. 2022 Aug 16;109(9):864-871.

doi: 10.1093/bjs/znac226.

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Sander Ubels¹, Moniek Verstegen¹, Bastiaan Klarenbeek¹, Stefan Bouwense², Mark van Berge Henegouwen³, Freek Daams³, Marc J van Det⁴, Ewen A Griffiths^{5

6}, Jan W Haveman⁷, Joos Heisterkamp⁸, Renol Koshy^{9

10}, Grard Nieuwenhuijzen¹¹, Fatih Polat¹², Peter D Siersema¹³, Pritam Singh^{14

15}, Bas Wijnhoven¹⁶, Gerjon Hannink¹⁷, Frans van Workum^{1

12}, Camiel Rosman¹; TENTACLE—Esophagus Collaborative Group

Collaborators, Affiliations

Collaborators

TENTACLE—Esophagus Collaborative Group:
E Matthée, C A M Slootmans, G Ultee, J Schouten, S S Gisbertz, W J Eshuis, M C Kalff, M L Feenstra, D L van der Peet, W T Stam, B van Etten, F Poelmann, N Vuurberg, J W van den Berg, I S Martijnse, R M Matthijsen, M Luyer, W Curvers, T Nieuwenhuijzen, A K E Taselaar, E A Kouwenhoven, M Lubbers, M Sosef, F Lecot, T C M Geraedts, S van Esser, J W T Dekker, F van den Wildenberg, W Kelder, M Lubbers, P C Baas, J W A de Haas, H H Hartgrink, R R Bahadoer, J W van Sandick, K J Hartemink, X Veenhof, H Stockmann, B Gorgec, P Weeder, M J Wiezer, C M S Genders, E Belt, B Blomberg, P van Duijvendijk, L Claassen, D Reetz, P Steenvoorde, W Mastboom, H J Klein Ganseij, A D van Dalsen, A Joldersma, M Zwakman, R P R Groenendijk, M Montazeri, St Mercer, B Knight, G van Boxel, R J McGregor, R J E Skipworth, C Frattini, A Bradley, M Nilsson, M Hayami, B Huang, J Bundred, R Evans, P P Grimminger, P C van der Sluis, U Eren, J Saunders, E Theophilidou, Z Khanzada, J A Elliott, J Ponten, S King, J V Reynolds, B Sgromo, K Akbari, S Shalaby, C A Gutschow, H Schmidt, D Vetter, K Moorthy, M A H Ibrahim, G Christodoulidis, J V Räsänen, J Kauppi, H Söderström, D K Manatakis, D P Korkolis, D Balalis, A Rompu, B Alkhaffaf, M Alasmar, M Arebi, G Piessen, F Nuytens, S Degisors, A Ahmed, A Boddy, S Gandhi, O Fashina, E Van Daele, P Pattyn, W B Robb, M Arumugasamy, M Al Azzawi, J Whooley, E Colak, E Aybar, A C Sari, M S Uyanik, A B Ciftci, R Sayyed, B Ayub, G Murtaza, A Saeed, P Ramesh, A Charalabopoulos, T Liakakos, D Schizas, E Baili, A Kapelouzou, M Valmasoni, E S Pierobon, G Capovilla, S Merigliano, C Silviu, B Rodica, A Florin, R Cristian Gelu, H Petre, R Guevara Castro, A F Salcedo, I Negoi, V M Negoita, C Ciubotaru, B Stoica, S Hostiuc, N Colucci, S P Mönig, C H Wassmer, J Meyer, F R Takeda, R A Aissar Sallum, U Ribeiro, I Cecconello, E Toledo, M S Trugeda, M J Fernández, C Gil, S Castanedo, A Isik, E Kurnaz, J F Videira, M Peyroteo, R Canotilho, J Weindelmayer, S Giacopuzzi, C A De Pasqual, M Bruna, F Mingol, J Vaque, C Pérez, A W Phillips, J Chmelo, J Brown, L E Han, J A Gossage, A R Davies, C R Baker, M Kelly, M Saad, D Bernardi, L Bonavina, E Asti, C Riva, R Scaramuzzo, M Elhadi, H Abdelkarem Ahmed, A Elhadi, F A Elnagar, A A A Msherghi, V Wills, C Campbell, M Perez Cerdeira, S Whiting, N Merrett, A Das, C Apostolou, A Lorenzo, F Sousa, J Adelino Barbosa, V Devezas, E Barbosa, C Fernandes, G Smith, E Y Li, N Bhimani, P Chan, K Kotecha, M W Hii, S M Ward, M Johnson, M Read, L Chong, M J Hollands, M Allaway, A Richardson, E Johnston, A Z L Chen, H Kanhere, S Prasad, P McQuillan, T Surman, M I Trochsler, W A Schofield, S K Ahmed, J L Reid, M C Harris, S Gananadha, J Farrant, N Rodrigues, J Fergusson, A Hindmarsh, Z Afzal, P Safranek, V Sujendran, S Rooney, C Loureiro, S Leturio Fernández, I Díez Del Val, S Jaunoo, L Kennedy, A Hussain, D Theodorou, T Triantafyllou, C Theodoropoulos, T Palyvou, M Elhadi, F Abdullah Ben Taher, M Ekheel, A A A Msherghi

Affiliations

¹ Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands.
² Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.
³ Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands.
⁴ Department of Surgery, ZGT hospital group, Almelo, the Netherlands.
⁵ Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
⁶ Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
⁷ Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
⁸ Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.
⁹ Department of Surgery, Newcastle upon Tyne Hospital NHS Trust, Newcastle upon Tyne, UK.
¹⁰ Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK.
¹¹ Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
¹² Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands.
¹³ Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
¹⁴ Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
¹⁵ Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK.
¹⁶ Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
¹⁷ Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.

PMID: 35759409
PMCID: PMC10364775
DOI: 10.1093/bjs/znac226

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Sander Ubels et al. Br J Surg. 2022.

. 2022 Aug 16;109(9):864-871.

doi: 10.1093/bjs/znac226.

Authors

Collaborators

TENTACLE—Esophagus Collaborative Group:
E Matthée, C A M Slootmans, G Ultee, J Schouten, S S Gisbertz, W J Eshuis, M C Kalff, M L Feenstra, D L van der Peet, W T Stam, B van Etten, F Poelmann, N Vuurberg, J W van den Berg, I S Martijnse, R M Matthijsen, M Luyer, W Curvers, T Nieuwenhuijzen, A K E Taselaar, E A Kouwenhoven, M Lubbers, M Sosef, F Lecot, T C M Geraedts, S van Esser, J W T Dekker, F van den Wildenberg, W Kelder, M Lubbers, P C Baas, J W A de Haas, H H Hartgrink, R R Bahadoer, J W van Sandick, K J Hartemink, X Veenhof, H Stockmann, B Gorgec, P Weeder, M J Wiezer, C M S Genders, E Belt, B Blomberg, P van Duijvendijk, L Claassen, D Reetz, P Steenvoorde, W Mastboom, H J Klein Ganseij, A D van Dalsen, A Joldersma, M Zwakman, R P R Groenendijk, M Montazeri, St Mercer, B Knight, G van Boxel, R J McGregor, R J E Skipworth, C Frattini, A Bradley, M Nilsson, M Hayami, B Huang, J Bundred, R Evans, P P Grimminger, P C van der Sluis, U Eren, J Saunders, E Theophilidou, Z Khanzada, J A Elliott, J Ponten, S King, J V Reynolds, B Sgromo, K Akbari, S Shalaby, C A Gutschow, H Schmidt, D Vetter, K Moorthy, M A H Ibrahim, G Christodoulidis, J V Räsänen, J Kauppi, H Söderström, D K Manatakis, D P Korkolis, D Balalis, A Rompu, B Alkhaffaf, M Alasmar, M Arebi, G Piessen, F Nuytens, S Degisors, A Ahmed, A Boddy, S Gandhi, O Fashina, E Van Daele, P Pattyn, W B Robb, M Arumugasamy, M Al Azzawi, J Whooley, E Colak, E Aybar, A C Sari, M S Uyanik, A B Ciftci, R Sayyed, B Ayub, G Murtaza, A Saeed, P Ramesh, A Charalabopoulos, T Liakakos, D Schizas, E Baili, A Kapelouzou, M Valmasoni, E S Pierobon, G Capovilla, S Merigliano, C Silviu, B Rodica, A Florin, R Cristian Gelu, H Petre, R Guevara Castro, A F Salcedo, I Negoi, V M Negoita, C Ciubotaru, B Stoica, S Hostiuc, N Colucci, S P Mönig, C H Wassmer, J Meyer, F R Takeda, R A Aissar Sallum, U Ribeiro, I Cecconello, E Toledo, M S Trugeda, M J Fernández, C Gil, S Castanedo, A Isik, E Kurnaz, J F Videira, M Peyroteo, R Canotilho, J Weindelmayer, S Giacopuzzi, C A De Pasqual, M Bruna, F Mingol, J Vaque, C Pérez, A W Phillips, J Chmelo, J Brown, L E Han, J A Gossage, A R Davies, C R Baker, M Kelly, M Saad, D Bernardi, L Bonavina, E Asti, C Riva, R Scaramuzzo, M Elhadi, H Abdelkarem Ahmed, A Elhadi, F A Elnagar, A A A Msherghi, V Wills, C Campbell, M Perez Cerdeira, S Whiting, N Merrett, A Das, C Apostolou, A Lorenzo, F Sousa, J Adelino Barbosa, V Devezas, E Barbosa, C Fernandes, G Smith, E Y Li, N Bhimani, P Chan, K Kotecha, M W Hii, S M Ward, M Johnson, M Read, L Chong, M J Hollands, M Allaway, A Richardson, E Johnston, A Z L Chen, H Kanhere, S Prasad, P McQuillan, T Surman, M I Trochsler, W A Schofield, S K Ahmed, J L Reid, M C Harris, S Gananadha, J Farrant, N Rodrigues, J Fergusson, A Hindmarsh, Z Afzal, P Safranek, V Sujendran, S Rooney, C Loureiro, S Leturio Fernández, I Díez Del Val, S Jaunoo, L Kennedy, A Hussain, D Theodorou, T Triantafyllou, C Theodoropoulos, T Palyvou, M Elhadi, F Abdullah Ben Taher, M Ekheel, A A A Msherghi

Affiliations

¹ Department of Surgery, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands.
² Department of Surgery, Maastricht University Medical Centre+, Maastricht, the Netherlands.
³ Department of Surgery, Amsterdam UMC, Cancer Centre Amsterdam, University of Amsterdam, Amsterdam, the Netherlands.
⁴ Department of Surgery, ZGT hospital group, Almelo, the Netherlands.
⁵ Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, UK.
⁶ Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
⁷ Department of Surgery, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands.
⁸ Department of Surgery, Elisabeth-TweeSteden Hospital, Tilburg, the Netherlands.
⁹ Department of Surgery, Newcastle upon Tyne Hospital NHS Trust, Newcastle upon Tyne, UK.
¹⁰ Department of Surgery, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK.
¹¹ Department of Surgery, Catharina Hospital, Eindhoven, the Netherlands.
¹² Department of Surgery, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands.
¹³ Department of Gastroenterology and Hepatology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.
¹⁴ Department of Surgery, Nottingham University Hospitals NHS Trust, Nottingham, UK.
¹⁵ Department of Surgery, Regional Oesophago-Gastric Unit, Royal Surrey County Hospital, Guildford, UK.
¹⁶ Department of Surgery, Erasmus University Medical Centre, Rotterdam, the Netherlands.
¹⁷ Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, The Netherlands.

PMID: 35759409
PMCID: PMC10364775
DOI: 10.1093/bjs/znac226

Abstract

Background: Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods: This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results: Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion: The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.

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Figures

**Fig. 1**
Calibration plot of the SEAL score The calibration slope was 1.12 (95 per cent c.i. 0.93 to 1.31) and resembles the strength of predictors. The calibration intercept was 0.00 (95 per cent c.i. –0.17 to 0.17), and resembles the ‘calibration in the large’ indicating whether the model systematically overpredicts or underpredicts. Discrimination: c-index 0.77 (95 per cent c.i. 0.73 to 0.81). The shaded area displays the 95 per cent confidence interval of the flexible calibration curve. The triangles plotted in the calibration curve represent observed proportion *versus* predicted probabilities for decile predictions, with error bars indicating 95 per cent confidence interval for a specific decile. The broom plot at the bottom shows the distribution of predicted probabilities for 90-day mortality in patients who did (1) or did not (0) die within 90 days. SEAL, Severity of oEsophageal Anastomotic Leak.

See this image and copyright information in PMC

References

1. Oesophago-Gastric Anastomosis Study Group; West Midlands Research Collaborative . Rates of anastomotic complications and their management following esophagectomy: results of the Oesophago-Gastric Anastomosis Audit (OGAA). Ann Surg 2022;275:382–390 - PubMed
1. van Workum F, Verstegen MHP, Klarenbeek BR, Bouwense SAW, van Berge Henegouwen MI, Daams F et al. Intrathoracic vs cervical anastomosis after totally or hybrid minimally invasive esophagectomy for esophageal cancer: a randomized clinical trial. JAMA Surg 2021;156:601–610 - PMC - PubMed
1. Kuppusamy MK, Low DE; International Esodata Study Group . Evaluation of international contemporary operative outcomes and management trends associated with esophagectomy: a 4-year study of > 6000 patients using ECCG definitions and the online Esodata database. Ann Surg 2020;275:515–525 - PubMed
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1. Dutch Upper Gastrointestinal Cancer Audit . Core Figures 2015–2019 (Basis Tabel 2015–2019). Leiden: Dutch Institute for Cancer Auditing, 2020

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Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Collaborators

Affiliations

Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score

Authors

Collaborators

Affiliations

Abstract

Figures

References

MeSH terms

Grants and funding

LinkOut - more resources

Full Text Sources

Medical