Management of Intra-thoracic Anastomotic Leak After Esophagectomy: a Single Center Experience

Z Torgersen, MD, K Lohani, MBBS, P Pallati, MBBS, E Hagen, BS, K Nandipati, MBBS, T Lee, MD, S K Mittal, MBBS. Creighton University Department of Surgery.

Objective: Intra-thoracic anastomotic leak is a known complication of esophageal resection and carries a significant morbidity and mortality. The aim of this study is to review the management and outcomes of anastomotic leak after esophagectomy at our institution.

Methods: After institutional review board approval, a prospectively maintained database was retrospectively reviewed to identify patients who underwent esophagectomy from 7/2003 to 8/2013. Patients who had an anastomotic leak after intra-thoracic anastomosis were identified and formed the study cohort. Data regarding their diagnosis, management and outcomes was collected. Leaks were defined as early or late based on their diagnosis on or before postoperative day seven.

Results: Two hundred thirty-seven patients underwent esophagectomy during the study period. Sixty patients had intra-thoracic anastomoses (38 thoracoscopic, 22 thoracotomy) of which eight patients had an anastomotic leak (13.3%). Of these eight patients, three had received neo-adjuvant therapy and seven had thoracoscopic procedures. Anastomoses were EEA stapled (6), linear stapled (1), and hand sewn (1). Mean time to diagnosis was 11 days (3-32). There were three early leaks. Six patients received Polyflex (Boston Scientific) esophageal stents. Three had their stents replaced during the course of management. There were no stent migrations. Mean time to stent removal was 21 days (7-56). All patients with early leaks were stented. Three patients had adjunctive endoscopic therapy (fibrin glue [2], vacuum sponge [1], botox injection [1]). Four patients required additional chest drainage (percutaneous CT guided drainage [2], tube thoracostomy [2]). Two patients underwent reoperation with takedown or repair of the anastomosis. One patient had operative repair and stenting simultaneously. Mean hospital stay was 40 days (13-92). One patient died after operation for late gastric conduit necrosis. The remaining seven leaks resolved.

Conclusion: The majority of intra-thoracic anastomotic leaks can be successfully managed without reoperation. Excluding the leak endoscopically (via stenting, glue, vacuum sponge) and draining fluid collections is the cornerstone of treatment. Surgery should be reserved for those with clinical deterioration despite non-operative modalities. The incidence of intra-thoracic leaks following thoracoscopy deserves further investigation.

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