TreatmENT of AnastomotiC Leakage After Esophagectomy

2. INTRODUCTION AND RATIONALE

The incidence of esophageal cancer is increasing, with an estimated annual incidence of 480.000 cases worldwide [Jemal 2011]. Esophagectomy remains the cornerstone of curative treatment, often in combination with chemotherapy or chemoradiotherapy. However, esophagectomy is associated with considerable morbidity and anastomotic leakage is a severe postoperative complication.

Anastomotic leakage is defined as a "full thickness gastrointestinal defect involving esophagus, anastomosis, staple line, or conduit irrespective of presentation or method of identification" according to the Esophagectomy Complications Consensus Group (ECCG) definition [Low 2015]. Anastomotic leakage has been described to occur in 0-30%. If anastomotic leakage occurs, it is associated with mortality rates ranging from 2% - 12% [Biere 2011, Saluja 2012]. In addition, it is often associated with a prolonged ICU treatment, hospital length of stay and multiple reinterventions [Lubbers 2019, submitted]. The impact of anastomotic leakage on quality of life is high and it is associated with a substantial burden in terms of hospital resources and costs [Biere 2011, Alanezi 2004, Luketich 2012, Blackmon 2007].

Treatment of anastomotic leakage ranges from conservative management (nil per mouth, antibiotics and nasogastric tube drainage) to radiologic drainage, endoscopic treatment with stents, drains or endoVAC (Vacuum Assisted Closure) systems, and surgical exploration. A recent systematic review performed by our group assessed the current literature for studies that specifically reported on specific therapies and outcome of anastomotic leakage [Verstegen 2018, submitted]. Nineteen studies with 273 patients were included and studies were of low to moderate quality. No meta-analysis was performed because of substantial clinical heterogeneity of the included studies. The main conclusion of the review was that due to small cohorts and clinical heterogeneity no evidence based treatment strategy could be composed from the current literature. A retrospective multicenter study of 79 patients revealed that the used treatment modality of an anastomotic leakage is not only patient dependent, but also hospital dependent [Lubbers 2019, submitted]. Until now the management of an anastomotic leakage is more or less based on expert opinion rather than on an evidence-based anastomotic leakage treatment algorithm. From these studies, it became evident that the absence of an anastomotic leakage severity score complicates performing robust research on this topic.

Anastomotic leakage severity is currently graded according to how it is treated (grade I: conservative treatment, grade II endoscopic or radiologic intervention and grade III surgical intervention) [Low 2015]. Although this scoring system is useful for reporting the consequences of anastomotic leakage, by definition it cannot be used to guide decision making when anastomotic leakage is diagnosed in a clinical setting. Examples of factors that may influence the severity of the anastomotic leakage are location of the anastomosis (intrathoracic or cervical), circumference of the defect, surface of the defect, extent of contamination (i.e. local, mediastinal, intrathoracic), degree of sepsis and time from diagnosis until therapy. However, little is known about to what extent these and other factors contribute to anastomotic leakage severity. In addition, there is a paucity of data on what leakage characteristics dictate the success of a specific treatment.