Clin Endosc.  2022 Jan;55(1):58-66. 10.5946/ce.2021.099.

Endoscopic Management of Anastomotic Leakage after Esophageal Surgery: Ten Year Analysis in a Tertiary University Center

• El-Sourani N
• Miftode S
• Bockhorn M
• Arlt A
• Meinhardt C

• KMID: 2525051
• DOI: http://doi.org/10.5946/ce.2021.099

Abstract

Background/Aims
Anastomotic leakage after esophageal surgery remains a feared complication. During the last decade, management of this complication changed from surgical revision to a more conservative and endoscopic approach. However, the treatment remains controversial as the indications for conservative, endoscopic, and surgical approaches remain non-standardized.
Methods
Between 2010 and 2020, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. The data of 28 patients diagnosed with anastomotic leak were further analyzed.
Results
Among 141 patients who underwent resection, 28 (19.9%) developed an anastomotic leak, eight (28.6%) of whom died. Thirteen patients were treated with endoluminal vacuum therapy (EVT), seven patients with self-expanding metal stents (SEMS) four patients with primary surgery, one patient with a hemoclip, and three patients were treated conservatively. EVT achieved closure in 92.3% of the patients with a large defect and no EVT-related complications. SEMS therapy was successful in clinically stable patients with small defect sizes.
Conclusions
EVT can be successfully applied in the treatment of anastomotic leakage in critically ill patients, while SEMS should be limited to clinically stable patients with a small defect size. Surgery is only warranted in patients with sepsis with graft necrosis.

Keyword

Anastomotic leak; Endoluminal vacuum therapy; Esophagus; Intrathoracic; Self-expanding metal stents

Figure

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  Fig. 1. Management of anastomotic leakage by endoluminal vacuum therapy (EVT). A 75-year-old patient with ypT3 pN1 M0 R0 Barrett’s carcinoma treated with thoracoabdominal esophagectomy after neoadjuvant chemotherapy. (A, B) An approximately 3-cm large anastomotic leakage cavity on the 10th postoperative day in which deeper fistulas could be excluded. (C, D) After EVT for 10 days, there was a clear tendency towards granulation. (E) The insufficiency cavity was significantly smaller and the EVT was completed after 14 days. (F) Endoscopic control after a total of 24 days showed an almost closed insufficiency.

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  Fig. 2. Management of anastomotic leakage using a self-expanding metal stent (SEMS). A 67-year-old patient with pT1b (sm1) pN0 M0 R0 adenocarcinoma was treated with transhiatal distal esophagectomy. (A) CT scan in the region of the anastomosis (a) with detection of extraluminal free air (b) and contrast medium (c) on the 7th postoperative day. (B) Endoscopy with detection of an approximately 6-mm small anastomotic leakage with an otherwise vital anastomosis. (C) In the absence of evidence for an abscess, a fully covered self-expanding metal stent with a diameter of 28 mm was implanted. (D) The stent was removed after three weeks. The small anastomotic leakage was almost completely closed.

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  Fig. 3. Treatment algorithm for patients treated for anastomotic leak after esophagectomy. Of the 28 patients, 13 were treated with endoluminal vacuum therapy (EVT), seven with self-expanding metal stents (SEMS), one with a clip, three were treated conservatively, and four patients required surgery to treat the defect.

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