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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
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O-G Leakage
Routine POD#7 Gastrograffin Swallows – No Leakage
1 2 3
Intra-Thoracic Oesophago-Gastric Anastomosis
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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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O-G Leakage
Repair of gastric tube around a 16Fr T-tube
Early Post-operative Leakage: Limited Necrosis of Gastric Tube
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O-G Leakage
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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O-G Leakage
• 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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O-G Leakage
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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O-G Leakage
Delayed Post-operative Leakage: Contained Sepsis, No Necrosis
Leakage from anastomosisMediastinal sinus, no cavity
Anastomotic dehiscenceNo necrosis
Non-Interventional Treatment
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O-G Leakage
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
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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
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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
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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
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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
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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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O-G Leakage
Normal repeated contrast swallowsNormal repeated cross-sectional imaging
Normal Upper GI Endoscopy
Clinically suspected delayed post-operative leakage; Normal radiology
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O-G Leakage
Neck Upper chest Lower chest Abdomen
Cervical Oesophago-Gastric Anastomosis
Routine POD#7 Gastrograffin Swallows – No Leakage
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O-G Leakage
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
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O-G Leakage
POD#12Neck Sinus
POD #17Retro-sternal sinus
POD#25Pre-vertebral cavity
Delayed Post-operative Cervical Anastomotic Leakage
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O-G Leakage
Implications of Anastomotic Leakage
• Immediate– Prolonged hospital stay
– Mortality
• Delayed– Anastomotic stricture
– Quality of life
– Long-term survival
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O-G Leakage
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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O-G Leakage
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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O-G Leakage
Site of Leakage
• Oesophago-gastric anastomosis
• Gastric linear staple-line
• Gastric tube necrosis
• Complex
• Oesophago-gastro-bronchial fistula
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O-G Leakage
Intra-Thoracic Anastomosis103 patients
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O-G Leakage
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
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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
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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
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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
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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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O-G Leakage
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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O-G Leakage
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