Esophagectomy and esophagogastric anastomotic procedures were performed in 875 patients for esophageal or esophagogastric junction cancer at our institution of Hebei General Hospital from January 2008 to December 2019. Of these patients, 56 (6.4%) patients were diagnosed with anastomotic leak. 13 patients were excluded because of simplex cervical anastomotic leaks, who were cured by opening of the wound and daily irrigation and packing. Eventually, 43(4.9%) patients developed intrathoracic anastomotic leaks postoperatively were enrolled into our study and their clinical data were retrospectively evaluated. All of them appeared mediastinitis and empyema. 23 cases underwent an McKeown esophagectomy with cervical anastomosis, 8 cases underwent an Ivor-Lewis esophagectomy and 12 cases underwent a Sweet esophagectomy with intrathoracic anastomosis. 28 patients had esophageal cancer and 15 patients had esophagogastric junction cancer. 28 male and 15 female, age from 52-74,average age 64.5±4.7. The stomach was mobilized and was used as a standard organ to reconstruct the continuity of the digestive tract in all patients. The anastomosis was performed via staplers in all 43 patients. The patients were divided into two groups according to the different treatments they received. 20 (47%) patients from January 2008 to December 2012 received conventional treatments (group 1), and 23 (53%) patients from January 2013 to December 2019 received new treatments (group 2),consisted of conventional therapies and the nasogastric placement of sump drainage tube through fistula into abscess cavity. Anastomotic leak was detected and confirmed by radiographic water-soluble iodine contrast esophagography when leak was under suspicion. The median time to confirmation of a significant leak was 6 days after surgery (range, 3–9 days). In all patients with intrathoracic anastomotic leaks, conservative methods of treatment were chosen, consisted of absence of oral intake, nasogastric suction drainage, enteral nutrition, antibiotic therapy, and drainage of the infected material through chest tube. This study was reviewed and approved by the institutional review board of the Hebei General Hospital.
The following patient characteristics were reviewed: age, gender, pathologic findings, chemoradiotherapy history, accompanying diseases, operation method, type of anastomosis location, timing of diagnosis and treatment of the leak, hospital mortality, and duration of hospitalization. The basic characteristics of the enrolled patients were shown in Table 1.
Table.1 The patients characteristics.
Patients’ characteristics
|
|
conventional treatments (group 1) (n=20)
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new treatments (group 2)(n=23)
|
P value
|
Age
|
|
64.2±4.8
|
65.1±4.2
|
P=0.259
|
Gender
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male
|
12
|
16
|
P=0.733
|
|
female
|
8
|
7
|
|
Cancer type
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Esophageal cancer
|
13
|
15
|
P=0.780
|
|
Esophagogastric junction cancer
|
7
|
8
|
|
Neoadjuvant chemotherapy
|
|
5
|
6
|
P=0.936
|
Comorbidity
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hypertension
|
6
|
7
|
P=0.895
|
|
diabetes
|
4
|
5
|
P=0.936
|
Anastomosis location
|
cervical anastomosis
|
8
|
15
|
P=0.818
|
|
intrathoracic anastomosis
|
10
|
8
|
|
Operation method
|
McKeown esophagectomy
|
8
|
15
|
P=0.611
|
|
Ivor-Lewis esophagectomy
|
4
|
4
|
|
|
Sweet esophagectomy
|
6
|
4
|
|
Timing of diagnosis
|
|
6.3
|
5.8
|
P=0.09
|
Operation and postoperative care.
For all patients, esophagectomy and esophagogastric anastomosis were performed. We used a circular mechanical stapler for anastomosis. A nasogastric decompression tube and thoracic and mediastinal drainage tubes were routinely placed during the procedure. The intubated patients were monitored in intensive care unit postoperatively. Following extubation, all patients stayed in intensive care unit for at least 24 hours. The patients who were stable were transferred to our thoracic surgical ward. All patients were treated with fasting, gastrointestinal decompression, parenteral nutrition, antacids, and broad-spectrum antibiotics. If the clinical situation of the patient was stable, Water-soluble iodine contrast esophagography wloud be routinely performed on the 5th-7th postoperative day. If purulent drainage, fever, dyspnea, empyema, or wound infection possibly related to fistula were observed, Water-soluble iodine contrast esophagography was given immediately in order to confirm anastomosis leakage. When anastomotic leak was confirmed, all patients were placed with naso-jejunum three lumen feeding tube under the radiographic or gastroscopic guidance. This tube not only ensures enteral nutrition, but also provides gastrointestinal decompression(Fig.1,B;Fig.3,B). If there was no fever, leukocytosis, dyspnea , purulent drainage, the chest tube was removed. The mediastinal drainage tube was not removed until oral feeding. All patients were followed up for at least six months in the outpatient department.
Conventional managements (group 1)
20 (47%) patients from January 2008 to December 2012 received conventional treatments (group 1). when intrathoracic anastomosis leak was confirmed, naso-jejunum three lumen feeding tube was placed under the radiographic or gastroscopic guidance. The functions of this tube include nasogastric decompression and nasojejunum enteral nutritional support. The chest drainage tubes should usually be placed under the guidance of ultrasonography. These patients were treated by the traditional “three-tube method”, In addition, other treatments, such as fasting, broad spectrum antibiotics and antacids, were routinely performed. When the patients became stable, a contrast esophagography was performed every other week. Those patients whose leaks are confirmed to have been healed radiologically may start oral feeding.
New managements(group 2)
23 (53%) patients from January 2013 to December 2019 received new treatments (group 2). Intrathoracic anastomotic leak was identified by radiographic water-soluble iodine contrast esophagography when leak was under suspicion. In addition to the conventional treatments previously described, A sump drainage tube was introduced through the nose, remanet esophagus and inserted through the fistula into mediastinum with the guidance of radiography or gastroscopy. The distal tip of the sump drainage tube should be positioned at the bottom of the abscess cavity (Fig. 1,A;Fig,2,A). Continuous suction with a negative pressure should be achieved for effective drainage. Contrast esophagography should be repeated once a week for treatment effect evaluation. The nasogastric sump drainage tube was used as the perianastomotic drain, which had multiple side holes. The drain position was checked under radiography by the injection of contrast medium through the tube. When the reduction of the cavity size was observed, the sump drainage tube was then retreated gradually. The sump drainage tube was pulled of 1-2 cm every 2-3 days until the tip of the tube was retreated to the esophageal cavity, the tube was removed. After termination of therapy, Contrast esophagography was performed once again to confirm the closure of the anastomotic leak . Thereafter, oral intake was gradually started.
Statistical analysis
Statistical analysis was performed with SPSS version 21.0 software (IBM Corporation, Armonk, NY). Continuous variables were expressed as the means±SD, and categorical variables were expressed as percentages. A two independent samples t test was used for intergroup comparisons of the continuous variables, whereas X2 test or Fisher’s exact test was used to compare the categorical data. All tests were two-sided, P<0.05 was considered statistically significant.