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©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 21, 2019; 25(3): 356-366
Published online Jan 21, 2019. doi: 10.3748/wjg.v25.i3.356
Incidence and treatment of mediastinal leakage after esophagectomy: Insights from the multicenter study on mediastinal leaks
Uberto Fumagalli, Gian Luca Baiocchi, Andrea Celotti, Paolo Parise, Andrea Cossu, Luigi Bonavina, Daniele Bernardi, Giovanni de Manzoni, Jacopo Weindelmayer, Giuseppe Verlato, Stefano Santi, Giovanni Pallabazzer, Nazario Portolani, Maurizio Degiuli, Rossella Reddavid, Stefano de Pascale
Uberto Fumagalli, Department of Digestive Surgery, IEO European Institute of Oncology IRCCS, Milano 20141, Italy
Gian Luca Baiocchi, Nazario Portolani, Department of Clinical and Experimental Studies, Surgical Clinic, University of Brescia, Brescia 25123, Italy
Andrea Celotti, Stefano de Pascale, General Surgery 2, ASST Spedali Civili di Brescia, Brescia 25123, Italy
Paolo Parise, Andrea Cossu, Department of Gastrointestinal Surgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milano 20132, Italy
Luigi Bonavina, Daniele Bernardi, Department of Surgery, IRCCS Policlinico San Donato, University of Milan, Milano 20122, Italy
Giovanni de Manzoni, Jacopo Weindelmayer, General and Upper GI Surgery Division, University of Verona, Verona 37134, Italy
Giuseppe Verlato, Department of Diagnostics and Public Health, University of Verona, Verona 37134, Italy
Stefano Santi, Giovanni Pallabazzer, Esophageal Surgery Unit, Tuscany Regional Referral Center for the Diagnosis and Treatment of Esophageal Disease, Cisanello Hospital, Pisa 56124, Italy
Maurizio Degiuli, Rossella Reddavid, University of Turin, Department of Oncology, Surgical Oncology and Digestive Surgery, San Luigi University Hospital, Orbassano 10043, Italy
Author contributions: Fumagalli U and de Pascale S conceived and designed the study; Fumagalli U implemented the study and drafted the article; Celotti A made substantial contributions to the acquisition and analysis of data; Baiocchi GL made substantial contributions to the analysis and interpretation of data; Verlato G reviewed the statistical analysis. All authors substantially contributed to the interpretation of data, made critical revisions related to important intellectual content of the manuscript, and approved the final version of the manuscript.
Institutional review board statement: The publication of this manuscript has been reviewed and approved by the institutional review board of the Department of Clinical and Experimental Sciences of the University of Brescia, Brescia, Italy.
Informed consent statement: Patients were not required to provide informed consent to this study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors have received no funding and declare no conflicts of interest in relation to this specific work.
Data sharing statement: No additional data are available.
Open-Access: This is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Uberto Fumagalli, MD, Director, Surgical Oncologist, Department of Digestive Surgery, IEO European Institute of Oncology IRCCS, Via Ripamonti 435, Milano 20141, Italy. ubertofumagalliromario@gmail.com
Telephone: +39-2-57489680 Fax: +39-2-57489930
Received: October 22, 2018
Peer-review started: October 22, 2018
First decision: November 29, 2018
Revised: January 4, 2019
Accepted: January 9, 2019
Article in press: January 9, 2019
Published online: January 21, 2019
BACKGROUND
Mediastinal leakage (ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has been difficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.
AIM
To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group (ECCG).
METHODS
Seven Italian surgical centers (five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies (n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017. Anastomotic MLs were defined according to the classification recently proposed by the ECCG.
RESULTS
Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8% (95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy (HE), respectively, and doubled (20%) after totally minimally invasive esophagectomy (TMIE) (P = 0.016). No other predictive factors were found. The 30- and 90-d overall mortality rates were 1.4% and 3.2%, respectively; the 30- and 90-d leak-related mortality rates were 5.1% and 10.2%, respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%, respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases. Endoscopic treatment had the lowest mortality rate (6.9%). Removal of the gastric tube with stoma formation was necessary in 8 (13.6%) cases.
CONCLUSION
The incidence of ML after esophagectomy was high mainly in the TMIE group. However, the general and specific (leak-related) mortality rates were low. Early treatment (surgical or endoscopic) of severe leaks is mandatory to limit related mortality.
Core tip: Anastomotic mediastinal leaks represent one of the most feared complications of esophageal resection. The incidence of mediastinal leaks and their associated mortality rates are reported with great variability, and a standard strategy for the diagnosis and treatment has been difficult to establish. Data on all esophagectomies performed in seven Italian centers from 2014 to 2017 were collected and analyzed. The two take-home messages of our multicenter retrospective study are as follows: (1) the surgical approach significantly influenced the rate of mediastinal leaks, with the highest leakage rate occurring after totally minimally invasive esophagectomy and lowest rate occurring after hybrid esophagectomy; and (2) early (surgical or endoscopic) treatment of mediastinal leaks is an essential tool to address this complication and prevent other major complications of esophagectomy.
