Intraoperative Screening of Anastomosis By Endoscopy May Lead to “Zero” Perioperative Anastomotic Complication in Digestive Surgery

Abstract

Background: Despite development of several surgical techniques and new anastomotic devises, anastomotic insufficiency remains a serious postoperative complication after digestive surgery. The aim of this study is to evaluate the efficacy of intraoperative endoscopy for achieving “zero” anastomotic complications. Method: Between January 2004 and November 2006, 108 patients underwent intraoperative endoscopy at completion of mechanical digestive tract anastomosis, which consisted of esophago-gastrostomy (E-G) after esophagectomy in 23, esopahago-jejunostomy (E-J) after total gastrectomy in 39, and colo-rectal (C-R) anastomosis after anterior resection in 46 patients. Flexible endoscopy was inserted to all patients either orally or anally to observe the suture line intraluminally for anastomotic observation and to confirm the air-tightness of the anastomosis by air-leak test. Result: Dehiscence of anastomosis was detected endoscopically by intraoperative air leakage (IAL) in the patient with E-G anastomosis. For the two patients with E-J anastomosis who developed postoperative anastomotic leakage (PAL) without IAL, one had wide dehiscence of the esophageal mucosa and another with incomplete E-J anastomotic suture line. Mucosal cracks around the staples at the anastomosis were detected in two C-R anastomotic patients with IAL, of whom one developed PAL. Three inadvertent occlusion of the true lumen of the E-J anastomosis was found only by the endoscopic observation, and all such errors were successfully corrected. Overall IAL was detected in one of 23 patients with E-G anastomosis (4.3%), two of 39 patients with E-J anastomosis (5.1%), and 7 of 46 patients with C-R anastomosis (15.2%). All patients with IAL underwent either reinforcement of the anastomosis, re-anastomosis or covering ileostomy of whom, three patients with C-R anastomosis developed PAL. Conclusion: Intraoperative endoscopy with air-leak test is a very useful and practical technique which can recognize and correct anastomotic insufficiency or inadvertent obstruction in digestive surgery. Despite reinforcement of the anastomosis, patients with intraoperative air leak at the CR anastomosis are at high risk for the development of subsequent anastomotic leakage.