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Routine Radiologic Assessment for Anastomotic Leak Is Not Necessary in Asymptomatic Patients After Esophagectomy for Esophageal Cancer

  • Original Article
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Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Anastomotic leaks (AL) are a major source of post-esophagectomy morbidity and patients are often initially asymptomatic. Debate exists on timing and utility of imaging to detect AL post-esophagectomy. We sought to evaluate the efficacy and timing of radiographic AL evaluation in esophageal cancer patients post-esophagectomy.

Methods

A retrospective database of esophageal cancer patients who underwent esophagectomy at a single institution from 2004 to 2020 was used to determine the utilization, timing, and sensitivity of radiologic testing for AL post-esophagectomy.

Results

Seventy-six patients were identified of which 37 (49%) had a cervical anastomosis. Sixty-four (84%) underwent 71 “asymptomatic radiographic leak tests” (ARLT), 7 of which had 2 different tests, including: 41 fluoroscopic esophagrams (58%), 18 CT-esophagrams (25%), and 12 upper GI studies (17%). Seventeen patients (22%) developed clinical signs of AL (hemodynamic instability, leukocytosis) and underwent “symptomatic radiographic leak tests” (SRLT) with fluoroscopic esophagram (n = 9, 12%), CT-esophagram (n = 7, 9%), or upper GI study (n = 1, 1%). ARLT and SRLT were positive in 2/64 (3%) and 17/17 (100%) patients, respectively, for 19 total ALs (25%). Among the 17 SRLT( +) patients, 1 was also ARLT( +), 13 were initially ARLT( −), and 3 were not evaluated by ARLT. The median postoperative day for ARLT and SRLT was 4.0 (IQR 3.0–5.5) and 9.0 days (IQR 6.0–13.0), respectively, with a statistically significant difference (p < 0.005). The sensitivity and specificity of ARLT for detecting AL were 13.3% and 100.0%, respectively.

Conclusions

Based on the low ARLT sensitivity, routine use of imaging to detect asymptomatic ALs post-esophagectomy may be limited. Symptomatic ALs were often present in a delayed fashion, even after initial negative imaging.

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References

  1. American Cancer Society. Cancer Facts & Figures 2021. American Cancer Society; 2021.

  2. Tepper J, Krasna MJ, Niedzwiecki D, et al. Phase III trial of trimodality therapy with cisplatin, fluorouracil, radiotherapy, and surgery compared with surgery alone for esophageal cancer: CALGB 9781. J Clin Oncol. 2008;26(7):1086-1092. https://doi.org/10.1200/JCO.2007.12.9593

    Article  CAS  PubMed  Google Scholar 

  3. Shapiro J, van Lanschot JJB, Hulshof MCCM, et al. Neoadjuvant chemoradiotherapy plus surgery versus surgery alone for oesophageal or junctional cancer (CROSS): long-term results of a randomised controlled trial. Lancet Oncol. 2015;16(9):1090-1098. https://doi.org/10.1016/S1470-2045(15)00040-6

    Article  PubMed  Google Scholar 

  4. Agzarian J, Visscher SL, Knight AW, et al. The cost burden of clinically significant esophageal anastomotic leaks—a steep price to pay. J Thorac Cardiovasc Surg. 2019;157(5):2086-2092. https://doi.org/10.1016/j.jtcvs.2018.10.137

    Article  PubMed  Google Scholar 

  5. Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg. 2004;10(2):5.

    Google Scholar 

  6. Fabbi M, Hagens ERC, van Berge Henegouwen MI, Gisbertz SS. Anastomotic leakage after esophagectomy for esophageal cancer: definitions, diagnostics, and treatment. Dis Esophagus. 2020;34(1):1-14. https://doi.org/10.1093/dote/doaa039

    Article  Google Scholar 

  7. Martin LW, Swisher SG, Hofstetter W, et al. Intrathoracic leaks following esophagectomy are no longer associated with increased mortality. Ann Surg. 2005;242(3):392-402. https://doi.org/10.1097/01.sla.0000179645.17384.12

    Article  PubMed  PubMed Central  Google Scholar 

  8. Agha FP, Orringer MB, Amendola MA. Gastric interposition following transhiatal esophagectomy: radiographic evaluation. Gastrointest Radiol. 1985;10(1):17-24. https://doi.org/10.1007/BF01893064

    Article  CAS  PubMed  Google Scholar 

  9. Cools-Lartigue J, Andalib A, Abo-Alsaud A, et al. Routine contrast esophagram has minimal impact on the postoperative management of patients undergoing esophagectomy for esophageal cancer. Ann Surg Oncol. 2014;21(8):2573-2579. https://doi.org/10.1245/s10434-014-3654-1

    Article  PubMed  Google Scholar 

  10. Solomon DG, Sasaki CT, Salem RR. An evaluation of the routine use of contrast radiography as a screening test for cervical anastomotic integrity after esophagectomy. Am J Surg. 2012;203(4):467-471. https://doi.org/10.1016/j.amjsurg.2011.04.005

    Article  PubMed  Google Scholar 

  11. Hu Z, Wang X, An X, Li W, Feng Y, You Z. The diagnostic value of routine contrast esophagram in anastomotic leaks after esophagectomy. World J Surg. 2017;41(8):2062-2067. https://doi.org/10.1007/s00268-017-3923-9

    Article  CAS  PubMed  Google Scholar 

  12. Jones CM, Clarke B, Heah R, Griffiths EA. Should routine assessment of anastomotic integrity be undertaken using radiological contrast swallow after oesophagectomy with intra-thoracic anastomosis? Best evidence topic (BET). Int J Surg. 2015;20:158-162. https://doi.org/10.1016/j.ijsu.2015.06.076

    Article  PubMed  Google Scholar 

  13. Jones CM, Heah R, Clarke B, Griffiths EA. Should routine radiological assessment of anastomotic integrity be performed after oesophagectomy with cervical anastomosis? Best evidence topic (BET). Int J Surg. 2015;15:90-94. https://doi.org/10.1016/j.ijsu.2015.01.034

    Article  PubMed  Google Scholar 

  14. Li C, Ferri LE, Mulder DS, et al. An enhanced recovery pathway decreases duration of stay after esophagectomy. Surgery. 2012;152(4):606-616. https://doi.org/10.1016/j.surg.2012.07.021

    Article  PubMed  Google Scholar 

  15. Nevo Y, Arjah S, Katz A, et al. ERAS 2.0: Continued refinement of an established enhanced recovery protocol for esophagectomy. Ann Surg Oncol. 2021;28(9):4850–4858. https://doi.org/10.1245/s10434-021-09854-7

  16. Page RD, Shackcloth MJ, Russell GN, Pennefather SH. Surgical treatment of anastomotic leaks after oesophagectomy. Eur J Cardiothorac Surg. 2005;27(2):337-343. https://doi.org/10.1016/j.ejcts.2004.10.053

    Article  PubMed  Google Scholar 

  17. Linn S, Grunau PD. New patient-oriented summary measure of net total gain in certainty for dichotomous diagnostic tests. Epidemiol Perspect Innov. 2006;3(11). https://doi.org/10.1186/1742-5573-3-11

  18. Haisley KR, DeSouza ML, Dewey EN, et al. Assessment of routine esophagram for detecting anastomotic leak after esophagectomy. JAMA Surg. 2019;154(9):879. https://doi.org/10.1001/jamasurg.2019.2162

    Article  PubMed  PubMed Central  Google Scholar 

  19. Ben-David K, Fullerton A, Rossidis G, et al. Prospective comprehensive swallowing evaluation of minimally invasive esophagectomies with cervical anastomosis: silent versus vocal aspiration. J Gastrointest Surg. 2015;19(10):1748-1752. https://doi.org/10.1007/s11605-015-2889-x

    Article  PubMed  Google Scholar 

  20. Park JK, Kim JJ, Moon SW. C-reactive protein for the early prediction of anastomotic leak after esophagectomy in both neoadjuvant and non-neoadjuvant therapy case: a propensity score matching analysis. J Thorac Dis. 2017;9(10):3693-3702. https://doi.org/10.21037/jtd.2017.08.125

    Article  PubMed  PubMed Central  Google Scholar 

  21. Barrie J, Cockbain A, Tsachiridi M, Surendrakumar V, Maxwell M, Tamhankar A. Predicting delayed complications after esophagectomy in the current era of early discharge and enhanced recovery. Am Surg. 2020;86(6):615-620. https://doi.org/10.1177/0003134820923314

    Article  CAS  PubMed  Google Scholar 

  22. Zhang C, Li XK, Hu LW, et al. Predictive value of postoperative C-reactive protein-to-albumin ratio in anastomotic leakage after esophagectomy. J Cardiothorac Surg. 2021;16(1):133. https://doi.org/10.1186/s13019-021-01515-w

    Article  PubMed  PubMed Central  Google Scholar 

  23. Low DE, Allum W, De Manzoni G, et al. Guidelines for Perioperative Care in Esophagectomy: Enhanced Recovery After Surgery (ERAS®) Society recommendations. World J Surg. 2019;43(2):299-330. https://doi.org/10.1007/s00268-018-4786-4

    Article  PubMed  Google Scholar 

  24. Parise P, Ferrari C, Cossu A, et al. Enhanced Recovery After Surgery (ERAS) pathway in esophagectomy: is a reasonable prediction of hospital stay possible? Ann Surg. 2019;270(1):77-83. https://doi.org/10.1097/SLA.0000000000002775

    Article  PubMed  Google Scholar 

  25. Findlay JM, Gillies RS, Millo J, Sgromo B, Marshall REK, Maynard ND. Enhanced recovery for esophagectomy: a systematic review and evidence-based guidelines. Ann Surg. 2014;259(3):413-431. https://doi.org/10.1097/SLA.0000000000000349

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. University of Florida College of Medicine, Gainesville, FL, USA

    Hansol Kang

  2. Department of Surgery, Mount Sinai Medical Center, Miami Beach, FL, USA

    Kfir Ben-David

  3. Section of General Surgery, North Florida/South Georgia Veterans Health System, Gainesville, FL, USA

    George A. Sarosi & Ryan M. Thomas

  4. Department of Surgery, University of Florida College of Medicine, PO Box 100109, Gainesville, FL, 32610, USA

    George A. Sarosi & Ryan M. Thomas

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  1. Hansol Kang
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  2. Kfir Ben-David
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Correspondence to Ryan M. Thomas.

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Kang, H., Ben-David, K., Sarosi, G.A. et al. Routine Radiologic Assessment for Anastomotic Leak Is Not Necessary in Asymptomatic Patients After Esophagectomy for Esophageal Cancer. J Gastrointest Surg 26, 279–285 (2022). https://doi.org/10.1007/s11605-021-05219-3

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