Published online Jan 21, 2019. doi: 10.3748/wjg.v25.i3.356
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
Cancer of the esophagus is a highly malignant disease with a poor prognosis. Esophagectomy is still a highly invasive surgical procedure, with significant morbidity rates and mortality rates. Minimally invasive esophagectomy was introduced with the aim of improving postoperative morbidity rates, yet possibly affecting the leakage rate. In fact, anastomotic mediastinal leakage (ML) represents one of the most feared complications of esophageal resection, being associated with mediastinitis, sepsis, acute respiratory distress syndrome, prolonged hospitalization, decreased quality of life, and reduced life expectancy.
A standard strategy for both the diagnosis and treatment of MLs remains difficult to establish because the incidence, the underlying risk factors, the associated mortality rates, and the treatment strategies of MLs reported in the literature vary widely. This heterogeneity in the reported findings is partly explained by the fact that different series and studies use different definitions of ML, which make it difficult to compare their findings, and, hence, to derive clear indications regarding the best strategy for the diagnosis and treatment of MLs.
The aim of our retrospective study was to evaluate the incidence, predictive factors, treatments, and associated mortality rates of ML after transthoracic esophagectomy using a standardized and commonly agreed upon definition of ML recently proposed by the Esophagectomy Complications Consensus Group (ECCG) and relying on a large, multicenter and comprehensive dataset of esophagectomies.
The data include all transthoracic esophagectomies intrathoracic esophagogastric anastomosis performed from 2014 to 2017 in seven Italian surgical centers (5 high-volume and 2 low-volume), which form a representative sample of Italian centers with surgical teams having significant expertise in esophageal resection. A total of 501 patients were identified by retrospective review of the prospectively maintained medical databases. MLs, patient ASA score and body mass index (BMI), tumor histology and stage, use of neoadjuvant treatment, pyloric procedure, duration of surgery, surgical approach, and anastomotic technique were coded. The Mann-Whitney U test was used to compare continuous variables not normally distributed [presented as the median and interquartile range (IQR)]. The normality of the distribution of variables was determined using the D’Agostino-Pearson test. Chi-square or Fisher’s exact tests, when appropriate, were used to compare categorical variables.
The overall incidence of ML was 11.8%, with a leakage rate varying across centers from 1.6% to 20%. Leakage incidence did not correlate with center volume. The 30- and 90-d total mortality rates were 1.4% and 3.2%. Meanwhile, the 30- and 90-d leak-related mortality rates were 0.6% and 1.8%. The ASA score, tumor histology and stage, use of preoperative (neoadjuvant) treatment, and duration of surgery did not correlate with the occurrence of ML. BMI was significantly correlated with an increased risk of ML (P = 0.032). The surgical approach significantly influenced the incidence rate of ML: the proportion of leakages was 10.5% and 9% after open Ivor Lewis esophagectomy and hybrid esophagectomy, respectively, and doubled (20%) after total minimally invasive esophagectomy (P = 0.016). Conservative treatment was the first-line treatment in 13.6% of ML cases. Endoscopy was the first-line treatment in 49% of ML cases. Surgery, as a first-line treatment, consisting of surgical debridement with or without stent placement, re-anastomosis or demontage, was performed in 37.3% of patients. Endoscopy had the highest rate of retreatment (17.2%) but the lowest mortality rate (6.9%).
The main novel finding from the analysis of our series is that technical aspects of esophageal resection, more specifically the use of a minimally invasive approach, seem to be one of the two predictive factors for the occurrence of ML (BMI being the other). In contrast, other factors, such as tumor histology and stage, multimodality treatment, and duration of surgery, did not seem to influence the occurrence of this postoperative surgical complication.
Our series shows that ML occurred mainly in the group of patients undergoing totally minimally invasive esophagectomy, suggesting that technical problems during the initial phase of the learning curve are likely the main drivers behind the occurrence of ML. The take-home message of our study is that early treatment of severe leaks, presenting either directly as severe or causing persistent sepsis after initial conservative treatment, is mandatory, and that there should be no hesitation before reoperation if the first attempt of conservative management fails. Further studies using large and comprehensive datasets from other countries yet relying on the same standardized definition of ML recently proposed through international consensus by the ECCG will enable to compare different series in a meaningful way. This in turn will significantly improve the understanding of the risk factors, incidence and treatment strategies for mediastinal leaks after esophageal resection.