Leakage after oesophagectomy
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Leakage after oesophagectomy

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Leakage after oesophagectomy Leakage after oesophagectomy Presentation Transcript

  • Anastomotic Leakage after Oesophagectomy for Cancer: A Mortality-Free Experience Abeezar I Sarela, Damian J Tolan, Keith Harris, Simon P Dexter, Henry M Sue-Ling Departments of Upper GI Surgery & Radiology The General Infirmary at Leeds J Am Coll Surg 2008;206:516–523
  • Intra-Thoracic Oesophago-Gastric Anastomosis Routine POD #7 Gastrograffin Swallows – No Leakage 1 2 3
  • Intra-Thoracic Leakage Case # 1
    • 40 years-old man
    • IDDM
    • Morbid obesity: BMI 44
    • T2N1 adenocarcinoma – Siewert Type 1
    • Neo-adjuvant chemotherapy
    • Uneventful Ivor Lewis operation
    • POD # 2: Gastric content in chest drain
  • Early Post-operative Leakage: Limited Necrosis of Gastric Tube Repair of gastric tube around a 16Fr T-tube
  • Intra-Thoracic Leakage Case # 2
    • 72 years-old man
    • IHD, COPD
    • T3N1 adenocarcinoma – Siewert Type 1
    • Neo-adjuvant chemotherapy
    • Ivor-Lewis operation
    • Re-laparotomy - inferior epigastric artery bleeding
    • POD#3 – tachycardia, chest pain, black fluid in chest drain
    • Stage 1
    • Re-thoracotomy, excision of tube, cervical oesophagostomy
    • Stage 2
    • Retrosternal colonic transposition
    Early Post-operative Leakage: Extensive Necrosis of Gastric Tube
  • Intra-Thoracic Leakage Case #3
    • 69 years-old woman
    • No medical illness
    • T3N1 adenocarcinoma – Siewert Type 2
    • Neo-adjuvant chemotherapy
    • Uneventful Ivor Lewis operation
    • POD#7– Fever, tachycardia, ↑ WCC, ↑ CRP
  • Delayed Post-operative Leakage: Contained Sepsis, No Necrosis Leakage from anastomosis Mediastinal sinus, no cavity Anastomotic dehiscence No necrosis Non-Interventional Treatment
  • Intra-Thoracic Leakage Case#4
    • 55 years-old male
    • IHD, MI
    • T3N1 adenocarcinoma – Siewert Type II
    • Neo-adjuvant chemo-radiation
    • Uneventful Ivor Lewis operation
    • POD#2: Fast atrial fibrillation
    • POD#6: Generally unwell, uncontrolled AF
  • Delayed Post-operative Intra-Thoracic Leakage: Apical Sinus + Pleural Cavity Leakage from apex of gastric tube Cavity with air-fluid level Percutaneous drainage by interventional radiology
  • Intra-Thoracic Leakage Case # 5
    • 69 years-old man
    • Truncal vagotomy & gastrojejunostomy
    • T4N1 adenocarcinoma – Siewert II
    • Prolonged neo-adjuvant chemotherapy
    • Ivor Lewis operation
    • Immediate post-op laryngospasm – ventilation
    • POD#1 – Re-laparotomy for bile leak
    • Normal contrast swallow on POD#7
    • Sudden-onset breathlessness on POD#9
  • Delayed Post-operative Leakage: Generalised Pleural Contamination POD#8 POD#9 6.30AM POD#9 9.00PM
    • Upper GI Endoscopy: no necrosis, nasogastric tube placed
    • Thoracoscopic decortication of right lung & pleural drainage
  • Intra-Thoracic Leakage Case # 6
    • 45 year old man
    • SCC – distal oesophagus
    • Neo-adjuvant chemotherapy
    • Uneventful Ivor Lewis operation
    • Clinically well
    • Routine contrast study on POD#7
    Suspected leakage at O-G anastomosis
  • Intra-Thoracic Leakage Case # 7
    • 66 years-old man
    • IHD, COPD, mild CRF, NIDDM
    • T2NO neuroendocrine carcinoma of distal oesophagus
    • Uneventful Ivor Lewis operation
    • POD#2 – Bronchospasm, AF
    • POD#8-15: Persistent chest pain, fever,
    • ↑ WCC, ↑ CRP
  • Clinically suspected delayed post-operative leakage; Normal radiology Normal repeated contrast swallows Normal repeated cross-sectional imaging Normal Upper GI Endoscopy
  • Cervical Oesophago-Gastric Anastomosis Neck Upper chest Lower chest Abdomen Routine POD #7 Gastrograffin Swallows – No Leakage
  • Cervical Leakage
    • 50 years-old miner
    • Advanced asbestos-related COPD on steroid therapy
    • Long-segment Barrett’s oesophagus with multi-focal HGD
    • Laparoscopic trans-hiatal oesophagectomy
    • Prolonged post-op ventilation
    • Debridement & packing of infected neck wound on POD#6 + tracheostomy
  • Delayed Post-operative Cervical Anastomotic Leakage POD#12 Neck Sinus POD #17 Retro-sternal sinus POD#25 Pre-vertebral cavity
  • Implications of Anastomotic Leakage
    • Immediate
      • Prolonged hospital stay
      • Mortality
    • Delayed
      • Anastomotic stricture
      • Quality of life
      • Long-term survival
  • Oesophageal Resection for Cancer The General Infirmary at Leeds
    • June, 2002 – July, 2005
    • 126 patients (42 oesophagectomies/year)
    • Operations
      • Open Ivor Lewis 103 (82%)
      • Open transhiatal 8
      • Lap. transhiatal 11
      • Open 3-stage 4
    • In-hospital mortality = 0
    • Actual one-year survival 87%
  • Identification of Leakage
    • Discharge of saliva or GI content via a chest or neck drain
    • Infected thoracotomy or neck incision with discharge of saliva/GI content
    • Extravasation of orally administered contrast
    • Extra-luminal intra-thoracic air-fluid collection on CT scan
  • Site of Leakage
    • Oesophago-gastric anastomosis
    • Gastric linear staple-line
    • Gastric tube necrosis
    • Complex
    • Oesophago-gastro-bronchial fistula
  • Intra-Thoracic Anastomosis 103 patients
  • Intra-Thoracic Anastomotic Leakage
    • 1/3: Early post-operative (<POD 5) – careful consideration to immediate re-thoracotomy
    • 2/3: Non-early leakage (>POD5) – avoid re-operation – consider percutaneous drainage
    • 1/3: Leakage from gastric tube – re-operate – high risk of mortality
    • 2/3: Leakage from circular anastomosis – avoid re-operation – low risk of mortality
  • Oesophageal Resection for Cancer Memorial Sloan Kettering Cancer Center
    • 1996 – 2001
    • Thoracic or Cervical 510 patients
    • Volume 85 patients/year
    • Overall mortality 8%
    • Leakage 21%
    • Cervical leakage 26%
    • Thoracic leakage 17%
    • Thoracic & GMT Services
    • Rizk NP, Bach PB, Schrag D et al. J Am Coll Surg 2004;198:42-50
  • Oesophageal Resection for Cancer Queen Mary Hospital, Hong Kong
    • 1996 – 2004
    • Thoracic or cervical 218 patients
    • Volume 27 patients/year
    • Overall mortality 0.9%
    • Leakage 3%
    • Leakage-mortality 0
    • Division of Oesophageal Surgery
    • Law S, Suen DT, Wong KH et al. Arch Surg 2005;140:33-39
  • Oesophageal Resection for Cancer Royal Victoria Hospital, Newcastle
    • 1990 – 2000
    • Thoracic 291 patients
    • Volume 26 patients/year
    • Overall mortality 5.5%
    • Leakage 6.5%
    • Leakage-mortality 32%
    • Northern Oesophagogastric Unit
    • Griffin SM, Lamb PJ, Dresner SM et al. Br J Surg 2001;88:1346-1351
  • Oesophageal Resection for Cancer University of Michigan
    • 1976 – 1998
    • Cervical 800 patients
    • Volume 35 patients/year
    • Overall mortality 4.5%
    • Leakage 14%
    • Section of General Thoracic Surgery
    • Orringer MB, Marshall B, Iannettoni MD. Ann Surg 1999;230:392-403
  • Conclusions
    • Incidence of leakage
      • Acceptable 5-10%
      • High 11-20%
      • Alarm >20%
    • Recognise anatomy & patho-physiology
    • Focussed management strategy
    • Incidence of mortality
      • Ideal 0-5%
      • High 6-10%
      • Unacceptable >10%
  • Personal Lessons
    • Anticipate complications
    • Attention to detail
    • Take nothing for granted
    • Low threshold for imaging and drainage
    • Beware of cardio-pulmonary problems
    • Restrict intra-venous fluids
    • Low threshold for re-operation
  •