Incidence and treatment of mediastinal leakage after esophagectomy: Insights from the multicenter study on mediastinal leaks study

Abstract

BACKGROUNDMediastinal leakage (ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has been difficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.AIMTo assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group (ECCG).METHODSSeven Italian surgical centers (five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies (n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017. Anastomotic MLs were defined according to the classification recently proposed by the ECCG.RESULTSFifty-nine cases of ML were recorded, yielding an overall incidence of 11.8% (95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy (HE), respectively, and doubled (20%) after totally minimally invasive esophagectomy (TMIE) (P = 0.016). No other predictive factors were found. The 30- and 90-d overall mortality rates were 1.4% and 3.2%, respectively; the 30- and 90-d leak-related mortality rates were 5.1% and 10.2%, respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%, respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases. Endoscopic treatment had the lowest mortality rate (6.9%). Removal of the gastric tube with stoma formation was necessary in 8 (13.6%) cases.CONCLUSIONThe incidence of ML after esophagectomy was high mainly in the TMIE group. However, the general and specific (leak-related) mortality rates were low. Early treatment (surgical or endoscopic) of severe leaks is mandatory to limit related mortality.

RAMIE: tradition drives innovation—feasibility of a robotic-assisted intra-thoracic anastomosis

“…In both trials, the anastomosis was, therefore, carried out in a traditional manner, thus highlighting the problems in the standardization of a minimally invasive intra-thoracic anastomosis. This reluctance is based on the high leakage rate encountered in the few published experiences on totally MIE [5]. Nevertheless, Ivor Lewis procedure is the procedure of choice for the majority of esophageal cancer in the West, considering the high incidence of esophageal and esophagogastric junction adenocarcinoma [12].…”

“…Notably, this HE approach led to a reduction in pulmonary complications in the French randomized MIRO trial [3]. Unfortunately, the attempts to perform a totally MIE with a thoracoscopic approach have led to an increase of anastomotic leak up to 15-20% [4,5].…”

T-drain esophagostomy under thoracoscopy for intrathoracic esophagogastric anastomotic leakage following esophagectomy for esophagogastric junction cancer: A case report

“…Eizaguirre E. et al reported that the mortality of patients who received reoperation is high [ 15 ], suggesting that it is important to carefully select patients who should undergo surgical treatment. It is important to note that early treatment of severe leaks is mandatory to limit related mortality [ 2 ].…”

“…Intrathoracic anastomotic leakage is associated with significant mortality [ 1 ]. Therefore, early treatment of leakage is mandatory to limit the associated mortality [ 2 ]. The principles of management of anastomotic leakage include drainage of the pleural and mediastinal cavities, intravenous broad-spectrum antibiotics, gastric decompression, and enteral or parenteral nutritional support.…”

Gastrointestinal Tract Leak: Is It One Entity or Spectrum of Conditions?

“…The extent of the morbidity resulting from GI perforation and leak is variable, may not be predictable, and can lead to death [1]. Leaks are associated with a wide spectrum of complications, such as local infection, sepsis, and multiple organ system failure, in addition to prolonged hospitalization and decreased quality of life.…”