Modern management of anastomotic leak after esophagogastrectomy

From 1970 to 1981, 167 patients, aged 35 to 84 years (mean 61), underwent resection of 94 adenocarcinomas and 73 squamous cell cancers. The operative mortality was 8.9 percent. Anastomotic leaks occurred in 19 patients (11.3 percent), including 18 of 72 (25 percent) after operations for palliation and 1 of 95 (1 percent) after procedures with curative potential (p less than 0.01). The leakage rate after esophagogastrostomy was 8.5 percent, compared with 43 percent after interposition operations. No leak is attributed to cancer in anastomotic margins. In contrast to previous reports of greater than 50 percent mortality from leaks, only 21 percent of our patients died in the past decade. Four of 19 contained leaks (sinus tract or upper gastrointestinal) were treated nonoperatively; esophagostomy was used only once. Factors responsible for improving results include early diagnosis with routine contrast studies on the fifth to seventh postoperative days, mandatory use of total parenteral nutrition, nonoperative management of contained leaks, accurate, aggressive use of adjuvant chest tubes, and selective esophagostomy for anastomotic disruption.