OPTIMAL DIAGNOSIS AND TREATMENT MODALITY FOR ANASTOMOTIC LEAK AFTER ESOPHAGECTOMY RECONSTRUCTION
Katsunori Nishikawa*, Yoshitaka Ishikawa, Keita Takahashi, Takanori Kurogochi, Masami Yuda, Yujiro Tanaka, Akira Matsumoto, Yuichiro Tanishima, Norio Mitsumori, Katsuhiko Yanaga
Surgery, Jikei Univeristy, Tokyo, Japan
(Background)
Anastomotic leakage (AL) after esophagectomy reconstruction not only prolongs hospitalization but also could lead to fatal outcome. Precise diagnosis of AL is not only essential for suitable therapeutic management but also important to save medical expenses.
(Patients and Methods)
A consecutive 220 patients with esophageal diseases who underwent subtotal esophagectomy following cervical esophagogastric anastomosis were studied. Serial serum CRPs could be retrieved in all patients on postoperative day (PD) 3 to 7, and CT scans were routinely taken before resuming oral intake. Also, anastomostic evaluation was performed endoscopically (EPE) within 2 weeks in 194 patients after surgery. A case in which only bubbles were observed around the anastomosis was defined as minor (mn) AL, and a case in which pus or salivary discharge was found from the wound site was defined as major (mj) AL.
(Results)
# Diagnosis of AL: mjAL and mnAL were encountered in 23 (8.8%) and 7 (3.2%) patients, respectively. Regardless of mjAL, an elevation of serum CRPs showed significant differences throughout PD3 to PD7 with noticeable elevation on PD5 (14.4 vs.9.1, p = 0.001). Re-increase rate, mean re-elevation date, and increase value from the day before re-increase of serum CRPs on mjAL/non-mjAL within PD7 days were 70%/37% (p = 0.001), PD5.1/PD5.8 (p = 0.01), 6.4 mg/L/4.5 mg/L (p = 0.02), respectively. EPE confirmed that 74% of mjAL and 57% of mnAL presented severe mucosal degeneration on the gastric mucosa in the vicinity of esophagogastric anastomosis.
# AL treatment: Drainage was performed for all cases of mjAL. Of these, two cases required re-operation due to gastric tube necrosis, and esophageal stent was inserted in another 2 cases. Conservative treatment such as NPO (+ antibiotics) was successfull in all cases of mnAL without transition to mjAL.
(Discussion)
Management of AL should be taken into considered when rapid increase in serum CRPs was encountered within one week after operation. Postoperative CT scans and EPE prior to resumption of oral intake may provide accurate diagnosis of AL, which could lead to optimal outcome.
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