Management of esophageal perforation and anastomotic leak by transluminal drainage

Optimizing the management of anastomotic leaks after esophagectomy: a narrative review of salvage strategies and outcomes

BACKGROUND

Anastomotic leaks (ALs) after esophagectomy remain a major postoperative complication, leading to increased morbidity, prolonged hospital stays, and higher mortality. Despite advancements in surgical techniques and perioperative care, AL management lacks standardized protocols. This review aimed to evaluate current salvage strategies, including conservative, endoscopic, and surgical approaches, to optimize outcomes and reduce complications.

METHODS

A comprehensive literature search was conducted using PubMed, Scopus, Cochrane Library, and Google Scholar databases to identify studies published between 2000 and 2025 on AL management after esophagectomy. Peer-reviewed clinical trials, guidelines, and expert consensus reports were reviewed, focusing on minimally invasive and surgical interventions, patient outcomes, and emerging treatment strategies.

RESULTS

AL management strategies were classified into 3 primary approaches. Conservative management includes nutritional support, antibiotic therapy, and percutaneous drainage, particularly for contained leaks. Endoscopic interventions, such as self-expanding metal stents and endoscopic vacuum-assisted closure, have shown high success rates, with vacuum-assisted closure achieving superior closure outcomes. Hybrid techniques, including stent-over-sponge and vacuum-assisted closure-stent, are emerging as promising alternatives. Surgical interventions remain the gold standard for severe or refractory leaks with options, including primary repair, esophageal diversion, and delayed conduit reconstruction.

CONCLUSION

A multidisciplinary approach is crucial for optimizing AL management, incorporating enhanced recovery protocols, early risk assessment, and individualized treatment plans. Endoscopic techniques have reduced the need for surgical revisions, but surgical intervention remains necessary for severe cases. Future research should focus on refining treatment algorithms, integrating novel technologies, and establishing standardized guidelines to improve patient survival and quality of life.

Risk Factors of Anastomotic Leakage After Esophagectomy With Intrathoracic Anastomosis

Purpose: Anastomotic leakage is one of the most common complications of esophagectomy, it serves as one of the main causes of postoperative death of esophageal cancer. It is of clinical significance to try to discover the risk factors that cause anastomotic leakage. Methods: This retrospective study was conducted on 1,257 consecutive esophageal cancer patients who underwent esophagectomy with intrathoracic anastomosis from January 2010 to December 2015 at a high volume cancer center. Multivariate Logistic Regression analysis, Spearman rank correlation analysis, Mann-Whitney U test and Kruskal-Wallis test were performed to identify the risk factors to the occurrence of anastomotic leakage and the length of hospital stay. Results: Intrathoracic anastomotic leakage occurred in 98 patients (7.8%). Older patients were more likely to develop anastomotic leakage. Patients with diabetes had a higher leakage rate. Intrathoracic anastomotic leakage, old age as well as comorbidities were associated with longer hospital stay. Conclusion: Our study suggested that old age and diabetes were risk factors to intrathoracic anastomotic leakage. In-hospital stay would be lengthened by intrathoracic anastomotic leakage, old age and comorbidities.

Anastomotic leakage and postoperative mortality in patients after esophageal cancer resection

Objective

Esophagectomy is a high-risk surgical procedure with significant postoperative morbidity and mortality. This study aimed to investigate the risk factors of cervical anastomotic leakage and postoperative mortality.

Methods

In this retrospective, observational study, we recruited 1010 patients with esophageal cancer. Cox regression analysis was performed to identify factors affecting anastomotic leakage and postoperative mortality. After propensity score matching, the Kaplan–Meier curve was used to evaluate the effect of leakage on postoperative mortality.

Results

The number of patients with cervical anastomotic leakage, in-hospital mortality, 30-day postoperative mortality, and 60-day postoperative mortality was 194 (19.2%), 13 (1.3%), 12 (1.2%), and 16 (1.6%), respectively. The total length of hospital stay and hospital stay postoperatively were 29.7 ± 21.1 and 21.3 ± 20.3 days, respectively. Diabetes, stage IV, and an upper thoracic tumor were significant risk factors for leakage. Leakage and diabetes were significant risk factors for postoperative mortality. After propensity score matching, leakage also significantly affected postoperative mortality.

Conclusions

Patients with tumors in the upper thoracic segment of the esophagus may be more prone to developing anastomotic leakage compared with those with tumors in the middle or lower thoracic segment. Anastomotic leakage may prolong the length of hospital stay and increase postoperative mortality.

Endoscopic vacuum therapy for anastomotic leak after esophagectomy: a single-center's early experience

Anastomotic leak is a serious complication after esophagectomy. Endoscopic vacuum therapy (EVT) has become increasingly popular in treating upper gastrointestinal anastomotic leaks over the last years. We are here reporting our current complete experience with EVT as primary treatment for anastomotic leak following esophagectomy. This is a retrospective study analyzing all patients with EVT as primary treatment for anastomotic leak after esophagectomy between November 2016 and January 2020 at Karolinska University Hospital, Sweden. The primary endpoint was anastomotic fistula healing with EVT only. Twenty-three patients primarily treated with EVT after anastomotic leak following esophagectomy were included. Median duration of EVT was 17 days (range 5-56) with a median number of 3 (range 1-14) vacuum sponge changes per patient. A total number of 95 vacuum sponges were placed in the entire cohort, of which 93 (97.9%) were placed intraluminally and 2 (2.1%) extraluminally. The median changing time interval of sponges was 5 days (range 2-8). Successful fistula healing was achieved in 19 of 23 patients (82.6%), of which 17 (73.9%) fistulas healed with EVT only. There were 2 (8.7%) airway fistulas following EVT. No other adverse events occurred. Three patients (13%) died in-hospital. In conclusion EVT seems to be a safe and feasible therapy option for anastomotic leak following esophagectomy. The effect of EVT on the risk for development of airway fistulas needs to be addressed in future studies and until more data are available care should be taken regarding sponge positioning as well as extended treatment duration.

Management of anastomotic leaks after esophagectomy and gastric pull-up

Anastomotic leak is one of the most feared complications of esophagectomy, leading to prolonged hospital stay, increased postoperative mortality, and additional cost both to the patient and the hospital. Historically, anastomotic leaks have been treated with several techniques including conservative measures, percutaneous or operative drainage, primary surgical repair with buttressing, T-tube drainage, or excision of the esophageal replacement conduit with end esophagostomy. With advances in treatment modalities, including endoscopic stenting, clips and suturing, endoluminal vacuum-assisted closure (EVAC), such leaks increasingly are being managed without operative re-intervention and with salvage of the esophageal replacement conduit. For the purposes of this review, we identified studies analyzing the management of postoperative leak after esophagectomy. We then compared the efficacy of the various newer modalities for closure of anastomotic leaks and gastric conduit defects. We found both esophageal stent and EVAC sponges are effective treatments for closure of anastomotic leak. The chosen treatment modality for salvage of the esophageal replacement conduit is entirely dependent on the patient’s clinical status and the surgeon’s preference and experience. Emerging endoscopic and endoluminal therapies have increased the armamentarium of tools the esophageal surgeon has to facilitate successful resolution of anastomotic leaks following esophagectomy with reconstruction. While some literature suggests that EVACs have a slightly superior result in conduit success, we question this endorsement as EVACs mostly are utilized for contained leaks, many of which may have healed with conservative measures. This poses a challenge as there is clearly a bias given patient selection.

Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study

BACKGROUND

Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available.

METHODS

In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed.

RESULTS

Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival.

CONCLUSIONS

Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.

Managing esophageal fistulae by endoscopic transluminal drainage in esophageal cancer patients with superior mediastinal sepsis after esophagectomy

The management of postoperative leaks into the mediastinum after esophagectomy remains a challenge. We describe our clinical management of this complication through endoscopic transluminal drainage. Between 2008 and 2011, 4 patients with esophageal squamous cell carcinoma (ESCC) who underwent McKeown-type esophagectomy with two-field lymphadenectomy experienced complicated anastomotic fistulae in the presence of superior mediastinal sepsis. All 4 patients underwent endoscopic transluminal drainage, and all survived. The mean healing period was 50 days (range, 31 to 58 days), the mean stay in the intensive care unit was 7.3 days (range, 1 to 18 days), and the mean hospital stay was 64.5 days (range, 49 to 70 days). Endoscopically guided transluminal drainage should be considered for ESCC patients with superior mediastinal fistulae after esophagectomy.

Fluoroscopically guided three-tube insertion for the treatment of postoperative gastroesophageal anastomotic leakage

Objective

To retrospectively evaluate the feasibility and effectiveness of three-tube insertion for the treatment of postoperative gastroesophageal anastomotic leakage (GEAL).

Materials and Methods

From January 2007 to January 2011, 28 cases of postoperative GEAL after an esophagectomy with intrathoracic esophagogastric anastomotic procedures for esophageal and cardiac carcinoma were treated by the insertion of three tubes under fluoroscopic guidance. The three tubes consisted of a drainage tube through the leak, a nasogastric decompression tube, and a nasojejunum feeding tube. The study population consisted of 28 patients (18 males, 10 females) ranging in their ages from 36 to 72 years (mean: 59 years). We evaluated the feasibility of three-tube insertion to facilitate leakage site closure, and the patients' nutritional benefit by checking their serum albumin levels between pre- and post-enteral feeding via the feeding tube.

Results

The three tubes were successfully placed under fluoroscopic guidance in all twenty-eight patients (100%). The procedure times for the three tube insertion ranged from 30 to 70 minutes (mean time: 45 minutes). In 27 of 28 patients (96%), leakage site closure after three-tube insertion was achieved, while it was not attained in one patient who received stent implantation as a substitute. All patients showed good tolerance of the three-tube insertion in the nasal cavity. The mean time needed for leakage treatment was 21 ± 3.5 days. The serum albumin level change was significant, increasing from pre-enteral feeding (2.5 ± 0.40 g/dL) to post-enteral feeding (3.7 ± 0.51 g/dL) via the feeding tube (p < 0.001). The duration of follow-up ranged from 7 to 60 months (mean: 28 months).

Conclusion

Based on the results of this study, the insertion of three tubes under fluoroscopic guidance is safe, and also provides effective relief from postesophagectomy GEAL. Moreover, our findings suggest that three-tube insertion may be used as the primary procedure to treat postoperative GEAL.