Treatment of Esophagojejunal Anastomosis Leakage: A Systematic Review from the Last Two Decades

Abstract

Esophagojejunal anastomosis leakage is one of the major complications after total gastrectomy for gastric cancer and is an independent predictor of survival. Our aim is to systematically review the literature and discuss the reported therapeutic approaches to identify the best therapeutic approach. Pubmed, EMbase, Cochrane Library, CILEA Archive, BMJ Clinical Evidence, and Up ToDate databases were screened limiting the research to articles written in English from January 1992 through December 2013. This way a total of 474 manuscripts were retrieved for furthermore evaluation. Eleven manuscripts were considered eligible and the study is focused on those works. We analyzed a total of 3,893 patients and 114 cases of esophagojejunal anastomosis leakage. Different treatments were grouped into three main categories: conservative approach (66 cases), endoscopic approach (21 cases), and surgical approach (27 cases). The overall mortality rate is 26.32 per cent and surgical approach showed the higher rate. According to the reported data, a complete resolution of the leakage can be achieved in an interval ranging from 7 to 28 days in the group treated conservatively. Conservative approach should always be considered as the treatment of choice. Reoperation may be necessary in case of wide dehiscence or when other treatments fail; therefore, the high mortality rate related to this procedure is due to the comorbidities of patients undergoing relaparotomy. Finally, endoscopic approach with endoclips seems promising but needs furthermore studies.

Failure to rescue patients from early critical complications of oesophagogastric cancer surgery

“…Major leakage from the oesophagojejunal anastomosis following total gastrectomy for gastric malignancy is usually early (within 72 hrs of surgery) and often fatal from mediastinitis. Surgical re-exploration is warranted with either taking down of the anastomosis, primary repair if feasible (but often futile) or creation of a controlled fistula with in all cases, washout, drainage, and insertion of feeding jejunostomy [76] , [77] .…”

“…If it is a small leak on contrast study and the patient not unwell, it can be managed conservatively with either distal feeding or TPN, and serial contrast studies to ensure resolution . [76] .…”

Treatment with vacuum assisted closure system: A case with anastomotic leak after the upper gastrointestinal surgery

“…Surgical re-exploration is warranted: either dismantling the anastomosis and performing a primary repair if feasible (but which is often futile), or the creation of a controlled fistula, and in all cases, performing washout, drainage, and insertion of feeding jejunostomy. [3,4] The best results can be achieved in leaks occurring after the very early postoperative phase with a covered self-expanding stent. [5] In delayed leaks, the decision is radiological drainage or surgical re-exploration.…”

“…[5] In delayed leaks, the decision is radiological drainage or surgical re-exploration. [3] Abdominal sepsis is the host's systemic inflammatory response to bacterial or yeast peritonitis. [6] Severe sepsis is defined as sepsis associated with organ dysfunction or tissue hypoperfusion.…”

Gastrointestinale Anastomoseninsuffizienz: operatives vs. konservatives Vorgehen

“…Ebenso können Patienten im Rahmen einer EVT trotz guter lokaler Heilung an den Folgen eines Myokardinfarktes oder einer Pneumonie versterben. Allerdings ist nach operativer Revision die Sterblichkeit im Vergleich zu den beschriebenen nicht operativen Maßnahmen mit 63 versus 29 % deutlich erhöht [13].…”