1. Clinicopathological characteristics of patients with different types of anastomotic complications
All the 88 patients were treated under endoscopy, and no related adverse events occurred during the operation. Among the enrolled patients, there were 43 cases of anastomotic stenosis of digestive tract, including 20 cases of upper and lower gastrointestinal stenosis and 23 cases of upper and lower gastrointestinal stenosis respectively. In the upper digestive tract anastomotic stenosis, there were 12 male patients and 6 female patients, with an average symptom onset time of 3.81 ± 3.46 months, 16 benign stenosis cases and 4 malignant stenosis cases. Preoperative Stooler grade: 3 cases of grade II, 10 cases of grade III, and 7 cases of grade IV.The average length of hospitalization was 4.94 ± 2.08 days.The average postoperative feeding time was 3.1 ± 5.0 days.In the lower digestive tract anastomotic stenosis, the symptom onset time of the patients was 7.97 ± 8.69 months, including 21 cases of benign stenosis and 2 cases of malignant stenosis. Preoperative Truong anastomotic stenosis classification: 2 cases of grade I, 12 cases of grade II and 9 cases of grade III.The stenosis length was 2.3 ± 1.36cm, the average length of hospitalization was 5.86 ± 4.02 days, and the postoperative feeding time was 3.0 ± 1.97 days.The average feeding time after operation for all patients with gastrointestinal stenosis was 3.38 ± 3.0 days.(Fig. 1A,1C,Table s1).
There were 22 cases of anastomotic obstruction of digestive tract, all of which were upper gastrointestinal tract. There were 15 cases of inflammatory obstruction and 7 cases of input/output loop obstruction.The onset time of symptoms was 12.5 ± 4.49 days. Postoperative feeding time was 8.65 ± 3.44 days, mainly nasogastric feeding through jejunal nutrient canal, and the average length of hospital stay was 26.13 ± 14.72 days.(Fig. 1G,Table s2).
There were 23 cases of anastomotic fistula, and the onset time of symptoms was 12 ± 6.28 days. The average postoperative feeding time was 5.44 ± 2.84 days, and nasal feeding was dominant. The average length of hospitalization was 26.21 ± 14.50 days.Low DE et al anastomotic classification: 8 cases of grade A, 12 cases of grade B, 3 cases of grade C.(Fig. 2A-2B,Table s3).
2. Endoscopic intervention measures and management of anastomotic complications
Among the endoscopic interventions for upper gastrointestinal anastomotic stenosis, there were 5 cases of upper gastrointestinal stent implantation, 5 cases of endoscopic incision, 4 cases of balloon dilatation, 1 case of endoscopic gastrostomy, 4 cases of surgical treatment and 1 case of conservative treatment after failure of intraoperative endoscopic treatment. Short-term postoperative complications: 1 patient with stent placement had stent displacement 20 days after the operation.
Endoscopic intervention measures for lower gastrointestinal anastomotic stenosis: stent implantation in 12 cases, endoscopic incision in 4 cases, balloon dilatation in 3 cases, stenosis incision plus stent implantation in 3 cases, and surgical treatment in 1 case after intraoperative endoscopy.Short-term postoperative complications occurred in 4 patients: 1 patient underwent stent displacement on the 4th day after surgery;Blood stool occurred 10 days after stent implantation in 1 case. One patient with subcutaneous emphysema, fever and suspected microperforation underwent conservative treatment after incision and stent implantation. Postoperative abdominal pain and discomfort occurred repeatedly in 1 patient with stent implantation (Fig. 1B,1D,Table s1).
Digestive tract obstruction: Among the patients with inflammatory obstruction, 15 cases were successfully placed with jejunal nutrition tube under endoscope, and 1 case received surgical treatment with no remission of postoperative symptoms. In input/output loop obstruction, 4 cases underwent successful endoscopic treatment, including 2 cases of input loop drainage under endoscopy and 2 cases of output loop obstruction with endoscope stent placement, three patients were treated by surgery after failure of intraoperative endoscopic treatment.(Fig. 1H,Table s2)
In the endoscopic intervention of anastomotic fistula of digestive tract, 8 cases were placed with jejunal nutrition tube under endoscope, 1 case was placed with stent, and 7 cases were clipped with metal clip. Among them, 5 cases of esophageal fistula were clipped with over-the-scope Clip(OTSC), and 2 cases with small esophagojejunostomy fistula were clipped with metal Clip, One case of endoscopic examination suspected anastomotic ischemia received surgical treatment and jejunal nutrition tube implantation.Short-term postoperative complications: 1 case of esophageal fistula developed high fever after OTSC clipping, endoscopic examination revealed that endoscopic jejunal nutrition tube placement was performed after failure of clipping.
In the lower digestive tract anastomotic fistula, 4 cases were placed with full-coverd metal stent, among which 1 case was found to have a small fistula closed with metal clamp 15 days after the stent was taken.Two patients with rectovaginal fistula: 1 case treated with full coverd metal stent and vacuum-assisted closure therapy, no significant relief was found and surgical treatment was selected,anothor patient was treated with vacuum-assisted closure therapy(Fig. 2C-2D,Table s3).
3. Changes in laboratory examination after endoscopic intervention
After 3 days of endoscopic treatment for anastomotic stenosis, anastomotic fistula and anastomotic obstruction, the ratio of white blood cells and neutrophils of the patients after the operation did not increase significantly compared with that before the operation, and there was no significant statistical significance.(Fig. 3,Table s7)
4. Postoperative follow-up outcomes
In the follow-up of patients with upper gastrointestinal anastomotic stenosis for 1 month after endoscopic therapy, 1 patient after stent implantation was found to still have stenosis and then underwent endoscopic balloon dilatation. Stooler classification: 10 cases of Grade 0, 2 cases of Grade I, 1 case of Grade II, and 2 cases of Grade III.During the 3-month follow-up, Stooler classification:11 cases of grade 0, 3 cases of grade I, 1 case of Grade III.One patient was placed into the jejunal nutrition tube again due to recurrent acid reflux and abdominal pain.The results of 1-year follow-up showed that the patients died due to tumor metastasis after gastrostomy, and the symptoms of the remaining patients with upper gastrointestinal anastomotic stenosis were all relieved. In the follow-up of patients with lower gastrointestinal anastomotic stenosis 1 month after operation, postoperative Truong anastomotic stenosis grade: 13 cases of grade 0-I, 5 cases of grade II, and 3 cases of grade III, among which 4 cases of stents were still not removed.Three patients with grade III stenosis received surgical treatment without significant relief. During the follow-up 3 months after surgery, postoperative Truong anastomotic stenosis was classified into 16 cases with grade 0-I and 2 cases with grade II.1 patient after stent removal and was reinserted; 1 patient had abdominal pain and was found to have edema around the anastomotic site after reexamination, and underwent stent removaland radial incision.During the follow-up of 1 year after operation, 2 patients were lost to follow-up, the remaining patients' symptoms were relieved, and no additional auxiliary intervention was needed, and no recurrence was found.(Fig. 1E-1F,Table s4).
Among the patients with digestive tract anastomotic obstruction, 1 case of the patients after stent implantation had stent displacement and returned to hospital for stent removal, and the anastomotic site returned to normal.After 3 months to 1 year of follow-up, all patients were in remission and returned to normal diet and exhaust and defecation. Stents were removed in all patients, and no patients experienced recurrence.(Fig. 1I,Table s5).
Among the patients with anastomotic fistula in the upper digestive tract, 5 patients with anastomotic fistula were followed-up 1 month after operation. The patients were followed-up 3 months after the operation, and the symptoms were all relieved. The patients were followed up 6 months after the operation, a patient was treated with OTSC for anastomotic fistula recurrence, and the anastomotic stoma was treated by OTSC again.After 1 year of follow-up, all patients with anastomotic fistula had been cured, without other anastomose-related complications. In patients with lower digestive tract anastomotic fistula: 1 month follow-up, 1 case selected surgical exploration, 1 case of rectovaginal fistula treated with vacuum-assisted closure therapy and anastomotic fistula was smaller than before. Six months vacuum-assisted closure therapy, rectovaginal fistula was treated by surgery. Results of 1-year follow-up showed none of the patients died and the function of exhaust and defecation was normal.(Fig. 2E-2F,Table s6).