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.)
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.
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.
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.
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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.