Abstract
Abstract Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge despite advancements in surgical techniques and investigation modalities. We seek to identify key clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries in our practice. 592 patients underwent UGI surgeries with an anastomosis in a single center between January 2011 and Jan 2021. The cohort comprises were 237 (40.0%) distal gastrectomies, 120 (20.3%) total gastrectomies, 104 (17.6%) Roux-en-y bariatric bypasses, 53 (9.0%) Ivor-Lewis esophagectomies, 41 (6.9%) proximal gastrectomies, 17 (2.8%) palliative gastro-jejunostomies and 20 (3.4%) Mckeown esophagectomies. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed. The overall occurrence of AL was 6.4%. AL was highest in esophagectomies (13.7%) and total gastrectomies (10.0%). Clinical parameters associated with AL include HR >120 BPM, desaturation, bilious or food contents in drain and leukocytosis. On multivariate analysis, HR >120 BPM and leukocyte count >19x1000000000/L were independent predictors of AL. Patients with high-risk anastomosis who had pre-emptive investigations, were more likely to be managed with antibiotics instead of requiring invasive therapy (p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had respective false negatives of 50.0%, 20.0% and 9.1%, while esophagogastroduodenoscopy had none. Our study demonstrates that the presence of a triad including desaturation, tachycardia and leukocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed to exclude a AL. A practice of evaluating high risk anastomosis prior to feeding decreases need for surgical intervention and improves the chances of successful conservative treatment.
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