate the effectiveness of IOE.

Conflicts of Interest

The authors declare no conflicts of interest.

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