Is Prophylactic Cervical Drainage Effective in Patients Undergoing McKeown Esophagectomy Reconstructed Through the Retrosternal Route with Two‐Field Lymphadenectomy?

Abstract

Background McKeown esophagectomy with two-field lymphadenectomy is the treatment of choice for oncologic esophagectomy. A cervical drain is placed in cases after modern two-field lymph node dissection (M2FD) to provide information on anastomotic leakage. However, the necessity of prophylactic cervical drainage during surgery remains unknown. This study aimed to clarify the clinical significance of cervical drainage in patients who underwent McKeown esophagectomy with M2FD. Methods A total of 293 patients underwent McKeown surgery with two-field lymphadenectomy at our institute between January 2013 and December 2019. We compared the day of drain removal, amount of drainage volume, and the appearance of drainage fluid between patients with and without anastomotic leakage. ResultsMcKeown esophagectomy reconstructed through the retrosternal route is 203 patients (69.3%) of all. Nineteen patients (6.5%) experienced anastomotic leakage. The amount of cervical drain discharge was comparable between patients with and without anastomotic leakage. In addition, no purulent or salivary discharge was observed in patients with anastomotic leakage. There was no difference in the median day of drain removal between the groups. The initial clinical findings for the diagnosis of anastomotic leakage were surgical site infection in 10 (52.6%), fever in 5 (26.3%), prolonged inflammation in a blood test in 3 (15.8%), and bloody discharge from the chest tube in 1 (5.3%). There was no mortality due to any cause. Conclusion A prophylactic cervical drain may not be mandatory in patients with esophageal cancer undergoing McKeown esophagectomy reconstructed through the retrosternal route with two-field lymphadenectomy.

Case report: Drainage tube penetrating anastomosis as a rare cause for long-term nonunion of esophagogastric anastomosis in neck

“…It can not only minimize the dead space after the dissection but also offer information about hemorrhage, chyle leak, or anastomotic leakage, and enable clinicians to start treatment rapidly (10). The usual practice of cervical drain is placing a silicone or polyurethane foam drainage tube posterior to the anastomosis (10,11). The size of the drainage tube ranges from 10 to 24 Ch/Fr according to physicians' choices.…”

“…The volume of drainage fluids is usually lower than 50 ml/24 h since the second postoperative day and the difference in amount between patients with or without leakage is not significant (10). However, if the drainage tube penetrates the anastomotic stoma and goes deep into the stomach, the gastric juice may be drained thus increasing the daily volume of drainage fluids significantly (up to 800 ml in the presented case 1) and turning the clear, hematic, light red, or dark red fluids into yellow-green or brown 3.…”

“…However, the timing for removing the cervical drainage tube is still controversial. There are multiple standards for cervical drainage tube removal such as removing on the first postoperative day except for patients with active bleeding or removing when the daily output amount reduces to 20 ml or less (10,20). Different indications could be expected to result in a huge difference in the drainage tube placement time.…”

“…The size of drainage tubes is another noteworthy factor. The size of drainage tubes ranging from 15 to 18 Ch/Fr is recommended (10). The material of drainage tubes should also be taken into consideration.…”

A randomized controlled trial exploring the effect of placement versus nonplacement of a drainage tube around the cervical anastomosis in McKeown esophagectomy

“…A randomized trial of 40 patients found that the routine use of a neck drain for esophageal anastomosis in the neck was not necessary, 10 but the study size was too small to evaluate the utility of a drain for anastomotic leakage. The authors of a larger study of 293 patients suggested that a prophylactic drain may not be universally mandatory for patients with esophageal cancer undergoing McKeown esophagectomy reconstructed through the retrosternal route with two-eld lymphadenectomy, 11 but the study was retrospective in nature.…”