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Anastomotic Leakage after Oesophagectomy for Cancer: A Mortality-Free Experience Abeezar I Sarela, Damian J Tolan, Keith H...
Intra-Thoracic Oesophago-Gastric Anastomosis Routine POD #7 Gastrograffin Swallows – No Leakage 1 2 3
Intra-Thoracic Leakage Case # 1 <ul><li>40 years-old man </li></ul><ul><li>IDDM </li></ul><ul><li>Morbid obesity: BMI 44 <...
Early Post-operative Leakage:  Limited Necrosis of Gastric Tube Repair of gastric tube around a 16Fr T-tube
Intra-Thoracic Leakage Case # 2 <ul><li>72 years-old man </li></ul><ul><li>IHD, COPD </li></ul><ul><li>T3N1 adenocarcinoma...
<ul><li>Stage 1 </li></ul><ul><li>Re-thoracotomy, excision of tube, cervical oesophagostomy </li></ul><ul><li>Stage 2 </li...
Intra-Thoracic Leakage Case #3 <ul><li>69 years-old woman </li></ul><ul><li>No medical illness </li></ul><ul><li>T3N1 aden...
Delayed Post-operative Leakage: Contained Sepsis, No Necrosis  Leakage from anastomosis Mediastinal sinus, no cavity Anast...
Intra-Thoracic Leakage Case#4 <ul><li>55 years-old male </li></ul><ul><li>IHD, MI </li></ul><ul><li>T3N1 adenocarcinoma – ...
Delayed Post-operative Intra-Thoracic Leakage: Apical Sinus + Pleural Cavity Leakage from apex of gastric tube Cavity with...
Intra-Thoracic Leakage Case # 5 <ul><li>69 years-old man </li></ul><ul><li>Truncal vagotomy & gastrojejunostomy </li></ul>...
Delayed Post-operative Leakage: Generalised Pleural Contamination  POD#8 POD#9 6.30AM POD#9 9.00PM <ul><li>Upper GI Endosc...
Intra-Thoracic Leakage Case # 6 <ul><li>45 year old man </li></ul><ul><li>SCC – distal oesophagus </li></ul><ul><li>Neo-ad...
Intra-Thoracic Leakage Case # 7 <ul><li>66 years-old man </li></ul><ul><li>IHD, COPD, mild CRF, NIDDM </li></ul><ul><li>T2...
Clinically suspected delayed post-operative leakage; Normal radiology Normal repeated contrast swallows Normal repeated cr...
Cervical Oesophago-Gastric Anastomosis Neck Upper chest Lower chest Abdomen Routine POD #7 Gastrograffin Swallows – No Lea...
Cervical Leakage <ul><li>50 years-old miner </li></ul><ul><li>Advanced asbestos-related COPD on steroid therapy </li></ul>...
Delayed Post-operative Cervical Anastomotic Leakage POD#12 Neck Sinus  POD #17 Retro-sternal sinus POD#25 Pre-vertebral ca...
Implications  of Anastomotic Leakage <ul><li>Immediate </li></ul><ul><ul><li>Prolonged hospital stay </li></ul></ul><ul><u...
Oesophageal Resection for Cancer The General Infirmary at Leeds <ul><li>June, 2002 – July, 2005 </li></ul><ul><li>126 pati...
Identification of Leakage <ul><li>Discharge of saliva or GI content via a chest or neck drain </li></ul><ul><li>Infected t...
Site of Leakage <ul><li>Oesophago-gastric anastomosis </li></ul><ul><li>Gastric linear staple-line </li></ul><ul><li>Gastr...
Intra-Thoracic Anastomosis 103 patients
Intra-Thoracic Anastomotic Leakage <ul><li>1/3: Early post-operative (<POD 5) – careful consideration to immediate  re-tho...
Oesophageal Resection for Cancer Memorial Sloan Kettering Cancer Center   <ul><li>1996 – 2001 </li></ul><ul><li>Thoracic o...
Oesophageal Resection for Cancer Queen Mary Hospital, Hong Kong <ul><li>1996 – 2004 </li></ul><ul><li>Thoracic or cervical...
Oesophageal Resection for Cancer Royal Victoria Hospital, Newcastle <ul><li>1990 – 2000 </li></ul><ul><li>Thoracic 291  pa...
Oesophageal Resection for Cancer  University of Michigan <ul><li>1976 – 1998 </li></ul><ul><li>Cervical 800  patients </li...
Conclusions <ul><li>Incidence of leakage </li></ul><ul><ul><li>Acceptable 5-10% </li></ul></ul><ul><ul><li>High 11-20% </l...
Personal Lessons <ul><li>Anticipate complications </li></ul><ul><li>Attention to detail </li></ul><ul><li>Take nothing for...
 
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Leakage after oesophagectomy

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Transcript of "Leakage after oesophagectomy"

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