How to preserve the native or reconstructed esophagus after perforations or postoperative leaks: A multidisciplinary 15-year experience

Abstract

Background: Esophageal perforation or postoperative leak after esophageal surgery remain a life-threatening condition. The optimal management strategy is still unclear.

Aim: To determine clinical outcomes and complications of our 15-year experience in the multidisciplinary management of esophageal perforations and anastomotic leaks.

Methods: A retrospective single-center observational study was performed on 60 patients admitted at our department for esophageal perforations or treated for an anastomotic leak developed after esophageal surgery from January 2008 to December 2023. Clinical outcomes were analyzed, and complications were evaluated to investigate the efficacy and safety of our multidisciplinary management based on the preservation of the native or reconstructed esophagus, when feasible.

Results: Among the whole series of 60 patients, an urgent surgery was required in 8 cases due to a septic state. Fifty-six patients were managed by endoscopic or hybrid treatments, obtaining the resolution of the esophageal leak/perforation without removal of the native or reconstructed esophagus. The mean time to resolution was 54.95 ± 52.64 days, with a median of 35.5 days. No severe complications were recorded. Ten patients out of 56 (17.9%) developed pneumonia that was treated by specific antibiotic therapy, and in 6 cases (10.7%) an atrial fibrillation was recorded. Seven patients (12.5%) developed a stricture within 12 months, requiring one or two endoscopic pneumatic dilations to solve the problem. Mortality was 1.7%.

Conclusion: A proper multidisciplinary approach with the choice of the most appropriate treatment can be the key for success in managing esophageal leaks or perforations and preserving the esophagus.

Keywords: Autologous emulsified stromal vascular fraction; Endoscopic suture; Endoscopic vacuum-assisted closure therapy; Esophageal perforations; Lateral esophagostomy; Metal stent; Postoperative leak.

Figure 1

Flowchart summarizing our multidisciplinary endoscopic, hybrid (endoscopic + surgical) or surgical management of esophageal perforations and postoperative leaks. EDPC: Endoscopic double-pigtail catheter; EVAC: Endoscopic vacuum-assisted closure therapy; SEMS: Self-expanding-metal stent; tSVFem: Emulsified autologous stromal vascular fraction.

Figure 2

Endoscopic image of anastomotic leak after distal esophagus diverticulatectomy. A: Initial aspect; B and C: After consecutive endoscopic vacuum-assisted closure therapy treatment; D: Complete resolution.

Figure 3

Management of the whole population of the study.

Figure 4

Resolution time and corresponding median diameter of the esophageal fistula per each type of treatment adopted in the study. EDPC: Endoscopic double-pigtail catheter; EVAC: Endoscopic vacuum-assisted closure therapy; SEMS: Self-expanding-metal stent; tSVFem: Emulsified autologous stromal vascular fraction.