Comparison of clinical outcomes after conservative and surgical treatment of isolated anastomotic leaks after esophagectomy for esophageal cancer

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.

Effect of anastomotic leaks on long-term survival after oesophagectomy for oesophageal cancer: systematic review and meta-analysis

INTRODUCTION

Long-term survival after curative surgery for oesophageal cancer surgery remains poor, and the prognostic impact of anastomotic leak (AL) remains unknown. A meta-analysis was conducted to investigate the impact of AL on long-term survival.

METHODS

A systematic electronic search for articles was performed for studies published between 2001 and 2020 evaluating the long-term oncological impact of AL. Meta-analysis was performed using the DerSimonian-Laird random-effects model to compute hazard ratios and 95% confidence intervals.

RESULTS

Nineteen studies met the inclusion criteria, yielding a total of 9885 patients. Long-term survival was significantly reduced after AL (HR: 1.79, 95% CI: 1.33-2.43). AL was associated with significantly reduced overall survival in studies within hospital volume Quintile 1 (HR: 1.35, 95% CI: 1.12-1.63) and Quintile 2 (HR: 1.83, 95% CI: 1.35-2.47). However, no significant association was found for studies within Quintile 3 (HR: 2.24, 95% CI: 0.85-5.88), Quintile 4 (HR: 2.59, 95% CI: 0.67-10.07), and Quintile 5 (HR: 1.29, 95% CI: 0.92-1.81). AL was significantly associated with poor long-term survival in patients with associated overall Clavien Dindo Grades 1-5 (HR: 2.17, 95% CI: 1.31-3.59) and severe Clavien Dindo Grades 3-5 (HR: 1.42, 95% CI: 1.14-1.78) complications.

CONCLUSIONS

AL has a negative prognostic impact on long-term survival after restorative resection of oesophageal cancers, particularly in low-volume centers. Future efforts must be focused on strategies to minimize the septic and immunological response to AL with early recognition and treatment thus reducing the impact on long-term survival.

Endoscopic negative pressure therapy for leaks with large cavities in the upper gastrointestinal tract: is it a feasible therapeutic option?

BACKGROUND

Endoscopic negative pressure therapy (ENPT) is an increasingly popular method for the treatment of various defects of the upper and lower gastrointestinal (GI) tract and has been associated with high success rates. The largest reported series focus on intraluminal therapy of local defects, whereas larger defects connected to the abdominal or pleural cavity are still regarded as indications for surgical revision in many units. The aim of our study is to assess the efficacy and the periinterventional characteristics of ENPT applications in patients with defects with large cavities in the upper GI tract.

METHODS

We retrospectively analysed all cases of ENPT applications in the upper gastrointestinal tract performed in our clinic between 1 January 2010 and 31 December 2019 and identified the patients with defects leading to large cavities with a length of at least 7 cm. The procedural characteristics, intraprocedural and late complications and overall clinical success were analysed.

RESULTS

We identified 14 cases meeting our inclusion criteria. In all cases, an intracavitary or combined intracavitary and intraluminal ENPT was applied. The average duration of therapy was 47.5 days and included an average of 10.4 changes per patient in an interval of 4.5 days. Clinical success rate was 92.9%, average hospital stay was 74.5 days. In three cases, a late stenosis occurred, which could be treated endoscopically.

CONCLUSION

Based on the data of our case series, we conclude that ENPT is a feasible and promising therapeutic option for upper GI defects with contact to large cavities.

Application of ozonated water for treatment of gastro-thoracic fistula after comprehensive esophageal squamous cell carcinoma therapy: A case report

BACKGROUND

Gastro-thoracic fistula is a serious complication after radical surgery for esophageal cancer, and a conservative approach or endoscopic intervention is commonly applied to treat most cases.

CASE SUMMARY

Here we describe the case of a patient with a gastro-thoracic fistula which could not be closed during gastroscopy after receiving postoperative radiotherapy, together with severe multiple drug-resistant bacterial infection and chest wall fistula. The abscess was drained and local irrigation applied with ozonated water, together with oral ozonated water, which achieved a good effect and highlighted a new way to cure fistula in such patients.

CONCLUSION

Patients with gastro-thoracic fistula that cannot be closed and severe infection can be treated by drainage and flushing with ozonated water.

Subtotal stomach in esophageal reconstruction surgery achieves an anastomotic leakage rate of less than 1%

Aim

The objective of this retrospective, single‐institution study was to assess the safety and feasibility of reconstruction using subtotal stomach (SS) with esophagectomy for patients with esophageal cancer (EC). Although several different gastric‐tube‐making and anastomotic methods have been reported, the incidence rate of anastomotic leakage with EC surgery is generally reported over 10%. Complications should be avoided, and patient quality of life (QOL) should be maintained postoperatively. We have used SS reconstruction and hand‐sutured cervical esophagus‐subtotal gastric anastomosis at the neck wound in EC surgery. Short‐ and long‐term outcomes in cases using SS are not well known.

Methods

Between January 2008 and September 2019, 300 patients underwent esophagectomy for EC and reconstruction using SS. The primary endpoint was the rate of anastomotic leakage. Secondary endpoints were postoperative morbidities, QOL, and changes in patients’ body weight and skeletal muscle weight.

Results

Anastomotic leakage was observed in two patients (0.67%), and pneumonia was observed in nine patients (3.0%). Fifteen patients (5.0%) had an anastomotic stenosis requiring a bougie. Nausea occurred in 11 patients (3.7%), and dumping syndrome occurred in seven patients (2.3%). Dysphagia and early feeling of abdominal fullness scores tended to be high after surgery but gradually decreased after 6 months. Good results were obtained for reflux feeling scores. Body weight changed with an average decrease of −2 ± 3.71 kg (P = .071) over 5 years.

Conclusion

Reconstruction using SS resulted in an extremely low rate of anastomotic leakage and good QOL postoperatively in patients with EC.

Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study

Background and study aims  Esophageal fistulas after esophagectomy are associated with high mortality and poor quality of life. They are sometimes intractable to conservative management and surgery that increases mortality. Few studies have assessed use of polyglycolic acid (PGA) sheets with fibrin glue for esophageal fistulas. We investigated the safety of using PGA sheets with fibrin glue for esophageal fistulas after esophagectomy. Patients and methods  This was a single-center prospective pilot study. Patients who had refractory esophageal fistulas after esophagectomy were included. PGA sheets were filled in the fistula using biopsy forceps. Fibrin glue was applied to the PGA sheets. We repeated the procedure 1 week later. The outcome measures were the incidence of adverse events (AEs) and closure of the fistula. Results  Five patients were assessed. No adverse events were observed. The esophageal fistula was closed with the application of PGA sheets four times in 40 % (2/5) of the cases. Conclusions  PGA sheets with fibrin glue were safe for esophageal fistula closure after esophagectomy and do not involve the risk of AEs.

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.

Choice of therapeutic strategies in intrathoracic anastomotic leak following esophagectomy

Background

The aim of this study was to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy.

Methods

Clinical data from 33 patients who developed intrathoracic anastomotic leak were evaluated retrospectively. These patients were selected from 1867 patients undergoing resection carcinoma of the esophagus and reconstruction between January 2003 and December 2012.

Results

Surgical intervention and the reformed “three-tube method” were applied in 13 and 20 patients, respectively. The overall incidence of intrathoracic anastomotic leakage was 1.8%. The median time interval from esophagectomy to diagnosis of leak was 9.7 days. Sixteen patients were confirmed as having leakage by oral contrast computed tomography (CT). Age and interval from surgery to diagnosis of leak were identified as statistically significant parameters between contained and uncontained groups. Moreover, patients with hypoalbuminemia had a longer time to leak closure than patients without hypoalbuminemia. Six patients died from intrathoracic anastomotic leak, with a mortality rate of 18.2%. There was no statistically significant difference in the time to leak closure between patients who underwent surgical exploration and those who received conservative treatment.

Conclusions

Intrathoracic anastomotic leak after esophagectomy was associated with significant mortality. Once intrathoracic anastomotic leakage following esophagectomy was diagnosed or highly suspected, individualized management strategies should be implemented according to the size of the leak, extent of the abscess, and status of the patient. In the majority of patients with anastomotic leak, we preferred the strategy of conservative treatment.

Nahtinsuffizienz intestinaler Anastomosen: Endoskopische und laparoskopische Therapieoptionen

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen die schwerwiegendste septische Komplikation nach viszeralchirurgischen Eingriffen dar. Neben der chirurgischen Therapie sind zunehmend endoskopische Behandlungsoptionen möglich. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Therapieoptionen von Anastomoseninsuffizienzen sind abhängig von der klinischen Symptomatik, der Art der Anastomose, der Defektgröße, den lokalen Gewebeverhältnissen sowie dem Zeitpunkt der Diagnose. Bei einer Nekrose oder Minderdurchblutung der Viszeralorgane müssen diese operativ reseziert werden. Prinzipiell sind alle operativen Revisionseingriffe auch laparoskopisch durchführbar. Bei erhaltener Gewebeperfusion können die Leckagen lokal übernäht oder endoskopisch verschlossen werden. Die Ergebnisse für die Stenttherapie nach Ösophagus- und Magenresektionen sind für moderne Stents sehr Erfolg versprechend. Im Gegensatz dazu sind die Ergebnisse der endoskopischen Stenttherapie bei Insuffizienz nach kolorektalen Eingriffen enttäuschend; dafür steht hier mit der Schwammtherapie eine vielversprechende endoskopische Alternative zur Verfügung. <b><i>Schlussfolgerung: </i></b>Die aktuellen Daten zeigen, dass neue laparoskopische und endoskopische Optionen zur Therapie von Anastomoseninsuffizienzen bestehen, die jedoch noch in prospektiven und randomisierten Studien evaluiert werden müssen.