Anastomotic Leak Does Not Impact on Long-Term Outcomes in Esophageal Cancer Patients

Abstract

Background. Esophagectomy is a technically demanding procedure associated with high levels of morbidity. Anastomotic leak (AL) is a common complication with potentially major ramifications for patients. It has also been associated with poorer long-term overall survival (OS) and disease recurrence. Objective. The aim of this study was to determine whether AL contributes to poor OS and recurrence-free survival (RFS) for patients with esophageal cancer. Methods. Consecutive patients undergoing a two-stage, two-field transthoracic esophagectomy from a single highvolume unit between 1997 and 2016 were evaluated. Clinicopathologic characteristics, along with oncological and postoperative outcomes, were stratified by no AL versus non-severe leak (NSL) versus severe esophageal AL (SEAL). SEAL was defined as ALs associated with Clavien-Dindo grade III/IV complications. Results. This study included 1063 patients, of whom 8% (87/1063) developed AL; 45% of those who developed AL were SEALs (39/87). SEAL was associated with a prolonged critical care stay (median 8 vs. 3 vs. 2 days; p \ 0.001) and prolonged hospital stay (median 43 vs. 27 vs. 15 days; p \ 0.001) compared with NSL or no AL. There were no significant differences in number of lymph nodes harvested and rates of R1 resection between groups. OS and RFS were not affected by either NSL or SEAL, and Cox multivariate regression showed NSL and SEAL were not independently associated with OS and RFS. Sensitivity analysis in patients receiving neoadjuvant therapy followed by esophagectomy demonstrated similar findings. Conclusion. These results demonstrate that AL leads to prolonged critical care and in-hospital length of stay; however, contrary to previous reports, our results do not compromise long-term outcomes and are unlikely to have a detrimental oncological impact. Esophagectomy remains a key component of treatment for patients with potentially curable esophageal cancer. While mortality levels from the procedure have fallen dramatically over the last 30 years, esophagectomy is still associated with high levels of morbidity. 1-3 Anastomotic leak (AL) is a commonly seen complication that has historically been associated with high mortality rates. 4 The Esophagectomy Complications Consensus Group (ECCG) defined AL as a full-thickness defect involving the esophagus, anastomosis, staple line or conduit, irrespective of the presentation or method of identification. 5 The classification further divided leaks into the management strategy employed: type I, those that require no change in treatment; type II, leaks that require intervention, but not surgery; and type III, leaks that require surgical intervention. The incidence of AL has been reported at between 3 and 30%. 6,7 This can result in a prolonged hospital stay, a need for reoperation, anastomotic stricturing that requires repeated dilations, and potentially poorer long-term survival. 8,9 A French multicenter study, which defined severe

Long-Term Oncologic Impact of Esophageal Anastomotic Leak After Esophagectomy

“…In contrast to the aforementioned studies, Kamarajah et al 9 demonstrated no statistical difference in overall survival or recurrence-free survival between the cohort with leak and the cohort without leak. This finding also was upheld in the subgroup analysis of patients who received neoadjuvant therapy followed by surgery, a group similar to the patients treated currently with trimodality therapy.…”

“…We applaud Kamarajah et al 9 for changing the focus from multicenter study with all tiers of experience included in esophageal surgery to a single high-volume study focused on oncologic outcome after anastomotic leaks. These authors retrospectively identified 1063 patients during 20 years who underwent a two-stage, two-field transthoracic esophagectomy and evaluated clinicopathologic characteristics as well as oncologic and postoperative outcomes for the patients.…”

“…Lymphadenectomy quantity (23 to 29 nodes resected), morbidity (67%), anastomotic leaks (8%), and 30-day mortality (3%) reflect quality data points comparable with those of other high-quality centers that specialize in esophageal surgery. 9,10 Of the 87 patients (8%) who experienced anastomotic leaks, 45% experienced a SEAL, with only two deaths reported, both occurring within 30 days and consisting of 5% of all patients who died during this period. A total of 38 patients died in the hospital postoperatively, and 28 of these patient deaths occurred within 30 days after index surgery.…”

“…The concept of a high-quality center for esophageal cancer surgery is the critical differentiator in this report. Whereas single-center studies often are overshadowed by multicenter collaborations, Kamarajah et al 9 purposefully used their high-volume and high-quality experience to compose an excellent single-institution study. Significant anastomotic leaks were few, and R1 resection was uncommon.…”

“…As with other reports from high-quality centers, theirs is associated with good outcomes in both the short-and long terms, with the latter irrespective of anastomotic leak. Perhaps Kamarajah et al 9 indirectly exposed the age-old concept that complex, standardized procedures with multiple complications are best managed in centers with experience and expertise, and that correlating these complications with survival end points can certainly be done well in a single-institution study.…”