Failure of Endo-VAC or Stenting Therapy after Oesophageal Anastomotic Insufficiency - How to Avoid Oesophagectomy

Abstract

Oesophageal anastomotic leak after oesophagectomy is a severe complication and associated with a high mortality rate. Initial treatment is conservative and includes stent implantation or endo-VAC therapy. This study describes a combined treatment strategy of endoscopic and surgical management after failure of conservative management. All patients were included who had been treated after oesophagectomy with gastric conduit reconstruction in our department of thoracic surgery between May 2008 and December 2016. Clinical data was evaluated from a prospectively acquired database. We surgically managed these patients with a combination of oesophageal stent implantation, transmural stent fixation with absorbable suture, stent coverage with muscle flap, radical debridement of mediastinal and pleural empyema and discontinuous pleural space irrigation, when conservative management failed. We evaluated the factors influencing mortality rate after surgical treatment of anastomotic insufficiency repair. 18 patients were introduced to our department after external failure of conservative therapy. 15 patients were introduced < 20 days after conservative therapy and three cases after > 20 days of conservative therapy. All patients presented with right sided pleural empyema, pneumonia, mediastinitis and sepsis. Three cases were accompanied by bilateral pleural empyema. Definitive successful surgical reconstruction occurred in 100%. The 90-day mortality rate was 20% (three patients), who died because of multi-organ failure. Oesophageal anastomotic leak after oesophagectomy can be managed successfully by the combined treatment strategy of endoscopic and surgical procedures following failure of conservative treatment. The only factor influencing mortality seems to be a prolonged conservative therapy of more than 20 days.