O-G Leakage

Anastomotic Leakage after Oesophagectomy

for Cancer: A Mortality-Free Experience

Abeezar I Sarela, Damian J Tolan, Keith Harris, Simon P Dexter, Henry M Sue-Ling

Departments of Upper GI Surgery & RadiologyThe General Infirmary at Leeds

J Am Coll Surg 2008;206:516–523

O-G Leakage

Routine POD#7 Gastrograffin Swallows – No Leakage

1 2 3

Intra-Thoracic Oesophago-Gastric Anastomosis

O-G Leakage

Intra-Thoracic LeakageCase # 1

• 40 years-old man

• IDDM

• Morbid obesity: BMI 44

• T2N1 adenocarcinoma – Siewert Type 1

• Neo-adjuvant chemotherapy

• Uneventful Ivor Lewis operation

• POD # 2: Gastric content in chest drain

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Repair of gastric tube around a 16Fr T-tube

Early Post-operative Leakage: Limited Necrosis of Gastric Tube

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Intra-Thoracic LeakageCase # 2

• 72 years-old man• IHD, COPD• T3N1 adenocarcinoma – Siewert Type 1• Neo-adjuvant chemotherapy • Ivor-Lewis operation• Re-laparotomy - inferior epigastric artery

bleeding

• POD#3 – tachycardia, chest pain, black fluid in chest drain

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• Stage 1

Re-thoracotomy, excision of tube, cervical oesophagostomy

• Stage 2

Retrosternal colonic transposition

Early Post-operative Leakage: Extensive Necrosis of Gastric Tube

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Intra-Thoracic LeakageCase#3

• 69 years-old woman

• No medical illness

• T3N1 adenocarcinoma – Siewert Type 2

• Neo-adjuvant chemotherapy

• Uneventful Ivor Lewis operation

• POD#7– Fever, tachycardia, ↑ WCC, ↑ CRP

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Delayed Post-operative Leakage: Contained Sepsis, No Necrosis

Leakage from anastomosisMediastinal sinus, no cavity

Anastomotic dehiscenceNo necrosis

Non-Interventional Treatment

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Intra-Thoracic LeakageCase#4

• 55 years-old male

• IHD, MI

• T3N1 adenocarcinoma – Siewert Type II

• Neo-adjuvant chemo-radiation

• Uneventful Ivor Lewis operation

• POD#2: Fast atrial fibrillation

• POD#6: Generally unwell, uncontrolled AF

O-G Leakage

Leakage from apex of gastric tube Cavity with air-fluid level

Percutaneous drainage by interventional radiology

Delayed Post-operative Intra-Thoracic Leakage: Apical Sinus + Pleural Cavity

O-G Leakage

Intra-Thoracic LeakageCase # 5

• 69 years-old man• Truncal vagotomy & gastrojejunostomy• T4N1 adenocarcinoma – Siewert II• Prolonged neo-adjuvant chemotherapy• Ivor Lewis operation• Immediate post-op laryngospasm – ventilation• POD#1 – Re-laparotomy for bile leak• Normal contrast swallow on POD#7• Sudden-onset breathlessness on POD#9

O-G Leakage

POD#8 POD#9 6.30AM POD#9 9.00PM

1. Upper GI Endoscopy: no necrosis, nasogastric tube placed2. Thoracoscopic decortication of right lung & pleural drainage

Delayed Post-operative Leakage: Generalised Pleural Contamination

O-G Leakage

Intra-Thoracic LeakageCase # 6

• 45 year old man• SCC – distal

oesophagus• Neo-adjuvant

chemotherapy• Uneventful Ivor Lewis

operation• Clinically well• Routine contrast

study on POD#7Suspected leakage at O-G anastomosis

O-G Leakage

Intra-Thoracic LeakageCase # 7

• 66 years-old man• IHD, COPD, mild CRF, NIDDM• T2NO neuroendocrine carcinoma of distal

oesophagus• Uneventful Ivor Lewis operation• POD#2 – Bronchospasm, AF• POD#8-15: Persistent chest pain, fever,

↑ WCC, ↑ CRP

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Normal repeated contrast swallowsNormal repeated cross-sectional imaging

Normal Upper GI Endoscopy

Clinically suspected delayed post-operative leakage; Normal radiology

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Neck Upper chest Lower chest Abdomen

Cervical Oesophago-Gastric Anastomosis

Routine POD#7 Gastrograffin Swallows – No Leakage

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Cervical Leakage

• 50 years-old miner• Advanced asbestos-related COPD on steroid

therapy• Long-segment Barrett’s oesophagus with multi-

focal HGD• Laparoscopic trans-hiatal oesophagectomy• Prolonged post-op ventilation• Debridement & packing of infected neck wound

on POD#6 + tracheostomy

O-G Leakage

POD#12Neck Sinus

POD #17Retro-sternal sinus

POD#25Pre-vertebral cavity

Delayed Post-operative Cervical Anastomotic Leakage

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Implications of Anastomotic Leakage

• Immediate– Prolonged hospital stay

– Mortality

• Delayed– Anastomotic stricture

– Quality of life

– Long-term survival

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Oesophageal Resection for CancerThe General Infirmary at Leeds

• June, 2002 – July, 2005• 126 patients (42 oesophagectomies/year)• Operations

– Open Ivor Lewis 103 (82%)– Open transhiatal 8– Lap. transhiatal 11– Open 3-stage 4

• In-hospital mortality = 0• Actual one-year survival 87%

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Identification of Leakage

• Discharge of saliva or GI content via a chest or neck drain

• Infected thoracotomy or neck incision with discharge of saliva/GI content

• Extravasation of orally administered contrast

• Extra-luminal intra-thoracic air-fluid collection on CT scan

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Site of Leakage

• Oesophago-gastric anastomosis

• Gastric linear staple-line

• Gastric tube necrosis

• Complex

• Oesophago-gastro-bronchial fistula

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Intra-Thoracic Anastomosis103 patients

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Intra-Thoracic Anastomotic Leakage

• 1/3: Early post-operative (<POD 5) – careful consideration to immediate re-thoracotomy

• 2/3: Non-early leakage (>POD5) – avoid re-operation – consider percutaneous drainage

• 1/3: Leakage from gastric tube – re-operate – high risk of mortality

• 2/3: Leakage from circular anastomosis – avoid re-operation – low risk of mortality

O-G Leakage

Oesophageal Resection for CancerMemorial Sloan Kettering Cancer Center

• 1996 – 2001• Thoracic or Cervical 510 patients

• Volume 85 patients/year

• Overall mortality 8%• Leakage 21%• Cervical leakage 26%• Thoracic leakage 17%

Thoracic & GMT ServicesRizk NP, Bach PB, Schrag D et al. J Am Coll Surg 2004;198:42-50

O-G Leakage

Oesophageal Resection for CancerQueen Mary Hospital, Hong Kong

• 1996 – 2004• Thoracic or cervical 218 patients

• Volume 27 patients/year

• Overall mortality 0.9%• Leakage 3%• Leakage-mortality 0

Division of Oesophageal SurgeryLaw S, Suen DT, Wong KH et al. Arch Surg 2005;140:33-39

O-G Leakage

Oesophageal Resection for CancerRoyal Victoria Hospital, Newcastle

• 1990 – 2000• Thoracic 291 patients

• Volume 26 patients/year

• Overall mortality 5.5%

• Leakage 6.5%

• Leakage-mortality 32%

Northern Oesophagogastric Unit

Griffin SM, Lamb PJ, Dresner SM et al. Br J Surg 2001;88:1346-1351

O-G LeakageOesophageal Resection for Cancer

University of Michigan

• 1976 – 1998

• Cervical 800 patients

• Volume 35 patients/year

• Overall mortality 4.5%

• Leakage 14%

Section of General Thoracic Surgery

Orringer MB, Marshall B, Iannettoni MD. Ann Surg 1999;230:392-403

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Conclusions

• Incidence of leakage– Acceptable 5-10%– High 11-20%– Alarm >20%

• Recognise anatomy & patho-physiology• Focussed management strategy• Incidence of mortality

– Ideal 0-5%– High 6-10%– Unacceptable >10%

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Personal Lessons

• Anticipate complications

• Attention to detail

• Take nothing for granted

• Low threshold for imaging and drainage

• Beware of cardio-pulmonary problems

• Restrict intra-venous fluids

• Low threshold for re-operation

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