Relationship of drain amylase and anastomotic leak after esophagectomy.

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118 Background: Esophagectomy is considered the only curative approach in patients with esophageal cancers without locally advanced or metastasis. Anastomotic leak can lead to significant morbidity and mortality. CT esophagram (CTE) is a sensitive method of evaluating for leak; however this test carries with it financial cost and radiation exposure. This study evaluates the utility of drain amylase in the prediction of anastomotic leak. Methods: Fifty-nine patients underwent esophagectomy between 3/10 and 8/12; serial drain amylases and CTE were obtained in 50. Leak was defined by extravasation of contrast or the presence of empyema on CTE. Elevated drain amylase was defined as any level > 400 IU/L. Chi-square and descriptive statistics were performed and the sensitivity of drain amylase >400 IU/L in predicting leak was calculated. Results: A minimally invasive esophagectomy was performed in 47, and an open Ivor-Lewis in 2 and a minimally invasive Ivor-Lewis in 1. Stapled intra-thoracic anastomoses were performed in 47, 3 had a cervical anastomoses. Average age was 61 years and 84% were males. Leak occurred in 6 patients (12.5%). One patient with a late leak was excluded from analysis as they did not have concurrent drain amylase values. This patient had low amylase levels and a normal CTE, though later presented with leak. The overall peri-operative mortality rate was 4.2% (2/48). Mortality in the non-leak and leak cohorts were 0% & 33%. Drain amylase was an accurate marker of anastomotic leak. Of 6 patients with an elevated drain amylase, 5 had an anastomotic leak (sensitivity 83.3%). 40/41 patients with low drain amylase had no leak. Using a cut-off value of 400 IU/L, the negative predictive value of drain amylase in predicting leak after esophagectomy was 97.6% (95%CI; 85.6, 99.9). Conclusions: Drain amylase is a simple and inexpensive test that has excellent sensitivity and negative prediction for the detection of anastomotic leak after esophagectomy. To our knowledge, this is the first study to demonstrate this finding. Routine evaluation of drain amylase may safely replace CTE in the management of patients after esophagectomy, thus reducing radiation exposure and overall cost.