Summary
Background
Esophagojejunal anastomosis leakage (EAL) after total gastrectomy for gastric adenocarcinoma represents one of the most serious complications, with increased mortality rates and prolonged hospital stay after surgery. Treatment options include conservative management, endoscopic therapy, and surgery. The aim of the study was to present our experience in the management of this fatal complication.
Patients and methods
From 2000 to 2016, we retrospectively reviewed all cases of EAL after total gastrectomy treated in our institution. The diagnosis of leakage was based on a combination of clinical and radiological findings. The type of treatment, postoperative stay, complications, cure, and mortality rates were analyzed.
Results
EAL was diagnosed in 32 patients (9.5%), of whom 24 (75%) recovered with conservative therapy and two (6.2%) with OVESCO OTSC placement. The other six patients (18.8%) underwent surgery: two cases of abdominal drainage, two cases of primary repair, and two cases of reconstruction of anastomosis. Overall treatment was successful in 26 patients (81.2%) while mortality occurred in six cases (18.8%).
Conclusion
Conservative management of EAL is an option for clinically stable patients with small leakages with a high rate of cure. Re-operation results in a high mortality rate and should only be considered when conservative management is not successful or in very unstable patients.
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References
Japanese Gastric Cancer Association. Japanese gastric cancer treatment guidelines 2010 (ver. 3). Gastric Cancer. 2011;14:113–23.
Roder JD, Böttcher K, Siewert JR, et al. Prognostic factors in gastric carcinoma. Results of the German Gastric Carcinoma Study 1992. Cancer. 1993;72(7):2089–97.
An JY, Kim KM, Kim YM, et al. Surgical complications in gastric cancer patients preoperatively treated with chemotherapy: their risk factors and clinical relevance. Ann Surg Oncol. 2012;19(8):2452–8.
Planells Roig MV, López Martínez C, Ballester C, et al. Factores predictivos de mortalidad en pacientes sometidos a gastrectomía total por adenocarcinoma gástrico. Cir Esp. 1998;64:129–35.
East German Study Group for Quality Control in Operative Medicine and Regional Development in Surgery, Meyer L, Meyer F, Dralle H, et al. Insufficiency risk of esophagojejunal anastomosis after total abdominal gastrectomy for gastric adenocarcinoma. Langenbecks Arch Surg. 2005;390:510–6.
Sauvanet A, Mariette C, Thomas P, et al. Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors. J Am Coll Surg. 2005;201:253–62.
Lang H, Piso P, Stukenborg C, et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol. 2000;26(2):168–71.
Ichikawa D, Kurioka H, Yamaguchi T, et al. Postoperative complications following gastrectomy for gastric cancer during the last decade. Hepatogastroenterology. 2004;51:613–7.
Deguchi Y, Fukagawa T, Morita S, et al. Identification of risk factors for esophagojejunal anastomotic leakage after gastric surgery. World J Surg. 2012;36(7):1617–22.
Sierzega M, Kolodziejczyk P, Kulig J, and the Polish Gastric Cancer Study Group. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg. 2010;97(7):1035–42.
Robb WB, Messager M, Goere D, et al. Predictive factors of postoperative mortality gastric adenocarcinoma. JAMA Surg. 2013;148(7):624–31.
Yoo HM, Lee HH, Shim JH, et al. Negative impact of leakage on survival of patients undergoing curative resection for advanced gastric cancer. J Surg Oncol. 2011;104:734–40.
Ruiz de Adana JC, Ortega Deballon P, Alonso Garcia MT, et al. Morbimortalidad atribuible a la fístula esofagoyeyunal tras gastrectomía total por cáncer gástrico. Cir Esp. 2001;70:3–5.
Persson S, Rouvelas I, Kumagai K, et al. Treatment of esophageal anastomotic leakage with self-expanding metal stents: analysis of risk factors for treatment failure. Endosc Int Open. 2016;4(4):E420–E6.
Bruce J, Krukowski ZH, Al-Khairy G, et al. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. Br J Surg. 2001;88:1157–68.
Carboni F, Valle M, Federici O, et al. Esophagojejunal anastomosis leakage after total gastrectomy for esophagogastric junction adenocarcinoma: options of treatment. J Gastrointest Oncol. 2016;7(4):515–22.
Schuchert MJ, Abbas G, Nason KS, et al. Impact of anastomotic leak on outcomes after transhiatal esophagectomy. Surgery. 2010;148:831–8. discussion 838–40.
Lee S, Ahn JY, Jung HY, et al. Clinical outcomes of endoscopic and surgical management for postoperative upper gastrointestinal leakage. Surg Endosc. 2013;27(11):4232–40.
Aurello P, Magistri P, D’Angelo F, et al. Treatment of esophagojejunal anastomosis leakage: a systematic review from the last twodecades. Am Surg. 2015;81(5):450–3.
Tonouchi H, Mohri Y, Tanaka K, et al. Diagnostic sensitivity of contrast swallow for leakage after gastric resection. World J Surg. 2007;31(1):128–31.
Lamb PJ, Griffin SM, Chandrashekar MV, et al. Prospective study of routine contrast radiology after total gastrectomy. Br J Surg. 2004;91(8):1015–9.
Migita K, Takayama T, Matsumoto S, et al. Risk factors for esophagojejunal anastomotic leakage after elective gastrectomy for gastric cancer. J Gastrointest Surg. 2012;16(9):1659–65.
Upponi S, Ganeshan A, D’Costa H, et al. Radiological detection of post-oesophaguectomy anastomotic leak—a comparison between multidetector CT and fluoroscopy. Br J Radiol. 2008;81:545–8.
Wang Q, Liu ZS, Qian Q, et al. Treatment of upper gastrointestinal fistula and leakage with personal stage nutrition support. World J Gastroenterol. 2008;14(32):5073–7.
Kim YJ, Shin SK, Lee HJ, et al. Endoscopic management of anastomotic leakage after gastrectomy for gastric cancer: how efficacious is it? Scand J Gastroenterol. 2013;48:111–8.
Kumar N, Thompson CC. Endoscopic therapy for postoperative leaks and fistulae. Gastrointest Endosc Clin N Am. 2013;23:123–36.
Dişibeyaz S, Köksal AŞ, Parlak E, et al. Endoscopic closure of gastrointestinal defects with an over-the-scope clip device. A case series and review of the literature. Clin Res Hepatol Gastroenterol. 2012;36:614–21.
Lee HL, Cho JY, Cho JH, et al. Efficacy of the over-the-scope clip system for treatment of gastrointestinal fistulas, leaks, and perforations: a Korean multi-center study. Clin Endosc. 2018;51(1):61–5. https://doi.org/10.5946/ce.2017.027.
Kobara H, Mori H, Fujihara S, et al. Outcomes of gastrointestinal defect closure with an over-the-scope clip system in a multicenter experience: an analysis of a successful suction method. World J Gastroenterol. 2017;23(9):1645–56.
Mizrahi I, Eltawil R, Haim N, et al. The clinical utility of over-the-scope clip for the treatment of gastrointestinal defects. J Gastrointest Surg. 2016;20(12):1942–9.
Raimondo D, Sinagra E, Facella T, et al. Self-expandable metal stent placement for closure of a leak after total gastrectomy for gastric cancer: report on three cases and review of the literature. Case Rep Gastrointest Med. 2014;2014:409283.
Shim CN, Kim HI, Hyung WJ, et al. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc. 2014;28:833–40.
Kumar N, Thompson CC. Endoscopic therapy for postoperative leaks and fistulae. Gastrointest Endosc Clin N Am. 2013;23:123–36.
Van Boeckel PG, Dua KS, Weusten BL, et al. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol. 2012;12:19.
Hoeppner J, Kulemann B, Seifert G, et al. Covered selfexpanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses. Surg Endosc. 2014;28:1703–11.
Feith M, Gillen S, Schuster T, et al. Healing occurs in most patients that receive endoscopic stents for anastomotic leakage; dislocation remains a problem. Clin Gastroenterol Hepatol. 2011;9:202–10.
Fischer A, Bausch D, Richter-Schrag HJ. Use of a specially designed partially covered self-expandable metal stent (PSEMS) with a 40-mm diameter for the treatment of upper gastrointestinal suture or staple line leaks in 11 cases. Surg Endosc. 2013;27:642–7.
Kucukay F, Okten RS, Parlak E, et al. Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas. Abdom Imaging. 2013;38:244–8.
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P. Priego, P. Giordano, M. Cuadrado, A. Ballestero, J. Galindo, and E. Lobo declare that they have no competing interests.
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The study was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki. All persons gave their informed consent prior to their inclusion in the study.
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Priego, P., Giordano, P., Cuadrado, M. et al. Management of esophagojejunal anastomosis leakage after total gastrectomy. Eur Surg 50, 262–269 (2018). https://doi.org/10.1007/s10353-018-0556-7
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DOI: https://doi.org/10.1007/s10353-018-0556-7