198. IDENTIFYING THE OPTIMAL MANAGEMENT OF ESOPHAGEAL ANASTOMOTIC LEAKS. A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

Abstract

Abstract Background There is currently no consensus as to how best to manage esophageal anastomotic leaks. Intervention with Endoscopic Vacuum Assisted Closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. Consequently, we aimed to conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. Methods A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. Results In total, 12 retrospective studies were included which included 511 patients. Of the 449 patients for whom data was available 371 (82.6%) were male, and 78 (17.4%) were female. The average age of patients was 62.6 years (Standard deviation (SD) 10.2). Overall, 94.5% of patients underwent initial esophagectomy for an underlying malignancy. The average Body Mass Index (BMI) reported was 25.9 kg/m2. The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The re-operation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (Odds ratio (OR) 0.23 95% confidence interval (CI) 0.09-0.58). EVAC had a significantly lower mortality rate than stenting (OR: 0.43, 95% CI 0.21; 0.87). Re-operation was used in significantly larger leaks than stenting (mean difference (MD) 14.66; 95%CI 4.61 24.70). Re-operation was also associated with a significantly increased mortality rate (OR: 2.66, 95% CI: 1.01-6.99.). Using stenting as a comparator, NMA failed to demonstrate a significant difference between interventions in terms of success rate. However, EVAC had the greatest difference in success rate (OR: 2.23, 95% CI 0.78-6.34). Conclusion The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. One aspect of EVT that was not examined in this study was the number of endoscopic interventions required. Sponge exchanges every 48 to 72 hours are necessary during EVT whereas stents may be left in place for 4-8 weeks. This may have significant implications for treatment choice in resource-limited settings and may have a profound impact on patient quality of life. Surgical management is often necessary for significantly larger leaks. Reoperation in the case of anastomotic leak is often the intervention of choice in systemically unwell patients and those with uncontained leaks. It therefore stands to reason that mortality rates are elevated among this patient cohort and differences in outcome are unlikely to be attributable to the modality of intervention alone.