Management and outcomes of anastomotic leakage after McKeown esophagectomy: A retrospective analysis of 749 consecutive patients with esophageal cancer

Retrospective Clinical Study on Early Prediction of Anastomotic Leak After Esophageal Cancer Resection Based on the Combination of Platelet Count and Neutrophil-to-Lymphocyte Ratio

OBJECTIVE

 The systemic inflammatory response may influence the occurrence of postoperative complications. This study aimed to evaluate the predictive potential of combining platelet count and neutrophil-to-lymphocyte ratio (COP-NLR) for esophagogastric anastomotic leak (AL) following esophageal cancer surgery.

METHODS

 We enrolled patients who developed AL after radical surgery for esophageal cancer and those who did not develop AL after the surgery at the First Affiliated Hospital of Chongqing Medical University, China, from June 2019 to February 2022. We analyzed the correlation between AL and several risk factors, including COP-NLR. Patients were categorized as COP-NLR 2 if both platelet count and neutrophil-to-lymphocyte ratio (NLR) were elevated, COP-NLR 1 if either parameter was elevated, and COP-NLR 0 if neither parameter showed elevation.

RESULTS

 A total of 190 patients were included in this study. The incidence of AL after esophageal cancer surgery was 14.7%. The critical values of preoperative NLR and preoperative platelet count were 2.41 (sensitivity 48.8%, specificity 92.9%, and area under the curve (AUC) 0.728) and 186 × 109/L (sensitivity 45.3%, specificity 78.9%, and AUC 0.667), respectively. According to multivariate analysis, COP-NLR was identified as an independent risk factor for AL (COP-NLR 1 vs. COP-NLR 0: odds ratio (OR) 4.98, 95% confidence interval (CI) 1.05-23.61; COP-NLR 2 vs. COP-NLR 0: OR 11.12, 95% CI 2.31-53.41).

CONCLUSION

 COP-NLR is a new predictor for AL after esophageal cancer resection.

Case report: Drainage tube penetrating anastomosis as a rare cause for long-term nonunion of esophagogastric anastomosis in neck

Anastomotic leakage is a life-threatening complication for esophageal cancer patients who received McKeown esophagectomy. Cervical drainage tube penetrating anastomosis is a rare but noteworthy cause of long-term nonunion of esophagogastric anastomosis. Here we reported two cases of esophageal cancer patients who received McKeown esophagectomy. The first case acquired the anastomotic leakage on postoperative day (POD) 7, and lasted for 56 days. The cervical drainage tube was removed at POD 38, and the leakage healed in 25 days. The second case acquired the anastomotic leakage on POD 8 and lasted for 95 days. The cervical drainage tube was removed at POD 57, and the leakage healed in 46 days. The two cases demonstrated the duration-prolonging effect of drainage tube penetrating anastomosis, which should not be overlooked in clinical practice. We suggested paying attention to the duration of leakage, the drainage fluids amounts and characteristics, and the imaging manifestations to help diagnose. If the cervical drainage tube penetrated the anastomosis, the tube should be eliminated as soon.

The comparison of manual and mechanical anastomosis after total pharyngolaryngoesophagectomy

Background

Total pharyngolaryngoesophagectomy (TPLE) is considered as a curative treatment for hypopharynx cancer and cervical esophageal carcinomas (HPCECs). Traditional pharyngo-gastric anastomosis is usually performed manually, and postoperative complications are common. The aim of this study was to introduce a new technique for mechanical anastomosis and to evaluate perioperative outcomes and prognosis.

Methods

From May 1995 to Nov 2021, a series of 75 consecutive patients who received TPLE for a pathological diagnosis of HPCECs at Sun Yat-sen Memorial Hospital were evaluated. Mechanical anastomosis was performed in 28 cases and manual anastomosis was performed in 47 cases. The data from these patients were retrospectively analyzed.

Results

The mean age was 57.6 years, and 20% of the patients were female. The rate of anastomotic fistula and wound infection in the mechanical group were significantly lower than that in the manual group. The operation time, intraoperative blood loss and postoperative hospital stays were significantly higher in the manual group than that in the mechanical group. The R0 resection rate and the tumor characteristics were not significantly different between groups. There was no significant difference in overall survival and disease-free survival between the two groups.

Conclusion

The mechanical anastomosis technology adopted by this study was shown to be a safer and more effective procedure with similar survival comparable to that of manual anastomosis for the HPCECs patients.

Is Prophylactic Cervical Drainage Effective in Patients Undergoing McKeown Esophagectomy Reconstructed Through the Retrosternal Route with Two-Field Lymphadenectomy?

BACKGROUND

McKeown esophagectomy with two-field lymphadenectomy is the treatment of choice for oncologic esophagectomy. A cervical drain is placed in cases after modern two-field lymph node dissection (M2FD) to provide information on anastomotic leakage. However, the necessity of prophylactic cervical drainage during surgery remains unknown. This study aimed to clarify the clinical significance of cervical drainage in patients who underwent McKeown esophagectomy with M2FD.

METHODS

A total of 293 patients underwent McKeown surgery with two-field lymphadenectomy at our institute between January 2013 and December 2019. We compared the day of drain removal, amount of drainage volume, and the appearance of drainage fluid between patients with and without anastomotic leakage.

RESULTS

McKeown esophagectomy reconstructed through the retrosternal route is 203 patients (69.3%) of all. Nineteen patients (6.5%) experienced anastomotic leakage. The amount of cervical drain discharge was comparable between patients with and without anastomotic leakage. In addition, no purulent or salivary discharge was observed in patients with anastomotic leakage. There was no difference in the median day of drain removal between the groups. The initial clinical findings for the diagnosis of anastomotic leakage were surgical site infection in 10 (52.6%), fever in 5 (26.3%), prolonged inflammation in a blood test in 3 (15.8%), and bloody discharge from the chest tube in 1 (5.3%). There was no mortality due to any cause.

CONCLUSION

A prophylactic cervical drain may not be mandatory in patients with esophageal cancer undergoing McKeown esophagectomy reconstructed through the retrosternal route with two-field lymphadenectomy.

Prophylactic endoluminal vacuum therapy after major gastrointestinal surgery: a systematic review

In the last decade, endoluminal vacuum therapy (eVAC) has emerged as an effective treatment for anastomotic leak (AL); however, little is known regarding its prophylactic use. In this systematic review we evaluated overall outcomes in patients undergoing major gastrointestinal surgery and treated with prophylactic eVAC. A systematic review of English articles on four electronic databases was performed according to the PRISMA statement up until January 2022. References of selected articles were manually screened to identify relevant missing papers. Primary endpoints were AL and mortality rates estimates. Secondary endpoints included analysis of eVAC-associated morbidity, treatment duration, long-term complications, and general indications for the eVAC management in the perioperative period. A total of 11 studies (5 case reports, 5 retrospective case series and a retrospective, case-control study) were included in the analysis. AL ranged from 0 to 25%. No major eVAC-associated complications were observed, except for sponge dislocation or obstruction. Overall mortality ranged between 0 and 12.5%; however, these fatalities were neither related to the use of eVAC, nor to AL-associated complications. The most frequent long-term complication was anastomotic stenosis responsive to endoscopic dilatation in most cases. The operating negative pressure ranged from -25 to -125 mmHg among different papers. In all studies but two, prophylactic eVAC was applied to anastomoses at high risk of dehiscence based on the subjective evaluation of the leading surgeon. In conclusion, prophylactic eVAC is safe and it could lead to potential benefit for prevention of AL, especially in high-risk anastomoses.

Microvascular myocutaneous and cutaneous free flap reconstruction in patients with terminal esophagostomy after complicated oncological esophagus resection

Background

Persisting anastomotic leakage after oncological esophagectomy is a severe problem associated with high mortality and morbidity. Unfortunately, treatment options with promising results are scarce, especially when conventional operative and endoscopic methods have failed. Due to limitation of oral intake and the need for artificial nutrition, quality of life (QOL) is reduced. Microvascular myocutaneous and cutaneous free flap (MFF) reconstruction could be a promising alternative.

Methods

This retrospective case series presents 7 patients treated between March 2017 and November 2020 at our surgical department, with persisting postoperative anastomotic leakage without further feasible treatment options. All patients received anastomotic MFF reconstruction; used flaps and important intraoperative factors like microvascular anastomosis were evaluated. Complications and patient contentment was assessed.

Results

The included 7 male patients had median age of 65.15 years (range: 48–75). MFF function was adequate in 6/7 patients, one flap necrosis was encountered. Whereas 5 patients initially had good results, surgical revision was performed in 1 patient to ensure graft function. Postoperative complications appeared in 6/7 patients. Mean duration of inpatient care was 63 days (range: 24–156). At the time of evaluation, 1 patient has died of his malignant disease. No more additional nutrition was needed in 3/6 patients with adequate graft function. Most patients reported improved QOL after MFF.

Conclusion

MFF free flap can be an alternative treatment option for patients with terminal esophagostomy after complicated oncological esophagus resection without further treatment options. The renewed ability of oral food intake results in a significant improvement of QOL.