Prevention of Esophageal Anastomotic Leaks

Prevention of Esophageal Anastomotic Leaks

Authors: Crispin Russell, Andrew Seely

Summary of Recommendations

Pre-operative –          Optimize nutrition, cardiovascular and diabetic control as well as smoking cessation as a pre-habilitation program (formal or otherwise) to reduce the risk of anastomotic
Intra-operative –          Cervical anastomosis has a 5 times greater leak rate than intrathoracic. Reserve anastomosis location based of tumor location

–          MIE’s have no difference in leak rate compared to open, operative technique should be based on surgeon skill and comfort level

–          There should be no tension or torsion on the gastric conduit and donuts should be inspected to ensure they are complete

–          Omentoplasty should be strongly considered to aid sealing microscopic leaks

–          There is no significant difference between hand sewn and stapled anastomosis, decision should be surgeon’s preference

Post-operative –          Judicious fluid management should be paramount in the post-operative period to maintain adequate perfusion to the gastric conduit

–          Early oral intake seems to have no increased risk of anastomotic leak and reduces length of stay this should be considered

–          Either no NG tube or early removal of NG tube (POD #2) does not significantly increase risk of anastomotic leak and should be considered

Diagnosis –          Routine contrast swallows in patients without clinical signs of anastomotic leak are not recommended

–          Patients with signs of anastomotic leak (tachycardia, atrial fibrillation, elevated CRP or drain amylase) a CT scan with oral contrast and endoscopy should be performed to determine the severity of the leak and plan optimal management

–          An Upper GI series should be reserved for equivocal cases

Management –          Leaks can be managed by stenting, endoscopic vacuum therapies, clips or surgical drainage. Pls see algorithm below for suggested management

Treatment Algorithm for Esophagogastric Anastomotic Leaks

(Turkyilmaz A, Eroglu A, Aydin Y et al. The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. Dis Esophagus. 2009; 22: 119–26.)

Background

As defined by the Esophagectomy Complications Consensus Group (ECCG), full thickness GI effect involving esophagus, anastomosis, staple line, or conduit irrespective of presentation or method of identification. Type I: Local defect requiring no change in therapy or medical treatment or with dietary modification. Type II: Localized defect requiring interventional but not surgical therapy, for example, interventional radiology drain, stent or bedside opening and packing of incision. Type III: Localized defect requiring surgical therapy.[i]

Anastomotic leak (AL) following esophagectomy results in prolonged hospital length of stay, increased use of health care dollars, morbidity and mortality. There is evidence that anastomotic leaks also result in poorer quality of life, decreased long term survival and increased cancer recurrence rates. This complication occurs in up 5-40% of patients.[ii] Diagnosis and management will depend on clinical judgement, resource availability and the status of the patient. These recommendations are based on expert opinion and the current literature.

Notes

Risk factors for AL can be broken into pre-operative (comorbidities, Neoadjuvant therapies), Intra-op (anastomotic location, surgical techniques) and peri-operative (hemodynamics, fluid management, analgesia).[iii]

Important comorbidities include:

Malnutrition (Albumin < 3.0 g/dL), obesity (BMI >30kg/m2) or under weight (BMI <18.5kg/m2), heart failure, hypertension, diabetes, renal insufficiency, steroids, tobacco use procedure lasting greater than 5 hours and type of procedure have been implicated in higher AL rates.[iv] Atherosclerotic calcification of the aorta has been implicated as an independent risk factor for AL.[v] Care should be taken in this patient population.

References

Low D.E.: Diagnosis and management of anastomotic leaks after esophagectomy. J Gastrointest Surg 2011; 15: pp. 1319-1322.

Fabbi, M. et al. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Diseases of the Esophagus 2021; 34, 1-14.

Low D E, Alderson D, Cecconello I et al. International consensus on standardization of data collection for complications associated with Esophagectomy: Esophagectomy complications consensus group (ECCG). Ann Surg. 2015; 262: 286–94.

Kassis E S,KosinskiAS,Ross P et al. Predictors of anastomotic leak after Esophagectomy: an analysis of the Society of Thoracic Surgeons general thoracic database. Ann Thorac Surg. 2013; 96: 1919–26.

Goense L, Van Rossum P S N, Weijs T J et al. Aortic calcification increases the risk of anastomotic leakage after Ivor-Lewis Esophagectomy. Ann Thorac Surg. 2016 Jul; 102(1): 247–52.

Gronnier C, Tréchot B, Duhamel A et al. Impact of neoadjuvant chemoradiotherapy on postoperative outcomes after esophageal cancer resection results of a european multicenter study. Ann Surg. 2014; 260: 764–71.

Markar S R, Arya S, Karthikesalingam A et al. Technical factors that affect anastomotic integrity following esophagectomy: systematic review and meta-analysis. Annals of Surgical Oncology. 2013 Dec; 20(13): 4274–81.

Biere S S, van Berge Henegouwen M I, Maas K W et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: amulticentre, open-label, randomized controlled trial. Lancet. 2012; 379: 1887–92.

Zhou D, Liu Q X, Deng X F et al. Anastomotic reinforcement with omentoplasty reduces anastomotic leakage for minimally invasive esophagectomy with cervical anastomosis. Cancer Manag Res. 2018 Feb 7; 10: 257–63.

Fumagalli U, Melis A, Balazova J et al. Intra-operative hypotensive episodes may be associated with post-operative esophageal anastomotic leak. Updates Surg. 2016 Jun; 68(2): 185–90.

Klevebro F, Boshier P R, Low DE. Application of standardized hemodynamic protocols within enhanced recovery after surgery programs to improve outcomes associated with anastomotic leak and conduit necrosis in patients undergoing esophagectomy. Journal of Thoracic Disease. 2019 Apr; 11(Suppl 5): S692–701.

Feltracco P, Bortolato A, Barbieri S et al. Perioperative benefit and outcome of thoracic epidural in esophageal surgery: a clinical review.Diseases of the esophagus? official journal of the International Society for Diseases of the Esophagus. 2018 May 1; 31(5).

Stippel D L1, Taylan C, Schröder W, Beckurts K T, Hölscher A H. Supraventricular tachyarrhythmia as early indicator of a complicated course after esophagectomy. Diseases of the Esophagus. 2005; 18(4): 267–73.

Park J K, Kim J J, Moon S W. C-reactive protein for the early prediction of anastomotic leak after esophagectomy in both neoadjuvant and non-neoadjuvant therapy case: a propensity score matching analysis. J Thorac Dis. 2017 Oct; 9(10): 3693– 702.

Miller D L, Helms G A, Mayfield W R. Evaluation of Esophageal anastomotic integrity with serial pleural amylase levels. Ann Thorac Surg. 2018 Jan; 105(1): 200–6.

Jones C M, Clarke B, Heah R et al. Should routine assessment of anastomotic integrity be undertaken using radiological contrast swallow after oesophagectomy with intra-thoracic anastomosis? Best evidence topic (BET). Int J Surg. 2015 Aug; 20: 158–62.

Gubler C, Vetter D, Schmidt H M et al. Preemptive endoluminal vacuum therapy to reduce anastomotic leakage after esophagectomy: a game-changing approach? Dis. Esophagus 2019 July; 32(7).

Hagel A F, Naegel A, Lindner A S et al. Over-the-scope clip application yields a high rate of closure in gastrointestinal perforations and may reduce emergency surgery. J. Gastrointest. Surg. 2012. (16), 2132-2138.

Ubels S, Verstegen MHP, Rosman C, Reynolds JV. Anastomotic leakage after esophagectomy for esophageal cancer: risk factors and operative treatment. Ann Esophagus 2021;4:8.

Kaaki S, Grigor E, Maziak D, Seely A. Early oral intake and early removal of NasoGastric tube post esophagectomy. A systematic review and Meta-analysis. Cancer Reports.

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[i] Low D E, Alderson D, Cecconello I et al. International consensus on standardization of data collection for complications associated with Esophagectomy: Esophagectomy complications consensus group (ECCG). Ann Surg. 2015; 262: 286–94.

[ii] Low D.E.: Diagnosis and management of anastomotic leaks after esophagectomy. J Gastrointest Surg 2011; 15: pp. 1319-1322.

[iii] Fabbi, M. et al. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Diseases of the Esophagus 2021; 34, 1-14.

[iv] Kassis E S,KosinskiAS,Ross P et al. Predictors of anastomotic leak after Esophagectomy: an analysis of the Society of Thoracic Surgeons general thoracic database. Ann Thorac Surg. 2013; 96: 1919–26.

[v] Goense L, Van Rossum P S N, Weijs T J et al. Aortic calcification increases the risk of anastomotic leakage after Ivor-Lewis Esophagectomy. Ann Thorac Surg. 2016 Jul; 102(1): 247–52.