Intraoperative and postoperative risk factors for anastomotic leakage and pneumonia after esophagectomy for cancer

Abstract

Morbidity and mortality after esophagectomy are often related to anastomotic leakage or pneumonia. This study aimed to assess the relationship of intraoperative and postoperative vital parameters with anastomotic leakage and pneumonia after esophagectomy. Consecutive patients who underwent transthoracic esophagectomy with cervical anastomosis for esophageal cancer from January 2012 to December 2013 were analyzed. Univariable and multivariable logistic regression analyses were used to determine potential associations of hemodynamic and respiratory parameters with anastomotic leakage or pneumonia. From a total of 82 included patients, 19 (23%) developed anastomotic leakage and 31 (38%) experienced pneumonia. The single independent factor associated with an increased risk of anastomotic leakage in multivariable analysis included a lower minimum intraoperative pH (OR 0.85, 95% CI 0.77-0.94). An increased risk of pneumonia was associated with a lower mean arterial pressure (MAP) in the first 12 hours after surgery (OR 0.93, 95% CI 0.86-0.99) and a higher maximum intraoperative pH (OR 1.14, 95% CI 1.02-1.27). Interestingly, no differences were noted for the MAP and inotrope requirement between patients with and without anastomotic leakage. A lower minimum intraoperative pH (below 7.25) is associated with an increased risk of anastomotic leakage after esophagectomy, whereas a lower postoperative average MAP (below 83 mmHg) and a higher intraoperative pH (above 7.34) increase the risk of postoperative pneumonia. These parameters indicate the importance of setting strict perioperative goals to be protected intensively.

Impact of postoperative complications on outcomes after oesophagectomy for cancer

“…The relevance of pulmonary complications and anastomotic leakage after oesophagectomy for cancer has been acknowledged in previous studies. Several strategies have been shown to protect against pulmonary complications and anastomotic leakage.…”

“…Reported overall rates of complications after oesophagectomy range from 40 to 60 per cent, with pulmonary and anastomotic complications being the most common. These postoperative complications have a significant effect on morbidity, duration of hospital stay, mortality and healthcare costs. Although advances in surgical techniques and perioperative care have reduced the frequency of complications over the years, postoperative morbidity rates remain high.…”

Intrathoracic versus cervical anastomosis and predictors of anastomotic leakage after oesophagectomy for cancer

“…Several factors are associated with an increased risk of anastomotic leakage, including patient‐related characteristics, intraoperative factors, postoperative factors and surgical technique. Controversy remains about the optimal anatomical location of the oesophagogastric anastomosis (intrathoracic versus cervical) after oesophagectomy.…”

Diagnosis, assessment, and management of surgical complications following esophagectomy

“…Not only safe anastomoses, but also timely identification of anastomotic or other surgical complications are essential to reduce morbidity, prolonged hospitalization, mortality, and, consequently, additional medical costs . Both surgical expertise and experience are key elements for limiting the leakage rate and managing its consequences after esophagectomy, and it is argued that centralizing surgical care may be a key determinant of lower leakage rates .…”

“…15 Not only safe anastomoses, but also timely identification of anastomotic or other surgical complications are essential to reduce morbidity, prolonged hospitalization, mortality, and, consequently, additional medical costs. [16][17][18] Both surgical expertise and experience are key elements for limiting the leakage rate and managing its consequences after esophagectomy, and it is argued that centralizing surgical care may be a key determinant of lower leakage rates. 5,19 Our goal is to provide a succinct review of key principles and current knowledge relating to risk factors, modalities to identify and manage anastomotic leakage as well as associated technical complications, particularly airway fistula, respiratory failure, and chylothorax, which can affect development of a leak in patients undergoing esophagectomy.…”