Management of anastomotic leaks after esophagectomy and gastric pull-up

Abstract

Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient's clinical status and the surgeon's preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.

Impact of Robotic Approach on Post-Anastomotic Leaks After Esophagectomy for Esophageal Cancer

“…Severity of anastomotic leaks is important to distinguish as major leaks are not only associated with septic sequelae but are also associated with peritonitis, wound infections, atrial fibrillation, pneumonia, and respiratory failure. 16 Given the common occurrence and poor prognosis of anastomotic leaks, extensive research has been performed to determine risk factors and surgical techniques to mitigate them. However, there remains variation in literature regarding systemic factors associated with anastomotic leaks.…”

The Unhappy Gastric Conduit: A Medical Perspective

“…The management of anastomotic leaks hinges on several factors, including the overall clinical status of the patient, presence of [multi]organ failure, spread or presence of infectious complications such as abscesses or mediastinitis, and viability of the tissue at the anastomosis, and can vary from conservative observation, primarily treated with antibiotics, to percutaneous drainage, and finally, surgery, pending the above factors. 14 Endoluminal stenting is a viable option for intrathoracic leaks in select patients, particularly those with contained leaks without broad mediastinal spread (Figure 1). The stent permits a barrier of protection for the healing esophageal mucosa and is coupled with appropriate antibiotic therapy, in addition to serial contrast examination approximately every 2 to 4 weeks to assess healing of the leak.…”

Comparative effectiveness of trimodal therapy versus definitive chemoradiation in older adults with locally advanced esophageal cancer.

“…52 The growing burden of esophageal cancer in older adults will necessitate comparative effectiveness research to elucidate optimal treatment strategies for this large and medically complex population that is chronically underrepresented in clinical trials. [56][57][58][59][60][61][62][63] Due to the complexity and invasiveness of the procedure, the overall operative mortality rate is 4%, though low-volume centers have been associated with rates as high as 20%. 64,65 An analysis of Medicare patients with non-metastatic cancers who received esophagectomy reported that 30% of patients had a hospitalization or adverse event within two months of the procedure and 4% of patients died within this short-term window.…”