Analysis of cervical esophagogastric anastomotic leaks after transhiatal esophagectomy: risk factors, presentation, and detection.
BACKGROUND
Transhiatal esophagectomy with cervical esophagogastric anastomosis is a common approach in patients requiring esophagectomy. Factors for developing cervical esophagogastric anastomosis leaks (CEGAL), their presentation, and the value of a routine postoperative screening barium swallow in detecting CEGALs and other complications were analyzed.


METHODS
This single-institution retrospective study used medical records and an esophagectomy database to assess results in 1,133 patients who underwent transhiatal esophagectomy and a cervical esophagogastric anastomosis, 241 for benign disease and 892 for cancer, between January 1996 and December 2006.


RESULTS
Esophagectomy patients who experienced CEGALs included 127 (14.2%) with cancer and 23 (9.5%) with benign disease. Logistic regression analysis identified increasing number of preoperative comorbidities (p < 0.001), active smoking history (p = 0.044), and postoperative arrhythmia (p = 0.002) as risk factors for CEGALs, and a side-to-side stapled cervical esophagogastric anastomosis compared with a manually sewn one as protective (p < 0.001). For cancer patients, higher pathologic stage disease (p = 0.050) was a risk factor for CEGALs. For patients with benign disease, a higher number of prior esophagogastric operations (p = 0.007) is a risk factor for CEGALs. Of the 90.7% of CEGALs that occurred on or before postoperative day 10, cervical wound drainage (63.3%) was the most common presenting symptom. Screening barium swallow identified postoperative complications and influenced outcome in 39 patients (3.8%).


CONCLUSIONS
Higher number of preoperative comorbidities, advanced pathologic stage, postoperative arrhythmia, an increased number of prior esophagogastric surgeries, and active smoking history are risk factors for developing CEGAL, and a side-to-side stapled cervical esophagogastric anastomosis is protective. Screening barium swallow identifies few postoperative complications, but provides quality control.
Cooke
David T
DT
Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan 48109, USA.
Lin
Giant C
GC
Lau
Christine L
CL
Zhang
Linda
L
Si
Ming-Sing
MS
Lee
Julia
J
Chang
Andrew C
AC
Pickens
Allan
A
Orringer
Mark B
MB
D000368:Aged; D000704:Analysis of Variance; D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods; D001466:Barium Sulfate; D015331:Cohort Studies; D004502:Education, Medical, Continuing; D004935:Esophageal Diseases / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery; D016629:Esophagectomy / Q000009:adverse effects* / Q000379:methods; D004943:Esophagogastric Junction / Q000473:pathology / Q000601:surgery*; D004945:Esophagoscopy / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000601:surgery*; D011336:Probability; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D017792:Surgical Stapling; D015996:Survival Rate; D016896:Treatment Outcome
D001466:Barium Sulfate