The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma

Abstract

Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% (n = 90) in the cervical region and 4.2% (n = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.

Road Map to Esophagectomy for Nurses

“…Patients who had a leak identified experienced an increased mortality rate of 37%. 33 The cervical anastomosis has a higher incidence of developing a leak, in about 10% of all cases. In contrast, mediastinal anastomosis leaks are rare, with about a 5% occurrence rate.…”

“…Anastomosis leak or failure of an anastomosis to heal properly is not uncommon, with reported incidences from 1% to 30%. 3,5,26,32,33 The esophageal tissue is more vulnerable to poor healing because of its lack of a protective serosal covering. Tension at anastomosis sites, reduced vascularity, and long surgical ischemic time along with poor nutritional status and history of chemoradiation are contributory.…”

Endotherapy for oesophageal anastomotic leaks – is it the way forward?

“…Leaks after thoracic oesophageal anastomosis are reported in 5-7 % of the cases (1). Traditionally these leaks are reported to carry a high mortality rate, of about 30% (2).…”

Medical thoracoscopy and gastroscopy for the treatment of intrathoracic anastomotic leakage following esophagectomy

“…The mortality rate is 12-46.2% (1)(2)(3). In general, the effect of conservative treatments, including conventional chest tube drainage, nasogastric decompression and nutritional support, is often poor, particularly in patients with adhesions of the pleural cavity and multiloculated empyema (1)(2)(3)(4). This study describes the combined application of medical thoracoscopy followed by gastroscopy for the treatment of an intrathoracic anastomotic leak in two patients.…”

“…Intrathoracic anastomotic leakage is an extremely intractable complication that occurs following esophagectomy, with an incidence that ranges from 1.3 to 5.1% (1)(2)(3). The mortality rate is 12-46.2% (1)(2)(3).…”