Intrathoracic esophagogastric anastomotic leakage following esophageal surgery Nikolaos Barbetakis, Christos Asteriou, Athanassios Kleontas and Christodoulos Tsilikas Interact CardioVasc Thorac Surg 2011;12:151DOI: 10.1510/icvts.2010.247866B
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://icvts.ctsnetjournals.org/cgi/content/full/12/2/151-a
Interactive Cardiovascular and Thoracic Surgery is the official journal of the European Association for Cardio-thoracic Surgery (EACTS) and the European Society for Cardiovascular Surgery (ESCVS). Copyright © 2011 by European Association for Cardio-thoracic Surgery. Print ISSN: 1569-9293.
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ARTICLE IN PRESS M. Schweigert et al. / Interactive CardioVascular and Thoracic Surgery 12 (2011) 147–151
State-of-the-art Best Evidence Topic Nomenclature Historical Pages Brief Case Report Communication
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Follow-up Paper
w1x Schweigert M, Dubecz A, Stadlhuber RJ, Muschweck H, Stein HJ. Treatment of intrathoracic esophageal anastomotic leaks by means of endoscopic stent implantation. Interact CardioVasc Thorac Surg 2011; 12:147–151.
Negative Results
Reference
Proposal for Bailout Procedure
Authors: Nikolaos Barbetakis, Department of Thoracic Surgery, Theagenio Cancer Hospital, Al. Simeonidi 2, Thessaloniki, Greece; Christos Asteriou, Athanassios Kleontas, Christodoulos Tsilikas doi:10.1510/icvts.2010.247866B We have read with great interest the article by Schweigert et al. concerning the treatment of intrathoracic esophageal anastomotic leaks by means of endoscopic stent implantation w1x. An important issue which is not clarified by the authors, is the relation between the fistula size and success of the proposed method, as well as the optimal time for stent removal. We also have three points for interactive discussion. The first point is that successful sealing of the leak is gratifying and important but it is not the complete management of an esophageal leakage. Other important components are the drainage of extraluminal fluid collections, decortication for pleural sepsis and separation of esophagus from adjacent structures, such as the aorta or airway, with vascularized tissue making the choice of the appropriate method of management difficult and debatable. The second point is how much we trust the scar that results from the stent alone. Another issue we would like to highlight is the reinforcement of esophagogastric anastomosis during surgery with vascularized tissue (pleural tenting or muscular flap) in order to prevent leakage.
ESCVS Article
eComment: Intrathoracic esophagogastric anastomotic leakage following esophageal surgery
Institutional Report
Authors: Stefano Cafarotti, Department of Thoracic Surgery, Catholic University, 00168 Rome, Italy; Filippo Lococo, Maria Letizia Vita, Venanzio Porziella doi:10.1510/icvts.2010.247866A We have read with interest the report by Michael Schweigert and colleagues on self-expanding stent as primary treatment of intrathoracic leak after esophagectomy w1x. Controversies still exist regarding the best treatment in cases of postesophagectomy anastomotic leak. When this complication occurs, the related mortality rate can reach more than 60% also due to lack of standardized
w1x Schweigert M, Dubecz A, Stadlhuber RJ, Muschweck H, Stein HJ. Treatment of intrathoracic esophageal anastomotic leaks by means of endoscopic stent implantation. Interact CardioVasc Thorac Surg 2011;12:147–151. w2x Whooley BP, Law S, Alexandrou A, Murthy SC, Wong J. Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer. Am J Surg 2001;181:198–203. w3x Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, van Raemdonck D. Anastomotic complications after esophagectomy. Dig Surg 2002;19; 92–98. w4x Cafarotti S, Cesario A, Porziella V, Granone P. Intrathoracic manifestations of cervical anastomotic leaks after transhiatal and transthoracic oesophagectomy. Br J Surg 2010;97:726–731.
Protocol
eComment: Treatment of thoracic anastomotic leaks after esophagectomy
References
Work in Progress Report
w1x Bonavina L, van Lanschot JJB. Complications in oesophageal and gastric surgery. Introduction. Dig Surg 2002;19:86–87. w2x Abunasra H, Lewis S, Beggs L, Duffy J, Beggs D, Morgan E. Predictors of operative death after oesophagectomy for carcinoma. Br J Surg 2005; 92:1029–1033. w3x Siewert JR, Stein HJ, Bartels H. Insuffizienzen nach Anastomosen im Bereich des oberen Gastrointenstinaltraktes. Chirurg 2004;75:1063– 1070. w4x Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10:71–75. w5x Griffin SM, Lamb PJ, Dresner SM, Richardson DL, Hayes N. Diagnosis and management of mediastinal leak following radical oesophagectomy. Br J Surg 2001;88:1346–1351. w6x Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg 1998;85:1446–1449. w7x Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, Van Raemdonck D. Anastomotic complications after esophagectomy. Dig Surg 2002;19: 92–98. w8x Kauer WK, Stein HJ, Dittler HJ, Siewert JR. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Surg Endosc 2008;22:50–53. w9x Stein HJ, Feith M, Siewert JR. Cancer of the esophagogastric junction. Surg Oncol 2000;9:35–41. w10x Stein HJ, Feith M, Siewert JR. Individualized surgical strategies for cancer of the esophagogastric junction. Ann Chir Gynaecol 2000;89: 191–198. w11x Siewert JR, Stein HJ, Sendler A, Fink U. Surgical resection for cancer of the cardia. Semin Surg Oncol 1999;17:125–131. w12x Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169:634–640. w13x Ho ¨lscher AH, Schro ¨der W, Bollschweiler E, Beckurts KTE, Schneider PM. ¨ sophagogastrostomie? Chirurg Wie sicher ist die hoch intrathorakale O 2003;74:726–733. w14x Pross M, Manger T, Reinheckel T, Mirow L, Kunz D, Lippert H. Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses. Gastrointest Endosc 2000;51:73–76. w15x Rodella L, Laterza E, De Manzoni G, Kind R, Lombardo F, Catalano F, Ricci F, Cordiano C. Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy 1998;30:453–456.
New Ideas
References
treatment algorithm w2x. The comprehensive classification from Lerut and co-workers w3x provides a good stratification in the case of esophageal fistulas. We agree with the authors that the use of modern endoscopic techniques would potentially reduce morbidity but we consider this into a multidisciplinary therapeutic algorithm based on a specific classification of the fistula that can be resumed as I) subclinical (drainage passage of methylene blue solution, without a clear radiological confirmation); II) minor (radiologically proven fistula with minor clinical complications); III) major (radiologically proven fistula with major clinical complications); IV) complete (gastric necrosis). Therefore, we generally use the self-expanding stents as primary choice only in the treatment of major intrathoracic leak or after unsuccessful conservative treatment of cervical anastomotic leaks in transhiatal esophagectomy. According to encouraging results in the closure of intrathoracic anastomotic leakage reported by the authors, it would be very useful to keep in mind the definite size of the ‘leak’ in the selection criteria for stent placement, this crucial data being not mentioned by the authors themselves. Finally, although the obvious benefits of self-expanding prosthesis in intrathoracic fistulas, we believe that transhiatal esophagectomy, when technically feasible, could represent the safest procedure to substantially decrease the mortality rate of anastomotic leaks w4x.
Editorial
was not related to the anastomotic leak but represents the extreme malignity of the underlying disease. In conclusion, this outcome study shows that successful treatment of intrathoracic anastomotic leaks after esophagectomy by means of endoscopic stent insertion is feasible with good results regarding closure of the leak and recovery of the patients.
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Intrathoracic esophagogastric anastomotic leakage following esophageal surgery Nikolaos Barbetakis, Christos Asteriou, Athanassios Kleontas and Christodoulos Tsilikas Interact CardioVasc Thorac Surg 2011;12:151DOI: 10.1510/icvts.2010.247866B This information is current as of January 26, 2011 Updated Information & Services
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