Management of anastomotic leaks following esophagectomy: when to intervene?

Abstract

Background: Esophagectomy is the mainstay treatment for early stage and locoregionally advanced esophageal cancer. Anastomotic leaks following esophagectomy are associated with numerous detrimental sequelae. The management of anastomotic leaks has evolved over time. The present study is a singleinstitution experience of esophageal leak management over an 11-year period, in order to identify when these can be managed nonoperatively. Methods: All patients undergoing esophagectomy with gastric reconstruction at our institution between 2004 and 2014 were identified. Preoperative patient characteristics and perioperative factors were reviewed. Failure of initial leak treatment was defined as need for escalation of therapy. Length of stay (LOS) and postoperative mortality were the primary outcomes. Follow-up was obtained through institutional medical records and the Social Security Death Index. Results: Sixty-one of 692 (8.8%) patients developed an anastomotic leak. Forty-six patients (75.4%) first underwent observation, which was successful in 35 patients. Predictors of successful observation included higher preoperative albumin (P=0.02), leak diagnosed by esophagram (P=0.004), and contained leaks (P=0.01). Successful observation was associated with shorter LOS (P=0.001). Predictors of mortality included lower preoperative serum albumin (P=0.01) and induction therapy (P=0.03). Thirty and 90-day mortality among patients who developed an anastomotic leak were 9.8% and 16.7%, respectively. Conclusions: Over half of anastomotic leaks were managed successfully with observation alone and did not require additional interventions. We have identified factors that may predict successful therapy with observation in these patients. Further research is warranted to determine more timely interventions for patients likely to fail conservative management.

Esophagectomy for Esophageal Cancer Performed During the Early Phase of the COVID-19 Pandemic

“…The increased, statistically nonsignificant, rate of anastomotic leaks seen during COVID-19 were not related to the pandemic and are within the range of recent studies (13)(14)(15). Upon inspection of our morbidity database from March 2020 through February 2021, 9 leaks occurred during the year with 4 during our study period for COVID-19.…”

Rates of Anastomotic Complications and Their Management Following Esophagectomy

“…However, most patients do not fit these polarized clinical presentations and treatment outcomes (whether endoscopic stent or EndoVac, or other therapies) are significantly more varied, providing no clear gold standard option for leak management. Studies evaluating anastomotic complication treatment often demonstrate marked heterogeneity, report data from small cohorts, and often lack important detail regarding leakage characteristics 22–24 . Several RCTs are in development, randomizing treatment to either covered stent or EndoVac therapies 25 .…”

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

“…Conservative therapy consists of withholding oral feeding while ensuring nutritional support, preferably enteral, through an intraoperatively placed jejunostomy [ 13 , 15 , 19 , 20 , 21 ]. An alternative is parenteral feeding through a central venous line.…”