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Mucha AW, Strandby RB, Nerup NA, Achiam MP. Treatment of intrathoracic anastomotic leakage following esophagectomy for gastroesophageal cancer: a systematic review. Dis Esophagus 2025; 38:doaf016. [PMID: 40048658 DOI: 10.1093/dote/doaf016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 10/20/2024] [Accepted: 02/24/2025] [Indexed: 05/13/2025]
Abstract
Anastomotic leakage (AL) is a significant complication following esophagectomy. AL affects 8%-17% of patients and is associated with increased morbidity, mortality, and hospital stay. To this date, no consensus exists on the most optimal treatment. This systematic review aimed to determine the most effective treatment approach. A systematic search of Medline, Web of Science, Cochrane, Scopus, and Embase databases was conducted. Only studies reporting on the treatment of intrathoracic anastomotic leakage after esophagectomy with gastric conduit reconstruction for cancer were included. Studies investigating other esophageal disorders or failing to report the location of the anastomosis were excluded. The methodological quality and risk of bias were assessed using the Newcastle-Ottawa Scale for cohort studies. Out of 12,966 identified studies, 38 were included for analysis after removing duplicates and screening titles, abstracts, and full texts. Of these, five were found to be of poor methodological quality and 33 were of moderate quality. The most researched treatment methods were Endoluminal vacuum therapy (EVT), naso-fistula tube drainage (NFTD), and stent treatment. The success and mortality rates for EVT were 82% and 10.7%, for NFTD, 94% and 5.2%, and, for stent treatment, 75.1% and 13.5%, respectively. AL can be effectively treated with EVT, stent treatment, and NFTD. The NFTD approach appeared to have a higher success rate and lower mortality than other treatment modalities. However, it requires a longer treatment duration. Due to limitations within the included studies, a definitive recommendation regarding the optimal treatment for AL cannot be made.
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Affiliation(s)
- Andreas Weise Mucha
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Rune Broni Strandby
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Nikolaj Albeck Nerup
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Surgery and Transplantation, Copenhagen University Hospital Rigshospitalet, Inge Lehmanns Vej 7, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
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Suction Drainage for Anastomotic Leakage After Ivor Lewis Esophagectomy. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:31-36. [PMID: 36730429 DOI: 10.1097/sle.0000000000001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 10/24/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anastomotic leakage is one of the most life-threatening complications after Ivor Lewis esophagectomy (ILE), with various treatment strategies. Endoscopic techniques are emerging as a less invasive alternative to surgery. Among the current endoscopic techniques, a single placement of an endoluminal nasogastric tube inside the cavity with controlled suction drainage (SD) seems to be an attractive option. The aim of this study was to evaluate the efficacy of SD as treatment for anastomotic leakage after ILE. METHODS This retrospective analysis was performed among patients who underwent ILE in a high-volume esophageal cancer center in the Netherlands. Patients with an anastomotic leakage that received SD as primary treatment were selected. A nasogastric tube was endoscopically placed into the cavity of the leakage for controlled suction with 15 mm Hg. RESULTS A total of 34 patients received SD and was successful in 26 patients (77%). Seven patients (21%) developed empyema despite the SD for which additional video-assisted thoracoscopic surgery was performed. Mortality was 5.9% (2 patients) and median intensive care unit and hospital stay were 3 days (1 to 9) and 25 days (14 to 43), respectively. The median time to closure of the leak was 41 days (23 to 65). A total of 16 patients underwent home treatment for a median of 23 (14 to 42) days. CONCLUSIONS Controlled SD seems to be an effective treatment for anastomotic leakage after ILE. This therapy can safely and effectively be completed in an ambulant, outpatient setting.
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Kim JH, Shin JH, Oh JS. Role of interventional radiology in the management of postoperative gastrointestinal leakage. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2022. [DOI: 10.18528/ijgii220039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ji Hoon Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Suk Oh
- Department of Radiology, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Gakuhara A, Fukuda S, Tsujimoto T, Tomihara H, Ohta K, Kitani K, Hashimoto K, Ishikawa H, Hida JI, Yukawa M. Successful management of gastric remnant necrosis after proximal gastrectomy using a double elementary diet tube: a case report. Surg Case Rep 2020; 6:296. [PMID: 33226508 PMCID: PMC7683626 DOI: 10.1186/s40792-020-01056-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 10/22/2020] [Indexed: 11/18/2022] Open
Abstract
Background The stomach has many incoming vessels and is resistant to ischemia due to the rich microvascular network within its submucosal layer. Although reports of gastric remnant necrosis after gastrectomy have been rare, mortality rates remain substantially high when present. A double elementary diet (W-ED) tube, which can be used for both enteral feeding and gastrointestinal tract decompression, has been developed for anastomotic leakage and postoperative nutritional management after upper gastrointestinal surgery. The current report presents a case of gastric remnant necrosis after proximal gastrectomy that was successfully managed through conservative treatment with a W-ED tube. Case presentation A 73-year-old male was referred to our hospital for an additional resection after endoscopic submucosal dissection (ESD) for gastric cancer. Endoscopic findings showed an ESD scar on the posterior wall of the upper portion of the stomach, while computed tomography (CT) showed no obvious regional lymph node enlargement and distant metastases. The patient subsequently underwent laparoscopic proximal gastrectomy and esophagogastrostomy but developed candidemia on postoperative day 7. On postoperative day 14, endoscopy revealed gastric ischemic changes around the anastomotic site, suggesting that the patient’s candidemia developed due to gastric necrosis. His vital signs remained normal, while the gastric remnant ischemia was localized. Given that surgery in the presence of candidemia was considered extremely risky, conservative treatment was elected. A W-ED tube was placed nasally, after which enteral feeding was initiated along with gastrointestinal tract decompression. Although the patient subsequently developed anastomotic leakage due to gastric remnant necrosis, local control was achieved and conservative treatment was continued. On postoperative day 52, healing of the gastric remnant necrosis and anastomotic leakage was confirmed, after which the patient started drinking water. Although balloon dilation was required due to anastomotic stenosis, the patient was able to resume oral intake and was discharged on postoperative day 88. Conclusions Herein, we present our experience with a case of gastric remnant necrosis after proximal gastrectomy, wherein conservative management was achieved using a W-ED tube. In cases involving high operative risk, the management should be mindful of gastric remnant necrosis as a post-gastrectomy complication.
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Affiliation(s)
- Atsushi Gakuhara
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan.
| | - Shuichi Fukuda
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Tomoyuki Tsujimoto
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Hideo Tomihara
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Katsuya Ohta
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Kotaro Kitani
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Kazuhiko Hashimoto
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Hajime Ishikawa
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Jin-Ichi Hida
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
| | - Masao Yukawa
- Department of Gastroenterological Surgery, Kindai University Nara Hospital, 1248-1, Otoda-cho, Ikoma, Nara, 630-0293, Japan
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An interventional radiology technique to treat pharyngeal or esophageal perforation associated with mediastinal abscess in children. J Pediatr Surg 2020; 55:437-440. [PMID: 31376916 DOI: 10.1016/j.jpedsurg.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 06/23/2019] [Accepted: 07/11/2019] [Indexed: 11/22/2022]
Abstract
PURPOSE Pharyngeal or esophageal perforation with mediastinal abscess is notably dangerous in children and can be very difficult to treat. We aimed to determine the safety and efficacy of the transnasal placement of a mediastinal drainage catheter and a nasojejunal feeding tube, with or without gastric decompression, in the treatment of the above perforations in children. METHODS We placed transnasal mediastinal drainage catheters and nasojejunal feeding tubes in 14 pediatric patients. Patients with esophageal perforation also underwent the placement of a gastric decompression tube. Four of these patients additionally received chest drainage tubes. RESULTS The fistula healed after a median of 66 days (range, 5-404 days). Corrosive esophagitis occurred in two patients with pharyngeal perforations. One of these patients underwent surgical treatment 2 months after fistula healing, and the other underwent repeated balloon dilatation procedures for cicatricial restenosis. Four months after the fistula had healed, the patients with esophageal perforations were all free from recurrence. CONCLUSION The use of interventional radiology to place a transnasal mediastinal drainage catheter, a nasojejunal feeding tube, and a gastric decompression tube is a safe, easy, inexpensive, and efficacious way to treat pharyngeal or esophageal perforation complicated by mediastinal abscess in children. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level IV.
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Verstegen MHP, Bouwense SAW, van Workum F, Ten Broek R, Siersema PD, Rovers M, Rosman C. Management of intrathoracic and cervical anastomotic leakage after esophagectomy for esophageal cancer: a systematic review. World J Emerg Surg 2019; 14:17. [PMID: 30988695 PMCID: PMC6449949 DOI: 10.1186/s13017-019-0235-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 03/14/2019] [Indexed: 01/28/2023] Open
Abstract
Background Anastomotic leakage (0-30%) after esophagectomy is a severe complication and is associated with considerable morbidity and mortality. The aim of this study was to determine which treatment for anastomotic leakage after esophagectomy have the best clinical outcome, based on the currently available literature. Methods A systematic literature search was performed in Medline, Embase, and Web of Science until April 2017. All studies reporting on the specific treatment of cervical or intrathoracic anastomotic leakage following esophagectomy with gastric tube reconstruction for esophageal or cardia cancer were included. The primary outcome parameter was postoperative mortality. Methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Results Nineteen retrospective cohort studies including 273 patients were identified. Methodological quality of all studies was poor to moderate. Mortality rates of intrathoracic anastomotic leakages in the treatment groups were as follows: conservative (14%), endoscopic stent (8%), endoscopic drainage (8%), endoscopic vacuum-assisted closure system (0%), and surgery treatment group (50%). Mortality rates of cervical anastomotic leakages in the treatment groups were as follows: conservative (8%), endoscopic stent (29%), and endoscopic dilatation (0%). Discussion Due to small cohorts, heterogeneity between studies, and lack of data regarding leakage characteristics, no evidence supporting a specific treatment for anastomotic leakage after esophagectomy was found. A severity score based on leakage characteristics instead of treatment given is essential for determining the optimal treatment of anastomotic leakage. In the absence of robust evidence-based treatment guidelines, we suggest customized treatment depending on sequelae of the leak and clinical condition of the patient. PrDepartment of Surgery, Radboudumc, P.O.B. 9101/618 NLactical advices are provided. Trial registration Registration number PROSPERO: CRD42016032374.
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Affiliation(s)
- Moniek H P Verstegen
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Stefan A W Bouwense
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Frans van Workum
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Richard Ten Broek
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Peter D Siersema
- 2Gastroenterology and Hepatology, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Maroeska Rovers
- 3Operating Rooms and Health Evidence, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Camiel Rosman
- 1Department of Surgery, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
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Zhang R, Zhang L. Feasibility of complete nasogastric tube omission in esophagectomy patients. J Thorac Dis 2019; 11:S819-S823. [PMID: 31080664 DOI: 10.21037/jtd.2018.11.98] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Routine nasogastric tube (NGT) placement is a common practice in esophagectomy patients. However, its continued application has been controversial in recent years. In this review, we will discuss the potential risks and benefits, including anastomosis leak, pneumonia, NGT reinsertion, patients' discomfort and hospital length of stay, to evaluate the feasibility of complete NGT omission in esophagectomy patients.
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Affiliation(s)
- Rusi Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510080, China.,Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou 510080, China
| | - Lanjun Zhang
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510080, China.,Department of Thoracic Surgery, Sun Yat-sen University Cancer Center, Guangzhou 510080, China
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Kanamori J, Okada N, Fujiwara H, Mayanagi S, Fujita T, Nagino M, Daiko H. Leak grading and percutaneous transanastomotic drainage for the treatment of cervical anastomotic leakage after esophagectomy. Dis Esophagus 2017; 30:1-7. [DOI: 10.1093/dote/dow029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Guo J, Chu X, Liu Y, Zhou N, Ma Y, Liang C. Choice of therapeutic strategies in intrathoracic anastomotic leak following esophagectomy. World J Surg Oncol 2014; 12:402. [PMID: 25547979 PMCID: PMC4320535 DOI: 10.1186/1477-7819-12-402] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2013] [Accepted: 12/03/2014] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | | | - Chaoyang Liang
- Department of Thoracic Surgery, PLA General Hospital, 28# Fuxing Street, Beijing, China.
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