Abstract
ObjectiveTo develop a CT-based prediction score for anastomotic leakage after esophagectomy and compare it to subjective CT interpretation.MethodsConsecutive patients who underwent a CT scan for a clinical suspicion of anastomotic leakage after esophagectomy with cervical anastomosis between 2003 and 2014 were analyzed. The CT scans were systematically re-evaluated by two radiologists for the presence of specific CT findings and presence of an anastomotic leak. Also, the original CT interpretations were acquired. These results were compared to patients with and without a clinical confirmed leak.ResultsOut of 122 patients that underwent CT for a clinical suspicion of anastomotic leakage; 54 had a confirmed leak. In multivariable analysis, anastomotic leakage was associated with mediastinal fluid (OR = 3.4), esophagogastric wall discontinuity (OR = 4.9), mediastinal air (OR = 6.6), and a fistula (OR = 7.2). Based on these criteria, a prediction score was developed resulting in an area-under-the-curve (AUC) of 0.86, sensitivity of 80%, and specificity of 84%. The original interpretation and the systematic subjective CT assessment by two radiologists resulted in AUCs of 0.68 and 0.75 with sensitivities of 52% and 69%, and specificities of 84% and 82%, respectively.ConclusionThis CT-based score may provide improved diagnostic performance for diagnosis of anastomotic leakage after esophagectomy.Key Points• A CT-based score provides improved diagnostic performance for diagnosis of anastomotic leakage.• Leakage associations include mediastinal fluid, mediastinal air, wall discontinuity, and fistula.• A scoring system yields superior diagnostic accuracy compared to subjective CT assessment.• Radiologists may suggest presence of anastomotic leakage based on a prediction score.
Highlights
Materials and methodsEsophageal cancer is the sixth leading cause of cancer-related mortality worldwide and the incidence rate is rapidly increasing [1]
283 were excluded because there was no clinically suspected leak (n = 238), no computed tomography (CT) scan was performed in case of a suspected anastomotic leak (n = 43) or the CT scan was of insufficient quality (n = 2)
The ALP scoring system improved the AUC (0.86 versus 0.75 and 0.68) with an net reclassification index (NRI) of 12.5% (p = 0.008) and 27.7% (p < 0.001) for the detection of anastomotic leakage compared to the systematic subjective CT assessment and original CT interpretation, respectively (Table 4). These findings indicate that with the ALP score 11.1% and 27.7% of the patients with definite anastomotic leakage, and 1.4% and 0% of patients without leakage were better classified compared to the systematic subjective CT assessment and original CT interpretation, respectively (Fig. 3)
Summary
Materials and methodsEsophageal cancer is the sixth leading cause of cancer-related mortality worldwide and the incidence rate is rapidly increasing [1]. Despite advances in surgical treatment and improvement in perioperative care, anastomotic leakage remains a frequently encountered complication after esophagectomy with reported frequency rates of up to 30% [2, 5]. Detection of anastomotic leakage is crucial, since delayed treatment is associated with significant morbidity, prolonged hospital stay, and mortality [6,7,8,9]. Several diagnostic modalities are available in case anastomotic leakage is clinically suspected, such as contrast swallow examination, endoscopy, or computed tomography (CT). Contrast swallow examinations are widely performed in order to assess anastomotic integrity. Contrast swallow examinations are very specific, multiple studies have shown that they are of poor sensitivity, failing to identify significant anastomotic leaks [10,11,12,13]. Most physicians are reluctant to utilize endoscopic examination early after esophagectomy as this invasive procedure may damage the anastomosis
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