The clinical presentation of leak varies depending on the location of anastomotic site and the importance of anastomotic dehiscence. The first evocative elements of leaks are postoperative fever and leukocytosis. Importantly, the presence of septic signs in the early postoperative period is a high index of suspicion of anastomotic leak. The diagnosis of leak is easier when anastomosis is located in the neck. Erythema, induration and fluctance development along the cervical incision often announces an underlying leak of cervical anatomosis. The presence of saliva or air in the cervical drain signifies a likely anastomotic leak and the diagnosis becomes obvious. In case of intrathoracic anastomosis, the development of pleural effusion in immediate postoperative days, particularly in the vicinity of the anastomosis should be considered as a leak until proved otherwise. The diagnosis of leak may be obvious and certain if presence of bile or saliva in the thoracic drainage. However the differential diagnosis arises with the chylothorax in the presence of pleural effusion and further investigations are necessary to accurate the diagnosis. Contrast study has been commonly used to detect anastomotic leak following esophageal reconstruction. It provides an assessment of anastomotic integrity and additional informations on the contour, straightness and emptying of the transposed graft. The contrast study is often performed between 5 and 8 postoperative days which correspond to time period of the development of most leaks.
The management of leak depends on the anastomosis location; the extent of anastomotic dehiscence; the adequacy of graft perfusion; the involvement of adjacent organs such as the airway and lung; the severity of sepsis and the hemodynamic stability of patient.
The cervical anastomotic leak is generally confined to the cervical soft tissue with less risk of intrathoracic or mediastinal extension. However leak of anastomosis located in the lower area of the neck immediately obvious to the sternal manubrium can extend to the mediastinum resulting in extensive mediastinitis. The cervical leak is often treated conservatively and in the presence of abscess, wound opening, packing and drainage become more necessary to avoid intrathoracic or mediastinal diffusion. The spontaneous closure is often obtained after introduction of nutritional support and suspension of oral intake. Enteral feeding is the first choice because of its efficiency and safety [18-21].
The intrathoracic leak is less common than the cervical leak. However leak in the chest can result in severe sepsis and mediastinitis. The treatment of intrathoracic leak is not standardized and there is a controversy about the most effective treatment method. Therefore the strategy of management is guided by the severity of clinical signs, magnitude of leak, patient conditions and experience of surgeon.
Several factors can impact the anastomotic healing including patient or systemic factors and technical or surgical factors (Table 1).Preoperative identification of predisposing factors to anastomotic leak, optimization of the modifiable patient risk factors and meticulous surgical technique are highly recommended to reduce the risk of leak.
| Patient factors
_ Severe malnutrition
_ Renal insufficiency
_ Heart failure
_ Coronary disease
_ Vascular disease
_ Graft ischemia and necrosis
_ Venous compromise
_ Extrinsic compression
_ Graft distention
_ Radiation therapy
_ Anastomotic tension
_ Anastomotic location
_ Anastomotic technique
_ Route of reconstruction
Healing process of esophageal anastomosis can be impaired by well-known multiple patient factors [8,34]. These risk factors include:
Severe malnutrition is associated with high rate of anastomotic leak and sepsis. The definition of severe malnutrition varied, however a weight loss greater than 20% of usual body weight or a serum albumin less than 3.0 g/dL are commonly accepted criteria to determine a severe nutritional depletion , and studies demonstrated that low serum albumin (< 3.5 g/dL) has been found to be an independent predictor of anastomotic leak . Esophageal surgical patients are often nutritionally depleted because they have a poor oral intake related to dysphagia or anorexia from an underlying esophageal malignant conditions and effects of chemo radiation therapy. Therefore the preoperative nutritional status evaluation is highly recommended in these patients to detect malnutrition. Correction of severe malnutrition prior to surgery is highly recommended by authors and acceptable nutritional patient conditions is primordial to improve surgical outcomes particularly surgical site infections, infectious complications [37-41]. The introduction of preoperative nutritional supports were greatly debated and their use is supported by most published studies only in patients with severe malnutrition [19, 38-40].
Blood supply to the graft is an important paramount in esophageal reconstruction. Preventing perioperative hypotension and hypovolemia is primordial to maintain a good graft perfusion [35, 45-47]. Although the definition of hypotension and the assessment of hypovolemia are not precise, perioperative hypotension and use of inotropes have been shown to be an independent predictive factors of anastomotic leak and patients who required inotropic support or developed hypotension in the postoperative period had a risk of leak four and three times greater respectively .
Several factors contribute to the development of anastomotic leak but surgical technique and in adequacy of graft blood supply are the major contributing factors esophageal leaks.
Adequacy perfusion of digestive graft and esophageal remnant is the most important factors impacting the esophago-digestive anastomotic integrity. However graft ischemia or necrosis remain the most important causes of leaks and graft blood supply insufficiency is the major cause of ischemia and necros is. The blood supply of the esophageal segment remaining after resection of diseased esophagus is not usually a concern for surgeon. However, the vasculature of esophageal extremity to be anastomosed with graft may be impaired and thus predisposing to anastomotic leak, if a long portion of esophagus has been mobilized during esophageal dissection. Ischemia of the proximal part of graft is a major risk factor for poor anastomotic healing.
Careful surgical technique reconstruction of anastomosis is an important technical paramount when reconstructing a gastrointestinal anastomosis.
Anastomotic tension is a detrimental factor for anastomotic healing and integrity of anastomosis. Anastomotic tension results in impairment of tissue healing and increasing risk of ischemia of fundal tip and proximal extremity of colon graft. Therefore the creation of a gastric graft or the selection of colon graft with adequate length in order to easily reach the neck is important paramount to perform a free tension cervical anastomosis. An appropriately created gastric tube has a sufficient length to reach cervical level without excessive tension. However, the reconstruction distance must be measured intra operatively to select a colon graft with appropriate length.
A variety of methods to construct the anastomosis between esophagus and digestive graft exists and includes hand-sewn (continuous or interrupted, single- or double-layer), stapled (circular or linear), and hybrid approaches combining sutures and staples. In addition, the anastomosis can be performed in an end-to-end, end-to-side, or side-to-side fashion. Regardless of the used technique, meticulous and careful reconstruction of anastomosis includes the incorporation of all layers of the esophagus and digestive graft walls, avoiding excessive tissue strangulation and creating a watertight closure with free tension. Choosing an anastomotic technique depends on the surgeon preference and operative conditions and surgeon is able to apply the best one in any specific situation. Multiple studies have investigated anastomotic leak by comparing various anastomotic techniques. The recent reported meta-analysis comparing completely hand-sewn and linear stapled techniques found lower leak rates with linear stapled anastomosis . However no difference in leak rates between linear and circular stapled anastomoses was found in reported meta-analysis . Independently of the used technique to reconstruct anastomosis, the leak incidence of cervical anastomosis is higher than that of intrathoracic anastomosis [61,62].
The graft placement during esophageal reconstruction is an important factor in the development of anastomotic leaks. Compared to posterior mediastinum, the substernal route is associated with higher leak rate of cervical anastomosis [3,67] and some reports revealed that the substernal route was a predisposing factor for cervical leak [3,68]. The substernal route has two major disadvantages; it is the longer route with potential risk of graft compression at the level of thoracic inlet. Therefore the longer distance of reconstruction and the risk of graft compression are the major causes of the high incidence of cervical leak during substernal graft interposition [69-72]. Many authors suggested to enlarge the thoracic inlet during substernal digestive graft interposition following esophagectomy [69-73]. The posterior route or posterior mediastinum is shorter, direct without angulations and it is the preferred route for immediate reconstruction after esophagectomy. However substernal route is used in delayed reconstruction or when posterior mediastinum is technically inaccessible.
The author has no conflict of interest to report
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