Anastomotic leak post eosphagectomy
The management of an anastomotic leak post eosphagectomy is a condition associated with a high morbidity and mortality. The diagnosis can be obvious, though it can present in a number of unusual ways:
Pleural effusion
Pneumothorax
Pain
Pyrexia
Atrial fibrillation
Collapse
Unwell
High white cell count
Increasing acidoisis
Pulmonary deterioration
BASICALLY ANY UNEXPECTED CAUSE IN THE DETERIORATION OF A PATIENT POST EOSPHAGECTOMY CAN BE CAUSED BY AN ANASTOMOTIC LEAK AND SHOULD PROMPT THE PERFORMANCE OF A CONTRAST SWALLOW.
Anastomotic leaks can be classified into cervical and intrathoracic
Cervical leaks can be managed conservatively if the leak is small, the patient is well and their is no mediastinal spread, by TPN or distal enteral feeding and opening the neck incision.
Intrathoracic leaks, unless discovered incidentally on a contrast study in a completely well patient, should probably mainly be managed operatively. We have found that contrast studies generally underestimate the size of the anastomotic leak.
Virtually all anastomotic leaks are caused by vascular ischaemia of the oesophageal replacement conduit, which is usually the stomach. This means that operative intervention rarely will consist of simply putting in a couple of extra stitches.
Operative management
Original wound is reopened
The pleural cavity is cleaned out
The anastomosis is inspected to assess the cause of the leak
Only rarely will a re anastomosis be performed as often the operating area is contaminated and the patients are quite often grossly septic and haemodynamically unstable.
The anastomosis is quite often taken down and the proximal oesophagus is stapled closed.
The oesphageal replacement conduit is then stapled through at a level that has an obvious good blood supply.
This is then dropped back into the abdomen.
A feeding jejunostomy is inserted
The cervical oesophagus is mobilised via a neck incision for for a fistula
The patient is then closed up and transferred back to the ITU.