Management of anastomotic leaks after esophagectomy and gastric pull-up

Early postoperative endoscopy for predicting anastomotic leakage after minimally invasive esophagectomy: A large-volume retrospective study

BACKGROUND

Anastomotic leakage is one of the most severe adverse events of minimally invasive esophagectomy for esophageal cancer. Early postoperative endoscopy is considered to be the most objective means to diagnose anastomotic leakage, but its safety is questioned by clinicians. This study aimed to evaluate the safety and effectiveness of early postoperative endoscopy in predicting anastomotic leakage.

METHODS

Patients who underwent minimally invasive esophagectomy (from January 2017 to June 2021) in our center were identified and divided into early postoperative endoscopy and control groups according to whether they underwent early postoperative endoscopy within 72 hours after surgery. Propensity score matching was used to balance baseline characteristics. The incidence of postoperative adverse events was compared between the 2 groups, risk variables for anastomotic leakage were identified using logistic regression, and abnormal endoscopic findings related to anastomotic leakage occurrence were explored.

RESULTS

A total of 436 patients were enrolled, of whom 134 underwent early postoperative endoscopy. One hundred and thirty-two pairs were matched by propensity score matching, and baseline characteristics were well-balanced. Both before and after propensity score matching, early postoperative endoscopy did not increase the incidence of postoperative adverse events (chyle leak, hypoproteinemia, pneumonia, etc) and in-hospital mortality. Notably, the incidence of anastomotic leakage (9.8% vs 22.7%) and the length of mean postoperative hospital stay (17.6 vs 20.9 days) was significantly decreased in the early postoperative endoscopy group. Finally, based on the findings under early postoperative endoscopy, we found that gastric graft ischemia is related to a higher incidence of anastomotic leakage (P = .023).

CONCLUSION

Early postoperative endoscopy does not increase postoperative adverse events after minimally invasive esophagectomy and may guide early prediction and intervention strategies for anastomotic leakage in patients undergoing minimally invasive esophagectomy.

Management of esophageal anastomotic leaks, a systematic review and network meta-analysis

There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.

Effective and alternative treatment of anastomotic leak after gastrojejunal bypass: endoluminal vacuum therapy

Anastomotic leak (AL) after with Roux-en-Y gastric bypass (RYGB) has a morbidity rate to 53% and it can be potentially lethal (mortality rate from 0.5 to 10%). In these cases, surgery is usually a challenge, so in recent years minimally invasive endoscopic treatment is gaining ground. Endoluminal vacuum therapy (EVAC) is a promising treatment that is being used in esophagogastric and rectal surgery for the management of AL. We present the case of a patient on his 5th postoperative day of bariatric surgery (RYGB) with an acute abdomen. He was diagnosed of dehiscence of gastrojejunal anastomosis and he needed urgent surgery twice. Subsequently, in control CT, a new anastomotic leak is evidenced. However, given the clinical stability of the patient, it was decided to start EVAC type ESO-Sponge® placed by endoscopy. A total of 4 changes are made every 3-4 days with a total duration of treatment of 15 days. EVAC was removed when the defect presented a 1 mm sized.

Minimally invasive treatment of postoperative fistulas, leakages, and perforations of the upper gastrointestinal tract: a single-center observational study

Introduction

Most anastomotic leaks in the upper gastrointestinal (GI) tract can be treated with minimally invasive techniques dominated by endoluminal vacuum therapy (EVT) or stent implantation. Chronic leaks often require additional solutions, such as tissue adhesives or cellular growth stimulants.

Aim

To present a treatment strategy for postoperative leakage of upper GI anastomoses with noninvasive procedures.

Material and methods

A group of 19 patients treated in the period 2015-2023 with postoperative upper GI tract leakage was enrolled for endoscopic treatment. The indication for the therapy was anastomotic dehiscence not exceeding half of the circumference and the absence of severe septic complications. All patients were managed using endoscopic vacuum therapy (EVT) or a self-expanding stent while persistent fistulas were additionally treated with alternative methods.

Results

The EVT was successfully implemented in 13 cases, but 7 patients required alternative methods to achieve definitive healing. Self-expanding stent placement was performed in 6 patients; however, in 3 cases a periprosthetic leakage occurred. In this group, 2 patients had the stent removed and the third one died due to septic complications. Post-treatment stenosis was identified in 5 patients after EVT that required balloon dilation with acceptable resolution in all cases.

Conclusions

Early detected anastomotic dehiscence limited to half of the circumference most effectively responded to the noninvasive treatment. Nutritional support as well as complementary endoscopic solutions such as tissue adhesives, growth stimulants and hemostatic clips increase the percentage of complete healing.

Diagnosis and management of anastomotic leaks after Ivor Lewis esophagectomy: a single-center experience

PURPOSE

Esophageal anastomotic leaks (ALs) after esophagectomy are a common and serious complication. The incidence, diagnostic approach, and management have changed over time. We described the diagnosis and management of patients who developed an esophageal AL after an Ivor Lewis esophagectomy at our center.

METHODS

After IRB approval, we queried our prospectively maintained database for patients who developed an esophageal AL after esophagectomy from August 2016 through July 2022. Data pertaining to demographics, comorbidities, surgical and oncological characteristics, and clinical course were extracted and analyzed.

RESULTS

During the study period, 145 patients underwent an Ivor Lewis esophagectomy; 10 (6.9%) developed an AL, diagnosed a median of 7.5 days after surgery, and detected by enteric contents in wound drains (n = 3), endoscopy (n = 3), CT (n = 2), and contrast esophagogram (n = 2). Nine patients (90%) had an increasing white blood cell count and additional signs of sepsis. One asymptomatic patient was identified by contrast esophagography. All patients received enteral nutritional support, intravenous antibiotics, and antifungals. Primary treatment of ALs included endoscopic placement of a self-expanding metal stent (SEMS; n = 6), surgery (n = 2), and SEMS with endoluminal vacuum therapy (n = 2). One patient required surgery after SEMS placement. The median length of ICU and total hospital stays were 11.5 and 22.5 days, respectively. There was no 30-day mortality.

CONCLUSION

The incidence of esophageal ALs at our center is similar to that of other high-volume centers. Most ALs can be managed without surgery; however, ALs remain a significant source of postoperative morbidity despite clinical advancements that have improved mortality.

A narrative review of anastomotic leak in the Ivor Lewis esophagectomy: expected, accepted, but preventable

Background and Objective

Anastomotic leak (AL) remains a common and highly morbid complication after Ivor Lewis Esophagectomy. Leak is associated with increased morbidity, mortality, strictures and even cancer recurrence. Unfortunately, despite advances in surgical technique and perioperative care, the reported frequency of AL has remained largely unchanged.

Methods

A PubMed search for all English-language articles that discuss Ivor Lewis esophagectomy, AL, risk factors, and outcomes was conducted from 1901 to 2023 prioritizing research from randomized trials that evaluated outcomes from patients undergoing esophagectomy.

Key Content and Findings

This narrative review will discuss the prevailing literature on AL, risk factors and outcomes with a focus on its relationship to the Ivor Lewis esophagectomy (ILE). In particular, we emphasize that the gastric conduit, as commonly created for most esophagectomy procedures, is inherently vulnerable to ischemia. We will show trends in the literature that have contributed to the high rate of postoperative complications, with a focus on the AL. In addition, we propose that the traditional Ivor Lewis procedure itself is a risk factor for AL. We review a surgical alternative that increases blood supply of the conduit, and is associated with reduced leak, no strictures, and improved surgical outcomes.

Conclusions

Multiple factors contribute to AL after esophagectomy; including several current surgical practices. We believe that some of them, especially the commonly accepted approach to the gastric conduit, can be modified to optimize tissue perfusion. With further investigation, we may reduce the incidence of short and long-term anastomotic complications and improve surgical outcomes.

Surgical Sealant with Integrated Shape-Morphing Dual Modality Ultrasound and Computed Tomography Sensors for Gastric Leak Detection

Postoperative anastomotic leaks are the most feared complications after gastric surgery. For diagnostics clinicians mostly rely on clinical symptoms such as fever and tachycardia, often developing as a result of an already fully developed, i.e., symptomatic, surgical leak. A gastric fluid responsive, dual modality, electronic-free, leak sensor system integrable into surgical adhesive suture support materials is introduced. Leak sensors contain high atomic number carbonates embedded in a polyacrylamide matrix, that upon exposure to gastric fluid convert into gaseous carbon dioxide (CO2 ). CO2 bubbles remain entrapped in the hydrogel matrix, leading to a distinctly increased echogenic contrast detectable by a low-cost and portable ultrasound transducer, while the dissolution of the carbonate species and the resulting diffusion of the cation produces a markedly reduced contrast in computed tomography imaging. The sensing elements can be patterned into a variety of characteristic shapes and can be combined with nonreactive tantalum oxide reference elements, allowing the design of shape-morphing sensing elements visible to the naked eye as well as artificial intelligence-assisted automated detection. In summary, shape-morphing dual modality sensors for the early and robust detection of postoperative complications at deep tissue sites, opening new routes for postoperative patient surveillance using existing hospital infrastructure is reported.

Chest vs. neck anastomotic leak post esophagectomy for malignancy: rate, predictors, and outcomes

BACKGROUND

Anastomotic leak is a major contributor to comorbidity and mortality following esophagectomy. We sought to assess rate and predictors of leak after esophagectomy and compare outcomes of chest versus neck anastomotic leaks.

METHODS

A retrospective review was performed utilizing National-Surgical-Quality-Improvement-Program data from 2016-2019 for patients undergoing esophagectomy for malignancy. Preoperative characteristics and postoperative outcomes were compared. Patients were classified into two groups: Ivor Lewis esophagectomy [ILE, chest leak (CL)] and transhiatal esophagectomy (THE)/McKeown esophagectomy [ME, neck leak (NL)]. Multivariable regression models were constructed to determine predictors of each type of leak and postoperative complications.

RESULTS

A total of 1,665 patients underwent esophagectomy with 14.1% reported post-operative leak, 61% of patients underwent ILE while 39% underwent THE or ME. Of patients who underwent ILE, 13.8% had CL with complications including significantly higher length of stay and mortality compared to patients without leak. Independent predictors of CL included: diabetes, hypertension, advanced disease stage, chronic steroid use, and operative time. Ninety-five patients (14.6%) who underwent either THE or ME had NL with similar complications. Diabetes, pre-operative white blood cell (WBC), and operative time were independent predictors for NL. On multivariable regression, CL was associated with greater odds of requiring intervention compared with NL.

CONCLUSIONS

Post-esophagectomy CL and NL are associated with higher morbidity and mortality. Diabetes and operative time were independent predictors for both leaks while steroid use, hypertension, and advanced disease stage predicted CL. CL was associated with greater odds of needing an intervention, but contrary to conventional wisdom, was not associated with higher morbidity or mortality.

The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review

Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives.

MATERIALS AND METHODS

We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022.

RESULTS

The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure.

CONCLUSIONS

Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.

Post-esophagectomy Anastomosis Leak: A 10-Year Experience at a Specialized Center for Cancer Surgeries in Pakistan

Esophageal cancer has been reported to be the seventh most common cancer and the sixth most common cause of mortality. Use of advanced diagnostic techniques has increased the detection of preoperative metastases and resulted in better patient selection for further management by curative surgery. We carried out a study to evaluate the outcome of esophagectomy at our institute in terms of acute leak, mortality and hospital stay. We also looked at various preoperative, intraoperative and postoperative risk factors contributing to leak after esophagectomy. We evaluated 589 patients during the period from January 2009 to December 2019. All these patients underwent elective esophagectomy for esophageal cancer at our hospital. Out of these, leak was seen in 30 patients (5.1%). We found no statistically significant difference when evaluating patient and tumour characteristics of patients who developed leak against those who did not. We also didn't find any significant difference in intraoperative or postoperative factors between the two groups. Proper preoperative evaluation and optimization are necessary to overcome various patient co-morbidities. On the basis of our study we conclude that when performed in high-volume centers with an adequately trained multi-disciplinary team approach, esophagectomy for carcinoma has a good outcome.

Planned oesophagectomy after chemoradiotherapy versus salvage oesophagectomy following definitive chemoradiotherapy: a systematic review and meta-analysis

BACKGROUND

Oesophageal cancer is the eighth most common cancer and sixth leading cause of cancer-related mortality worldwide. Salvage oesophagectomies are associated with an increased risk of mortality, although recent data suggests that long-term survival rates following salvage oesophagectomy are similar to planned oesophagectomy. The aim was therefore to meta-analyse outcomes for patients undergoing salvage versus planned oesophagectomies to assess the differences in short-term mortality and long-term survival.

METHODS

A systematic review of Medline, Scopus, Web of Science and PubMed was performed to identify relevant studies. Data were extracted and compared by meta-analysis, using odds ratio and mean differences with 95% confidence intervals.

RESULTS

Nineteen studies meeting inclusion criteria were included in the meta-analysis, which compared patients in the planned oesophagectomy group (n = 23 555) to patients in the salvage oesophagectomy group (n = 2227). There were significant differences between the groups in terms of rates of postoperative mortality (5.7% salvage oesophagectomy versus 3.1% planned oesophagectomy, P = 0.0004), anastomotic leak (20.6% salvage oesophagectomy versus 14.5% planned oesophagectomy, P < 0.00001), pulmonary complications (37.1% salvage oesophagectomy versus 24.2% planned oesophagectomy, P < 0.0001) and R0 margin (87.6% salvage oesophagectomy versus 91.3% planned oesophagectomy, P < 0.0001). There was no statistical difference between long-term survival rates at 5 years with 39.2% for salvage and 42.6% for planned oesophagectomy (P = 0.28).

CONCLUSIONS

Salvage oesophagectomies do offer a meaningful chance of long-term survival (at 5 years) for select patients with oesophageal cancer, but the elevated risk of post-operative complications and mortality following salvage oesophagectomy should be recognized.

The Etiology, Diagnosis, and Management of Esophageal Perforation

BACKGROUND

Esophageal perforation is a serious and potentially life-threatening medical emergency. Given multiple etiologies and varying clinical presentations of the perforated esophagus, the diagnosis is commonly delayed, complicating expeditious and optimal intervention.

METHODS

We thoroughly reviewed the latest literature on the subject and herein describe the various treatment strategies in varying settings.

RESULTS

Treatment depends on multiple factors including the cause and location of the perforation, the time interval between the inciting event and presentation to the managing clinician, the overall medical stability of the patient, comorbidities including pre-existent esophageal pathology or prior foregut operations, and both the location and extent of extra-esophageal fluid collections. Because of these various considerations, determining the best diagnostic and therapeutic approach requires considerable clinical experience and judgment on the part of the physician. Management principles include (1) adequate fluid resuscitation; (2) expeditious administration of appropriate broad-spectrum antibiotics; (3) repair, occlusion, exclusion, diversion, or exteriorization of the perforation site; (4) drainage of extraluminal fluid collections; (5) relief of distal obstruction; and (6) nutritional support.

CONCLUSIONS

For decades, operative intervention has been the mainstay of therapy for esophageal perforation. More recently, endoscopic therapies, including stenting, clipping, suturing, or endoscopic vacuum therapy, have been introduced, expanding the clinician's therapeutic armamentarium while supplanting surgical approaches in many cases. With further experience and introduction of novel therapies, the management of esophageal perforation undoubtedly will continue to evolve.

Adequate Management of Postoperative Complications after Esophagectomy: A Cornerstone for a Positive Outcome

BACKGROUND

Esophagectomy for cancer is one of the most complex procedures in visceral surgery. Postoperative complications negatively affect the patient's overall survival. They are not influenced by the histology type (adenocarcinoma (AC)/squamous cell carcinoma (SCC)), or the surgical approach (open, laparoscopic, or robotic-assisted). Among those dreadful complications are anastomotic leak (AL), esophago-respiratory fistula (ERF), and chylothorax (CT).

METHODS

In this review, we summarize the methods to avoid these complications, the diagnostic approach, and new therapeutic strategies.

RESULTS

In the last 20 years, both centralization of the medical care, and the development of endoscopy and radiology have positively influenced the management of postoperative complications. For the purpose of their prevention, perioperative measures have been applied. The treatment includes conservative, endoscopic, and surgical approaches.

CONCLUSIONS

Post-esophagectomy complications are common. Prevention measures should be known. Early recognition and adequate treatment of these complications save lives and lead to better outcomes.

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

INTRODUCTION

Although mortality rates after esophagectomy have decreased over the last 30 years, anastomotic leaks still commonly persist and portend significant morbidity. Previous studies have analyzed patient and perio-perative risk factors for leaks, yet data describing the association of leaks and an open or minimally invasive approach are lacking. The purpose of this study was to evaluate the impact of operative approach on leak rates and subsequent management of the leaks.

METHODS

We queried the Procedure-Targeted National Surgical Quality Improvement Program Database for patients undergoing esophagectomy for cancer in the years from 2016 to 2019. Patient demographics, disease-related information, peri-operative data, and short-term outcomes were reviewed. Multivariable, stepwise logistic regression analysis was performed to investigate factors associated with post-operative anastomotic leaks.

RESULTS

Of the 2696 patients who underwent esophagectomy for cancer, anastomotic leaks occurred in 374 (14%). Based on approach, 13% of open, 14% of laparoscopic, and 18% of robotic cases were complicated by leak (P = .123). Multivariable analysis identified the following significant risk factors for leak: diabetes (OR 1.32, P = .047), hypertension (OR 1.32, P = .022), and longer operative time (OR 1.61, P < .001). The percentage of leaks requiring endoscopic or operative intervention was 75% for open, 79% for laparoscopic, and 54% for robotic cases (P = .004).

CONCLUSIONS

Anastomotic leaks after esophagectomy for cancer occur frequently regardless of surgical approach. Furthermore, these leaks are managed differently after an open, laparoscopic, or robotic approach. Robotic esophagectomies complicated by anastomotic leak required less invasive management.

Outcomes of Gastric Conduit in Corrosive Esophageal Stricture: a Systematic Review and Meta-analysis

BACKGROUND

Gastric conduit has emerged as the preferred treatment option for both esophageal bypass and replacement for corrosive stricture of the esophagus. There is a lack of consensus and a dearth of published literature regarding the short- and long-term complications of using a gastric conduit. This meta-analysis aims to evaluate the outcomes, morbidity, and complications associated with it.

METHODS

MEDLINE, Cochrane Library, and Google Scholar (January 1960 to May 2020) were systematically searched for all studies reporting short- and/or long-term outcomes and complications following the use of a gastric conduit for corrosive esophageal stricture.

RESULTS

Seven observational studies involving 489 patients (53.2% males, mean age ranging from 22.1 to 41 years) who had ingested a corrosive substance (acid in 74.8%, alkali in 20.7%, and unknown in the rest) were analyzed. Gastric pull-up was performed in 56.03% (274/489) of patients. Median blood loss in the procedure was 187.5 ml with a mean operative duration of 298.75 ± 55.73 min. The overall pooled prevalence rate of anastomotic leak was 14.4% [95% CI (6.2-24.0); p < 0.05, I² = 67.38], and anastomotic stricture was 27.2% [95% CI (13-42.8); p < 0.001, I² = 80.11]. Recurrent dysphagia according to pooled prevalence estimates occurred in 14.4% patients [95% CI (5.4-25.1); p < 0.05, I² = 69.1] and 90-day mortality in 4.8% patients [95% CI (1.5-9.1%); I² = 31.1, p = 0.202]. The dreaded complication of conduit necrosis had a pooled prevalence of 1.3% [95% CI (0.1-3.4%); I² = 0, p = 0.734].

CONCLUSION

The stomach can be safely used as the conduit of choice in corrosive strictures with an acceptable rate of complications, postoperative morbidity, and mortality.