| Popis: |
Anastomotic leakage after total gastrectomy is an extremely serious complication, with mortality rates as high as 30%. This complication depends on various factors: the surgeon’s experience, the stage of disease, the extension of the surgical intervention, patient age, sepsis, and malnutrition. Some local factors, such as vascularization of the graft, traction on the anastomosis suture line, and local infections, have been implicated as contributing to anastomotic failure. If infection is absent and if the leakage is drained correctly, treatment is conservative and is based on nutritional support (enteral or parenteral) and antibiotic therapy. Surgical intervention is indicated for peritonitis, mediastinitis, graft necrosis, or ineffective external drainage. If operation is needed, numerous repair techniques exist: simple perianastomotic drainage with jejunostomy, esophageal exclusion with cervical esophagostomy and jejunostomy (a further operation is required for recanalization of the digestive tract), or removal of the fistula with a new intrathoracic esophagojejunal anastomosis through a left thoracophrenolaparotomy. We present an alternative surgical repair technique that involves temporary double exclusion of the esophagojejunal anastomosis. This technique is similar to that reported by Assens and colleagues and Bardini and associates for esophageal perforations. Closure of the esophagus and the efferent jejunal loop is performed with a mechanical stapler (Roticulator 55 Poly.170; Auto Suture, US Surgical Corp, Norwalk, CT) with absorbable copolymer staples (Lactomer, US Surgical Corp., Norwalk, CT). Bipolar exclusion prevents pancreaticobiliary reflux and the transit of saliva, which favors the healing process of the leakage. Clinical studies have shown that copolymer staples are absorbed in tissue by hydrolysis and maintain a tensile strength greater than 50% over 2 months. Staple absorption, which takes 10 to 25 days, ensures spontaneous esophagojejunal recanalization. |
