Ultrathin endoscopy versus computed tomography in the detection of anastomotic leak in the early period after esophagectomy

Intraluminal migration of a surgical drain near an anastomosis site after total gastrectomy: A case report

BACKGROUND

Esophagojejunal anastomotic leakage (EJAL) is a severe complication following gastrectomy for gastric cancer, typically treated with drainage and nutritional support. We report a case of intraluminal drain migration near the esophagojejunal anastomosis (EJA), resulting in persistent drainage and mimicking EJAL after total gastrectomy.

CASE SUMMARY

A 64-year-old male underwent open total gastrectomy with Roux-en-Y reconstruction for gastric adenocarcinoma, with two silicone drains placed near the EJA. On postoperative day (POD) 4, the patient developed signs of peritonitis and sepsis, necessitating surgical re-exploration abscess drainage, peritoneal lavage, and drain repositioning. A contrast swallow study on POD 18 revealed rapid filling of the abdominal drain without extraluminal contrast collection. Persistent drainage prompted an upper gastrointestinal endoscopy on POD 59, which revealed approximately 5 cm of the drain within the esophagus, with the perforation site located 2 cm distal to the intact EJA. The drain was repositioned under endoscopic guidance. A repeat contrast radiograph on POD 67 demonstrated no evidence of extraluminal contrast extravasation or filling of the abdominal drain. The patient was subsequently discharged without further incident.

CONCLUSION

Intraluminal drain migration is a rare complication following gastric surgery but should be considered when persistent drainage occurs.

Performance of a consensus-based algorithm for diagnosing anastomotic leak after minimally invasive esophagectomy for esophageal cancer

Anastomotic leak (AL) is a common and severe complication after esophagectomy. This study aimed to assess the performance of a consensus-based algorithm for diagnosing AL after minimally invasive esophagectomy. This study used data of the ICAN trial, a multicenter randomized clinical trial comparing cervical and intrathoracic anastomosis, in which a predefined diagnostic algorithm was used to guide diagnosing AL. The algorithm identified patients suspected of AL based on clinical signs, blood C-reactive protein (cut-off value 200 mg/L), and/or drain amylase (cut-off value 200 IU/L). Suspicion of AL prompted evaluation with contrast swallow computed tomography and/or endoscopy to confirm AL. Primary outcome measure was algorithm performance in terms of sensitivity, specificity, and positive and negative predictive values (PPV, NPV), respectively. AL was defined according to the definition of the Esophagectomy Complications Consensus Group. 245 patients were included, and 125 (51%) patients were suspected of AL. The algorithm had a sensitivity of 62% (95% confidence interval [CI]: 46-75), a specificity of 97% (95% CI: 89-100), and a PPV and NPV of 94% (95% CI: 79-99) and 77% (95% CI: 66-86), respectively, on initial assessment. Repeated assessment in 19 patients with persisting suspicion of AL despite negative or inconclusive initial assessment had a sensitivity of 100% (95% CI: 77-100). The algorithm showed poor performance because the low sensitivity indicates the inability of the algorithm to confirm AL on initial assessment. Repeated assessment using the algorithm was needed to confirm remaining leaks.

An Approach to Accelerate Healing and Shorten the Hospital Stay of Patients With Anastomotic Leakage After Esophagectomy: An Explorative Study of Systematic Endoscopic Intervention

Objective

To explore the comprehensive role of systemic endoscopic intervention in healing esophageal anastomotic leak.

Methods

In total, 3919 consecutive patients with esophageal cancer who underwent esophagectomy and immediate esophageal reconstruction were screened. In total, 203 patients (5.10%) diagnosed with anastomotic leakage were included. The participants were divided into three groups according to differences in diagnosis and treatment procedures. Ninety-four patients received conventional management, 87 patients received endoscopic diagnosis only, and the remaining 22 patients received systematic endoscopic intervention. The primary endpoint was overall healing of the leak after oncologic esophageal surgery. The secondary endpoints were the time from surgery to recovery and the occurrence of adverse events.

Results

173 (85.2%; 95% CI, 80.3-90.1%) of the 203 patients were successfully healed, with a mean healing time of 66.04 ± 3.59 days (median: 51 days; range: 13-368 days), and the overall healing rates differed significantly among the three groups according to the stratified log-rank test (P<0.001). The median healing time of leakage was 37 days (95% CI: 33.32-40.68 days) in the endoscopic intervention group, 51 days (95% CI: 44.86-57.14 days) in the endoscopic diagnostic group, and 67 days (95% CI: 56.27-77.73 days) in the conventional group. The overall survival rate was 78.7% (95% CI: 70.3 to 87.2%) in the conventional management group, 89.7% (95% CI: 83.1 to 96.2%) in the endoscopic diagnostic group and 95.5% (95% CI: 86.0 to 100%) in the systematic endoscopic intervention group. Landmark analysis indicated that the speed of wound healing in the endoscopic intervention group was 2-4 times faster at any period than that in the conservative group. There were 20 (21.28%) deaths among the 94 patients in the conventional group, 9 (10.34%) deaths among the 87 patients in the endoscopic diagnostic group and 1 (4.55%) death among the 22 patients in the endoscopic intervention group; this difference was statistically significant (Fisher exact test, P < 0.05).

Conclusion

Tailored endoscopic treatment for postoperative esophageal anastomotic leakage based on endoscopic diagnosis is feasible and effective. Systematic endoscopic intervention shortened the treatment period and reduced mortality and should therefore be considered in the management of this disease.