1. Review on Post-esophagectomy Anastomotic leakage
Dr. PC Wong
Department of Surgery
Queen Mary Hospital

2. I. Introduction II. Risk factor and Prevention III. Management

3. Post-esophagectomy leakage
Leakage rate 5-30%
Mortality up to 50%
Ladak et al, Surg Endosc, 2019

4. I. Introduction II. Risk factor and Prevention III. Management

5. Surgical-related factor
Reason for leakage
Patient factor
Surgical-related factor

6. Patient factor Diabetes BMI (<18.5kg/m2, p=0.01) Smoking
Preoperative optimization of nutritional status
Better patient selection
Diabetes
BMI (<18.5kg/m2, p=0.01)
Smoking
Neoadjuvant CTRT
Previous irradiation to H&N
Other medical co-morbidities: liver cirrhosis, renal impairment, immunosuppressants
Higher leakage in irradiated field of esophagus
Drug
Immunosuppressant
Previous irradiation to Head and neck
Whole stomach / narrow tube
Surgical related factor
Tension – level of anastomosis
Preop optimization of nutrition: Paper
Retrospective review of 483 patients
BMI >18.5 kg/m2 associated with less leakage (p=0.01)
Shichinohe et al, Ann Surg Oncol, 2019
Li et al, Dis Esophagus, 2017
Gao et al, Medicine (Baltimore), 2018
Roh et al, Korean J Thorac Cardiovasc Surg, 2019

7. Surgical-related factor
Tension
Blood supply
Tissue

8. Surgical-related factor: 1. Surgical approach
MIE vs Open
No difference in leakage (5.7% vs 5.3%)
No difference in recurrent laryngeal nerve palsy (20.1% vs 18.7%)
MIE is superior to Open in terms of
Wound infection (3.7% vs 10.7%, p = 0.01)
Blood loss (220 vs 400ml, p < 0.001)
Respiratory complications (29% vs 55%, p<0.001)
724 patients over 22 years
33 per year
Handsewn vs stapled QMH
+ slide for ischemic preconditioning
Narrow tube stomach
Super-charge (inferior thyroid, internal mammary)
Ileal interposition
Routine colonic interposition
Chan et al, Dis Esophagus, 2018

9. Surgical-related factor: 2. Anastomosis
Level of anastomosis
Cervical (12%) vs Intrathoracic (9.8%); OR 0.56, p=0.021
Handsewn vs Circular stapler2
Meta-analysis of 12 RCTs
No difference in leakage rate
Higher rate of anastomotic stricture in CS (OR 1.67, p=0.006)
Handsewn vs Linear stapler3
Meta-analysis of 3 RCTs + 12 comparative studies
Lower rate of anastomotic leakage (OR 0.51, p< ) and stricture (OR 0.56, p< ) in LS
1. Ryan et al, Ann Surg Oncol, 2017
2. Honda et al, Ann Surg, 2015
3. Deng et al, World J Gastroenterol, 2015

10. Surgical-related factor: 3. Route of reconstruction
Controversial
Retrosternal
Posterior mediastinal
Less tumor bed recurrence in conduit
Shorter distance
Avoid conduit irradiation
Less tension
Less complication of anastomotic leakage
Less angulation
Better gastric emptying
Residual / R2 Resection
Less mediastinitis
Ease of drainage and reoperation
Urschel et al, Am J Surg, 2001

11. Surgical-related factor: 4. Choice of conduit
Narrow gastric tube vs Whole stomach
Meta-analysis of 3 RCT + 3 retrospective studies
No difference in anastomotic leakage and stricture
Gastric tube has less reflux esophagitis (OR 0.36, p=0.01)
Zhang et al, PLoS One, 2017

12. Surgical-related factor: 5. Blood supply
Intraoperative ICG fluorescence angiography
Sensitivity: 78%; Specificity: 74%
Intervention
Resection of devitalized segment
Addition of vessel anastomosis
Leak rate
5.7% (ICG group) vs 22.9% (control group)
Absolute risk reduction 69% (OR 0.31, p=0.001)
Ischemia: one of the most important risk factor for leakage
Colour temperature pulsation
Sample size Limitation
Observational cohort study, small sample size
Use: before / after anastomosis
ICG Cutoff
Outcome: clinical / radiological leak
Ladak et al, Surg Endosc, 2019

13. I. Introduction II. Risk factor and Prevention III. Management

14. Management principles
Pus / air / saliva from neck drain
Pulmonary complication, Mediastinitis
Early recognition
OGD
Contrast swallow / CT with IV + oral contrast
Confirm diagnosis
Resuscitation, Ventilatory support, Nutrition
Broad spectrum antibiotics
Control sepsis & organ support
Radiological / Endoscopic / Surgical
Drainage
Endoscopic / Surgical
Repair
Control sepsis – Broad spectrum antibiotics
Drainage
Radiological: Percutaneous drainage of neck / pleural collection
Endoscopic: Gastric conduit
Surgical: Exploration and drainage
Wound dressing
Negative pressure therapy (For neck wound)
Nutritional support
Enteral nutrition: Nasojejunal tube feeding, Feeding jejunostomy
Parenteral nutrition

15. Neck wound exploration
Anastomotic leakage
Cervical
Drainage
Neck wound exploration
VAC
Septic
Intrathoracic
Exploration: Open vs VATS
Conduit healthy
Primary repair
Conduit ischemia  Resection
Adequate length
Re-anastomosis
Inadequate length
Stable
Immediate reconstruction
Esophagostomy
Delayed reconstruction
QMH usual protocol
Jejunal interposition
Conduit in abdomen and feeding jejunostomy
Conduit in subcutaneous and free jejunum / flap reconstruction

16. Neck wound exploration
Anastomotic leakage
Cervical
Drainage
Neck wound exploration
VAC
Septic
Intrathoracic
Exploration: Open vs VATS
Conduit healthy
Primary repair
Conduit ischemia  Resection
Adequate length
Re-anastomosis
Inadequate length
Stable
Immediate reconstruction
Esophagostomy
Delayed reconstruction
QMH usual protocol
Jejunal interposition
Conduit in abdomen and feeding jejunostomy
Conduit in subcutaneous and free jejunum / flap reconstruction

17. Stable but persistent defect: Consider Endoscopic treatment
Anastomotic leakage
Cervical
Drainage
Neck wound exploration
VAC
Septic
Intrathoracic
Exploration: Open vs VATS
Conduit healthy
Primary repair
Conduit ischemia  Resection
Adequate length
Re-anastomosis
Inadequate length
Stable
Immediate reconstruction
Esophagostomy
Delayed reconstruction
QMH usual protocol
Jejunal interposition
Conduit in abdomen and feeding jejunostomy
Conduit in subcutaneous and free jejunum / flap reconstruction
Stable but persistent defect:
Consider Endoscopic treatment

18. Endoscopic treatment Mechanism Success rate Limitation Complication
Esophageal stenting
Self-expanding covered metal stent
60-90%
1-10 weeks
Migration
Bleeding
Perforation
Stricture
Clip
Full thickness closure
60-70%
Small defect
Vacuum-assisted closure
Sponge within abscess cavity
Decrease bacterial load and edema
Promote granulation
>90%
1-6 weeks
Exchange every 3-5 days
Stent patients
Clip: small case series for anastomotic leakage
Persson et al, Dis Esophagus, 2017; Plum et al, World J Surg, 2019; Hwang et al, Medicine (Baltimore), 2016;
Pines et al, J Laparoendosc Adv Surg Tech A, 2018; Haito-Chavez et al, Gastrointest Endosc, 2014

19. Summary
Post-esophagectomy anastomotic leakage leads to significant morbidity and mortality
Preoperative optimization and systematic management strategies are crucial
Emerging intraoperative techniques and endoscopic treatment yield promising results
Intraoperative ICG with subsequent intervention has potential in reducing leakage rate
Endoscopic therapy is associated with good success rate in clinically stable patients with minor leakage

20. Reference
Ladak et al, Indocyanine green for the prevention of anastomotic leakage following esophagectomy. Surg Endosc. 2019
Gao et al, Impact of high body mass index on surgical outcomes and long-term survival among patient undergoing esophagectomy. Medicine (Baltimore). 2017
Li et al, Diabetes mellitus and risk of anastomotiic leakage after esophagectomy. Dis Esophagus. 2017
Deng et al. Hand-sewn vs linearly stapled esophagogastric anastomosis for esophageal cancer. World J Gastroenterol. 2015
Boostma et al, Towards optimal intraoperative conditions in esophageal surgery. Int J Surg. 2018
Messager et al. Recent improvements in the management of esophageal anastomotic leak after surgery for cancer. EJSO. 2016