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
Mediastinal leakage (ML) is one of the most feared complications of esophagectomy. A standard strategy for its diagnosis and treatment has been difficult to establish because of the great variability in their incidence and mortality rates reported in the existing series.
To assess the incidence, predictive factors, treatment, and associated mortality rate of mediastinal leakage using the standardized definition of mediastinal leaks recently proposed by the Esophagectomy Complications Consensus Group (ECCG).
Seven Italian surgical centers (five high-volume, two low-volume) affiliated with the Italian Society for the Study of Esophageal Diseases designed and implemented a retrospective study including all esophagectomies (n = 501) with intrathoracic esophagogastric anastomosis performed from 2014 to 2017. Anastomotic MLs were defined according to the classification recently proposed by the ECCG.
Fifty-nine cases of ML were recorded, yielding an overall incidence of 11.8% (95%CI: 9.1%-14.9%). The surgical approach significantly influenced the occurrence of ML: the proportion of leakage was 10.5% and 9% after open and hybrid esophagectomy (HE), respectively, and doubled (20%) after totally minimally invasive esophagectomy (TMIE) (P = 0.016). No other predictive factors were found. The 30- and 90-d overall mortality rates were 1.4% and 3.2%, respectively; the 30- and 90-d leak-related mortality rates were 5.1% and 10.2%, respectively; the 90-d mortality rates for TMIE and HE were 5.9% and 1.8%, respectively. Endoscopy was the first-line treatment in 49% of ML cases, with the need for retreatment in 17.2% of cases. Surgery was needed in 44.1% of ML cases. Endoscopic treatment had the lowest mortality rate (6.9%). Removal of the gastric tube with stoma formation was necessary in 8 (13.6%) cases.
The incidence of ML after esophagectomy was high mainly in the TMIE group. However, the general and specific (leak-related) mortality rates were low. Early treatment (surgical or endoscopic) of severe leaks is mandatory to limit related mortality.
Core tip: Anastomotic mediastinal leaks represent one of the most feared complications of esophageal resection. The incidence of mediastinal leaks and their associated mortality rates are reported with great variability, and a standard strategy for the diagnosis and treatment has been difficult to establish. Data on all esophagectomies performed in seven Italian centers from 2014 to 2017 were collected and analyzed. The two take-home messages of our multicenter retrospective study are as follows: (1) the surgical approach significantly influenced the rate of mediastinal leaks, with the highest leakage rate occurring after totally minimally invasive esophagectomy and lowest rate occurring after hybrid esophagectomy; and (2) early (surgical or endoscopic) treatment of mediastinal leaks is an essential tool to address this complication and prevent other major complications of esophagectomy.