Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review

doi:10.1016/j.amjsurg.2014.05.011

The American Journal of Surgery

Volume 208, Issue 4, October 2014, Pages 536-543

https://doi.org/10.1016/j.amjsurg.2014.05.011 Get rights and content

Abstract

Background

Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak.

Data Sources

We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy.

Conclusions

Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.

Section snippets

Data Sources

Eligible studies for inclusion were identified using a systematic search strategy (Table 1). Titles and abstracts of 465 articles were reviewed and all English language studies examining intrathoracic esophageal anastomotic leak after esophagectomy were identified for inclusion. Articles were excluded if they were published in abstract only, reported leaks predominately for operations other than esophagectomy and esophagogastric anastomosis, were case reports with less than 3 patients, or did

Conclusions

Early recognition and appropriate management of intrathoracic anastomotic leaks have decreased leak-associated mortality, yet morbidity associated with the complication remains significant. Over the past several decades, there has been a shift in management of anastomotic leaks from aggressive surgical intervention to conservative management, and more recently to increasing utilization of endoscopic interventions. The basic principles of these management strategies remain the same, including

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While the endoscopic management of surgical complications like leaks, fistulas, and perforations is rapidly evolving, its core principles revolve around closure, drainage, and containment. Effectively managing these conditions relies on several factors, such as the underlying cause, chronicity of the lesion, tissue viability, co-morbidities, availability of devices, and expertise required to perform the endoscopy. In contrast to acute perforation, fistulas and leaks often demand a multimodal approach requiring more than one session to achieve the required results. Although the ultimate goal is complete resolution, these endoscopic interventions can provide clinical stability, enabling enteral feeding to lead to early hospital discharge or elective surgery. In this discussion, we emphasize the current state of knowledge and the prospective role of endoscopic interventions in managing surgical complications.
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We compared the clinical outcomes between endoscopic vacuum therapy (EVT) and conventional treatment (CT) for the management of post-esophagectomy anastomotic leakage.
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EVT could be considered as an adequate treatment option for post-esophagectomy anastomotic leakage. EVT might have better clinical outcomes compared to CT for managing anastomotic leakage after transthoracic esophagogastrostomy, and further studies are needed to evaluate the effectiveness of EVT in patients who undergo cervical esophagogastrostomy.
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: Supported by the National Cancer Institute of the National Institutes of Health under award numbers 5K07CA151613 (K.S.N.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Association of Women SurgeonsOptimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review

Abstract

Background

Data Sources

Conclusions

Section snippets

Data Sources

Conclusions

Tech Gastrointest Endosc

Gastrointest Endosc

Semin Thorac Cardiovasc Surg

J Gastrointest Surg

Ann Thorac Surg

Surgery

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Clin Gastroenterol Hepatol

Am J Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Adv Surg

Gastrointest Endosc

Gastrointest Endosc

J Gastrointest Surg

J Gastrointest Surg

Ann Thorac Surg

Anastomotic complications after esophagectomy

Dig Surg

Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume centre

Eur J Cardiothorac Surg

Association of Women Surgeons
Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review