Role of Barium Swallow in Diagnosing Clinically Significant Anastomotic Leak following Esophagectomy

Abstract

Background: Barium swallow is performed following esophagectomy to evaluate the anastomosis for detection of leaks and to assess the emptying of the gastric conduit. The aim of this study was to evaluate the reliability of the barium swallow study in diagnosing anastomotic leaks following esophagectomy.

Methods: Patients who underwent esophagectomy from January 2000 to December 2013 at our institution were investigated. Barium swallow was routinely done between days 5-7 to detect a leak. These results were compared to clinically determined leaks (defined by neck wound infection requiring jejunal feeds and or parenteral nutrition) during the postoperative period. The sensitivity and specificity of barium swallow in diagnosing clinically significant anastomotic leaks was determined.

Results: A total of 395 esophagectomies were performed (mean age, 62.2 years). The indications for the esophagectomy were as follows: malignancy (n=320), high-grade dysplasia (n=14), perforation (n=27), benign stricture (n=7), achalasia (n=16), and other (n=11). A variety of techniques were used including transhiatal (n=351), McKeown (n=35), and Ivor Lewis (n=9) esophagectomies. Operative mortality was 2.8% (n=11). Three hundred and sixty-eight patients (93%) underwent barium swallow study after esophagectomy. Clinically significant anastomotic leak was identified in 36 patients (9.8%). Barium swallow was able to detect only 13/36 clinically significant leaks. The sensitivity of the swallow in diagnosing a leak was 36% and specificity was 97%. The positive and negative predictive values of barium swallow study in detecting leaks were 59% and 93%, respectively.

Conclusion: Barium swallow is an insensitive but specific test for detecting leaks at the cervical anastomotic site after esophagectomy.

Keywords: Anastomotic leak; Barium; Esophagectomy; Esophagus.

Fig. 1

Flow diagram showing the distribution of patients who underwent esophagectomy at our institution. Between 2000–2013, 395 patients underwent esophagectomy and 368 were studied with a postoperative barium swallow to detect an anastomotic leak. There were 36 (9.8%) clinically significant leaks in the cohort. Barium swallow picked up only 13 (36%) of these clinically significant leaks. There were 9 false positive leaks on the swallow and 23 false negative leaks. The sensitivity of the barium swallow in detecting a leak was 36%, and the specificity was 97%. The positive predictive value was 59%, and the negative predictive value was 93%.