Background
Esophageal anastomotic leak (AL) is one of the most serious complication after esophagectomy,it is estimated to occur in 11.4% of patients, leading to prolonged hospital stay and to high mortality rates. Despite the frequency of AL and its associated morbidity, literature evaluating risk factors for AL following esophagectomy is mixed. In recent years, there has been a growing interest in the use of inflammatory serum markers as potential predictors of postoperative outcomes of patients undergoing esophagectomy. However, most of the studies have focused on prognosis with a minority focusing on postoperative complications. In this study, we sought to investigate patient and procedure characteristics associated with AL, with a particular focus on the possible role of preoperative inflammatory biomarkers.
Methods
Patients who underwent esophagectomy for cancer in our Center were included. Patients experiencing an AL were identified, and univariate and multivariable logistic regression were performed to identify variables independently associated with an AL. Only patients who had a complete preoperative analysis of serum inflammatory biomarkers were included and neutrophil-lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet-lymphocyte ratio (PLR), and CRP- albumin ratio (CAR) were calculated and analyzed.
Results
Of 324 patients included, 83% were male and the median age was 64 years.Thirty patients developed a postoperative AL (9.2%), which required a surgical reintervention in three cases. Patients with AL had more frequently additional complications (87% vs 36%,p< .001), higher rates of reoperation (64% vs 11%,p< .001) and mortality (8% vs 2%,p= .001). Patients with AL had more often preexisting chronic kidney disease (CKD) (10% vs 1.36%,p=.0019), cardiovascular disease (46.67% vs 16.33%, p<.0001) and were more frequently smoker or ex-smokers (73.3%vs47%, p=.0114). With regard to preoperative laboratory values, patients with AL had a higher preoperative monocyte count (p=0.0321) and higher LMR (p=0.0085). No other differences in TNM staging criteria or in the surgical approach existed between the groups. After adjusting for patient and procedure characteristics, preexisting cardiovascular disease (OR 3.78, 95% CI 1.022 - 1.115,p=.003) and a smoking habit (OR 1.323, 95% CI 1.048 - 1.670,p=.03) were independently associated with anastomotic leak.
Conlusions
Anastomotic leak is a major risk of esophagectomy, and efforts to reduce its associated morbidity could potentially improve both postoperative and oncologic outcomes for patients with esophageal cancer. In our analysis, patients with AL had higher preoperative monocyte counts and higher rates of lymphocyte to monocyte ratios. However, at multivariate analysis, preexisting cardiovascular disease and a history of smoking were the only two variables independently associated with AL.
