Elsevier

Surgery

Volume 148, Issue 4, October 2010, Pages 831-840
Surgery

Central Surgical Association
Impact of anastomotic leak on outcomes after transhiatal esophagectomy

Presented at the Central Surgical Association 2010 Annual Meeting, March 10–13, 2010, Chicago, Illinois.
https://doi.org/10.1016/j.surg.2010.07.034Get rights and content

Background

The development of anastomotic leaks and/or strictures can be associated with considerable morbidity and impairment of quality of life. In the current study, we evaluated the outcomes of patients who developed anastomotic complications after esophagectomy to elucidate the impact of these events on morbidity, mortality, and subsequent need for dilation.

Methods

We analyzed retrospectively the clinical course of 235 patients who underwent transhiatal esophagectomy for cancer from 2001 to 2009. Patients with confirmed anastomotic leaks were identified and classified with the following scale: class 1: Radiographic leak only, no intervention; class 2: leak requiring opening of the wound, cervical and/or percutaneous drainage; class 3: disruption of anastomosis (10–50% circumference) with perianastomotic abscess requiring video-assisted thoracoscopic surgery or thoracotomy; and class 4: gastric tip necrosis with anastomotic separation (>50% circumference).

Results

Anastomotic leaks were encountered in 30 patients (13%). Anastomotic leaks were associated with greater morbidity (70% vs 47%; P = .02) and stricture formation (57% vs 19%; P = .0001). Mortality was not different. Increasing leak class was associated with an increased need for postoperative anastomotic dilations (P = .016).

Conclusion

Anastomotic integrity after esophagectomy has a substantial impact on perioperative course and long-term swallowing. A more formal radiographic and endoscopic leak classification system seems justified.

Section snippets

Patients

Approval for this study was provided by the Institutional Review Board of the University of Pittsburgh, and individual patient consent was waived given the retrospective nature of the analysis. We performed a review of 235 consecutive patients who underwent transhiatal esophagectomy for pathologically confirmed cancer at the University of Pittsburgh from 2001 to 2009. The patients were identified from the billing records of the Heart, Lung and Esophageal Surgery Institute as well as the Cancer

Patient and tumor characteristics

Patient and tumor characteristics are summarized in Table I. The mean age for the entire cohort was 65 years. The male:female ratio was 180:55. Adenocarcinoma was the most commonly encountered tumor (81%), followed by squamous cell carcinoma (16%). Neoadjuvant therapy was employed in 37 (16%) of patients. No significant differences were found in age, preoperative patient co-morbidities, histology, or use of neoadjuvant therapy between patients who developed a leak and those with no leak.

Discussion

Although anastomotic leaks represent one of the most common and important major complications after esophagectomy, there is no established consensus regarding what defines a leak. In fact, less than 50% of published series include a clear definition of what constitutes an anastomotic leak.15 The reported incidence of anastomotic leak correspondingly varies widely, averaging 10–15% in the largest series (Table III).4, 16, 17, 18, 19 Some authors define a leak based on radiographic findings,

References (25)

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    Citation Excerpt :

    Anastomotic leak is defined as oral secretions or contrast extravasation at the anastomotic site and are graded using the Pittsburgh Leak Scale. ( Class 0 = no leak; Class 1 = radiographic leak only, no intervention; Class 2 = leak [<10% of circumference] requiring cervical and/or percutaneous drainage; Class 3 = disruption of anastomosis [10%-50% circumference] with perianastomotic abscess and associated pleural or mediastinal collection requiring video-assisted thoracoscopic surgery) or thoracotomy; and Class 4 = gastric tip necrosis with anastomotic separation [>50% circumference]).11 Short-term mortality was defined as in-hospital death or death within 30-days after the operation.

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