Diagnostic performance of a CT-based scoring system for diagnosis of anastomotic leakage after esophagectomy: comparison with subjective CT assessment

Abstract

Objective: To develop a CT-based prediction score for anastomotic leakage after esophagectomy and compare it to subjective CT interpretation.

Methods: Consecutive 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.

Results: Out 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.

Conclusion: This 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.

Keywords: Anastomotic leakage; Computed tomography; Esophageal cancer; Esophagectomy; Prediction score.

Fig. 1

Flowchart demonstrates the selection process of patients with a suspicion of anastomotic leakage (AL)

Fig. 2

ROC curve analysis of the ‘anastomotic leakage prediction score’ (green line), the systematic subjective CT assessment by expert radiologists (red dotted line) and the original interpretation (blue dotted line) indicating their ability to discriminate between patients with and without anastomotic leakage

Fig. 3

Examples of CT findings associated with the presence of anastomotic leakage after esophagectomy. A: Image shows a fistula between the gastric tube and right pleural cavity (arrow). B: Image shows a fluid collection (arrow) in the mediastinum. C: Image shows a visible discontinuity of the esophagogastric wall (arrow). D: Image shows a mediastinal air cavity (arrow) after esophagectomy