Leakage from an access enterotomy used for insertion of a stapling device or from anastomotic lines remains a complication with high mortality and morbidity after oesophagogastric surgery. We present three cases in which leakage occurred from these sites secondary to bowel distension. This appeared to have occurred due to premature removal of nasogastric tube, clot formation with bowel distension and early oral intake respectively. In all three cases the access enterotomy had been closed in a single layer. There are important lessons for surgical practise to be learnt from these complications. The safety associated with circular stapling devices may result in a complacent attitude to basic principles of upper GI surgery. We recommend that access line enterotomy should always be oversewen after closure and it should be placed as far away as practicable from stapled anastomosis. Adequate haemostasis should be ensured and patients should be started oral intake gradually with careful monitoring at ward level.
A sixty-year-old man underwent an Ivor-Lewis esophagogastrectomy for cancer of esophagus with distal gastric tube reconstruction. Postoperatively; the NG tube was removed on the second day by the patient. Leakage from a chest drain was noticed on day three. Lack of improvement on conservative management prompted a reopening of thoracotomy. This revealed a dehiscence of the access gastrostomy suture line. It was closed with insertion of a T-tube. The patient was managed in HDU for a prolonged period and enteral nutritional support was established. The patient was readmitted eight weeks later as a chronic empyema had developed. This needed drainage and tube insertion in the abscess cavity. The early removal of the NG tube and resistant hold up at the pylorus despite pyloromyotomy caused accumulation of air and fluid with distension of stomach and access suture line disruption.
A fifty four year old woman developed severe dysplasia in long standing Barrett's esophagus with strong suspicion of invasive adenocarcinoma. She also suffered from long-standing scleroderma and chronic renal failure and had undergone a failed transplant and thus was dialysis dependent. She underwent esophagogastrectomy with Roux-En-Y reconstruction. On the fourth postoperative day, it was noticed that she had blood stained fluid in her NG tube and also had malaena with a falling haemoglobin. At exploration, it was found that she had a large clot at the enteroenterostomy with a defect in the jejunum. The enteroenterostomy was opened, the clot evacuated, haemostasis obtained and the defect closed. It was postulated that coagulation defects secondary to chronic renal failure and inadequate staple line haemostasis had resulted in the bleeding. This led to gross overdistention and a breach in the enteroenterostomy.
A fifty one year old man underwent a total gastrectomy and reconstruction with a Hunt-Lawrence esophagojejunostomy pouch for gastric lymphoma. He was allowed oral intake after five days and subsequently ate a large meal on day six. This resulted in development of an enterocutaneous fistula. At reoperation it was discovered that the enterotomy on the ascending limb of jejunum had given way. The cut edges were closed using vicryl 2-0. The patient had a prolonged hospital stay of thirty-nine days needing HDU admission and reversion to enteral feeding via a surgically placed jejunostomy tube. He eventually recovered and was discharged. Unfortunately he died six months later due to rapid progression of an aggressive T- cell lymphoma. In all 3 cases, the jejunostomy feeding tube, which is routinely inserted in our unit, allowed early introduction of enteral nutrition.
Anastomotic and access staple line leaks along with pulmonary complications have been documented as the most frequent causes of death after operations for esophageal and gastric carcinoma (1). Patients with leakage from access gastrostomy suffer from a more severe clinical picture with an increased volumess and duration of leakage and frequent reoperations (2). Most of these patients tolerate reoperation poorly and this is associated with a mortality rate of up to 75% following re-exploration (3).
The use of circular stapling devices has resulted in a dramatic reduction in the incidence of anastomotic leak (4,5) with leakage rates of as low as 2.6% with certain devices being demonstrated 5. It is claimed that a stapled anastomosis is faster to perform, resulting in a shorter operative time and decreased blood loss (6). However this enhanced safety of stapling devices may result in a tendency to a complacent attitude towards certain basic principles in oesophagogastric surgical management such as meticulous closure of enterotomy used for device access.
Lack of oversewing of access line gastrostomy has led to a greater incidence of leakage and oversewing or two layer closure has been reported as leading to a significant reduction of leakage rates (7). Similarly, the placement of access line enterostomies distant from the stapled anastomosis has also been recommended (7) and should be facilitated by longer, more flexible stapling instruments. There is a tendency towards early oral intake with desire to reintroduce enteral stimulation (7) . Strict feeding protocols (7) and careful monitoring of patients is required at ward level as patients may, with better pain control and an early feeling of well, may be tempted to rapidly increase oral intake.
As demonstrated by these three case reports, leakage from staple device access enterotomies can cause high morbidity with increased postoperative stay and contribute to a high cost of care. These events may lead to early postoperative death. The early loss of NG tube in the first patient, imperfect haemostasis and clot accumulation in the second and early intake of a large meal in the third resulted in accumulation of air/fluid/ blood. This caused overdistention in the area of a staple line. Careful attention is required to the timing of removal of NG tube and introduction of oral feeding. Haemostasis at these sites should be checked carefully.
The lack of oversewing of stapled access suture line or a single layer closure may provide a relatively weak closure point. Oversewing of access stapled line and placement of these lines away from the esophagogastric / jejunal anastomosis should minimise such mishaps. The era of safe stapled anastomosis should not divert the surgeon from adherence to safe basic surgical techniques.
1. Poslethwaite RW, Durham MD. Complications and deaths after operations for esophageal carcinoma. J Thorac Cardiovasc Surg 1983;85:827-831.
2. Griffin SM, Lamb PJ, Dresner SM, Richardson DL, Hayes N. Diagnosis and management of a mediastinal leak following radical esophagectomy. Br J Surg 2001;88:1346-1351.
3. Tam PC, Fok M, Wong J. Reexploration for complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 1989;98: 1122-1127.
4. West PN, Marbarger JP, Martz MN, Roper CL. Esophagogastrostomy with EEA stapler. Ann Surg 1981;193: 76-81.
5. Wong J, Cheung H, Lui R, Fan YW, Smith A, Siu KF. Esophagogastric anastomosis performed with a stapler; the occurrence of leakage and stricture. Surgery 1987;101:408-415.
6. Craig SR, Walker WS, Cameron EWJ, Wightman AJA. A prospective randomised study comparing stapled with handsewn esophagogastric anastomosis. J.R.Coll.Surg.Edinb 1996;41:17-19.
7. Muehrcke DD, Donnelly RJ. Complications after esophagogastrectomy using stapling instruments. Ann Thorac Surg 1989;48:257-262.
