Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Abstract

Background Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score. Methods This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally. Results Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification. Conclusion The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

Management of anastomotic leaks after oesophagectomy and gastric pull-up

“…CT scan allows evaluation of the magnitude and location of the leak, which is helpful in placing the chest tubes directly into the infected collections and pleural effusions. An early diagnosis reduces the severity of contamination and sepsis, which are important determinants of surgical intervention (17). Non-operative management should not be considered as a conservative treatment.…”

Treatment of anastomotic leak after oesophagectomy for oesophageal cancer: large, collaborative, observational TENTACLE cohort study

“…Characteristics of the participating centres can be found in Table S1 . Data quality validation by independent local validators showed a data accuracy of 96.5 per cent 23 . The protocol was approved by the institutional review board of Radboud University Medical Centre (review file 2018-4585) and by local ethical committees if needed.…”

“…The TENTACLE—Esophagus study is an international retrospective cohort study in 71 centres across 20 countries. Details of the TENTACLE—Esophagus study have been published previously (NCT03829098) 23 . Characteristics of the participating centres can be found in Table S1 .…”

Nationwide Association of Surgical Performance of Minimally Invasive Esophagectomy With Patient Outcomes

“…These surgeons had a minimum of 5 years’ experience with MIE, had performed at least 120 MIE procedures, 9 and were each experienced in 1 of 3 primary anastomotic techniques: intrathoracic end-to-side, intrathoracic side-to-side, and cervical hand-sewn end-to-end. Considering that the anastomosis is a clinically relevant phase, 26 4 additional Dutch expert surgeons (B.R.K., W.O.d.S., M.N.S., and B.W.) with a minimum of 5 years’ experience and extensive expertise in their preferred anastomotic technique conducted the anastomotic phase assessment of their daily practice–preferred anastomosis.…”

“…These surgeons had a minimum of 5 years' experience with MIE, had performed at least 120 MIE procedures, 9 and were each experienced in 1 of 3 primary anastomotic techniques: intrathoracic end-to-side, intrathoracic side-to-side, and cervical handsewn end-to-end. Considering that the anastomosis is a clinically relevant phase, 26…”