544 Management of Acute Anastomotic Complications After Ivor-Lewis Esophagectomy

Abstract

Anastomotic leak (AL) and conduit necrosis (CN) are among the most serious surgical complications after esophageal resection. Endoscopic, radiological and surgical methods are used in their treatment. The aim of this paper is to evaluate the results of the treatment of acute anastomotic complications after Ivor-Lewis esophagectomy in a single high-volume center. Methods We performed a retrospective audit of a consecutive cohort of 815 patients undergoing transthoracic esophagectomy with intrathoracic esophago-gastric anastomosis from 2005 to 2019. AL was graded according to Esophagectomy Complications Consensus Group recommendation. Results There were 79 patients with AL and 6 patients with CN (10%). AL type I, II and III was diagnosed in 33 (39%), 25 (29%) and 27 (32%) patients, respectively. Esophageal stent was used in 40 patients. Primary surgical revision (with/without stent insertion) was performed in 14 patients. Reoperation was necessary overall in 25 patients (29%). Seventeen patients (20%) ended-up with esophageal diversion. Treatment with esophageal stent was successful in 28/40 patients (70%). Endoscopic vacuum-therapy was successfully used in three patients for peristent leak after stent extraction. Mortality of severe AL (type II and III) was 10/52 patients (19%). Conclusion Successful management of acute anastomotic complications requires early diagnosis and an individual treatment approach with the use of endoscopic, radiological and surgical methods. The primary attempt for anastomosis preservation using esophageal stent is desirable. Considering the clinical condition and CT finding, we recommend not to hesitate with surgical revision with debridement and drainage of pleural cavity and mediastinum. If primary therapy fails, life-saving procedure is the esophageal diversion.

The Use of Esophageal Stents in the Management of Postoperative Fistulas—Current Status, Clinical Outcomes and Perspectives—Review

“…Although the groups of patients included in the studies vary, the rate of successful fistula closure by stenting varies between 63.5 and 100% [16,[22][23][24]. Segura et al in a 2022 study reported fistula healing using a single stent with the covered double-layer metal stent (Niti S™ DOUBLE™ Esophageal Metal Stent Model) in a percentage of 75% and 100% in terms of using the method [25], and Haruštiak et al revealed an efficiency of 84% in closing the fistula by stenting in an average time of 55.7 ± 27.11 days/patient (mean of 39 ± 24.30 days/stent) [26].…”

“…In order to reduce the consequences of a persistent post-stenting fistula, it is necessary that it be recognized and managed properly. The reported incidence of fistula persistence varies but may be seen in approximately 10-38% of patients [24,26,[34][35][36]. Stephens et al [19] proposed in 2014 a classification of persistent post-stent fistula into five types based on radiographic evaluation with water-soluble contrast: Type 1-proximal; Type 2-retrograde distal; Type 3-through holes in the film covering the stent; Type 4-between stents; and Type 5-migrated stent.…”

“…In the literature, according to studies, it has been shown that most aortic fistulas appear after prolonged maintenance of the stent, from 26 to 36 days [49]. Haruštiak et al described the presence of esoaerial fistula in 4/39 (10%) of stented patients [26]. We discovered the esotracheal fistula and proliferation of cartilaginous tissue, probably of tracheal origin in a patient after the extraction of the second stent, placed for a persistent anastomotic fistula 6 weeks after the insertion of the first stent (Figures 5 and 6).…”