A novel stepwise and continuous high-volume irrigation drainage technique for managing cervical anastomotic leaks post-esophagectomy

Abstract

Background: Recently, minimally invasive surgical modalities have become the mainstream approach for the treatment of esophageal cancer, but the incidence rate of anastomotic leak (AL) has not significantly decreased. Compared to intrathoracic anastomoses, cervical anastomotic leaks (CALs) occur at a higher rate. However, there is still a lack of consensus regarding the local management for CALs. In recent years, we have innovated an irrigation and drainage technique for patients with CALs. The aim of this article is to investigate the therapeutic effect of this novel technique.

Methods: The current study was designed as a retrospective study. Patients with CALs in Shanghai Changzheng Hospital were included consecutively. Data regarding healing time (HT), frequency of dressing changes (DC), post-operative hospital stay, mortality, morbidity, as well as laboratory indicators, such as white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) were recorded.

Results: The current study included a total of 53 patients with CALs. Among them, 26 patients received conventional DC treatment (DC group), while 27 patients were treated with irrigation and drainage treatment (IDT) group. IDT significantly expedited the HT of CALs (45 vs. 22 days, P<0.01), reduced the frequency of DC (2.6 vs. 1.5 times/day, P<0.01), shortened the length of post-operative hospital stay (76.5 vs. 43 days, P<0.01), and decreased the mortality rate of patients (15.4% vs. 0%, P<0.05). Additionally, the incidence of sepsis (23.1% vs. 3.7%, P<0.05) and pneumonia (30.8% vs. 7.4%, P<0.05) significantly decreased in the IDT group. Laboratory tests indicated that IDT significantly reduced the CRP and IL-6 levels on the 3rd and 7th days of treatment.

Conclusions: The irrigation and drainage technique is an effective treatment for CALs and merits broad implementation within clinical practice.

Keywords: Esophageal cancer; anastomotic leak (AL); irrigation and drainage treatment (IDT).

Figure 1

Patient flow chart. CAL, cervical anastomotic leak; DC, dressing changes; IDT, irrigation and drainage treatment.

Figure 2

Treatment of CAL with the IDT. (A) The placement of IT and DT. Red arrow, IT. Green arrow, DT. The IT and DT are placed parallel to each other. (B) The fixation of IT and DT. Red arrow, IT. Green arrow, DT. Adhesive tape is used to fix the IT and DT to the patient’s temple and clavicular area. Care is taken to leave room for movement, ensuring that neck movement does not exert tension on the tubes. (C) A case of CAL with conduit necrosis. The figure shows necrosis of the gastric wall in the anastomotic area (black arrow), with local accumulation of pus and necrotic tissue. (D) Photograph of the wound of the same patient taken 8 days after IDT. The necrotic tissue has been replaced by freshly growing granulation tissue (black arrow), and the size of the fistula has been reduced. (E) CT image of a patient with esophageal cancer on the 5th day post-esophagectomy. The diagnosis of CAL was clear by the evidence of contrast leakage. White arrow, the fistula cavity. (F) CT image of the same patient on the 10th day after IDT. The fistula cavity (white arrow) was significantly reduced. These images are published with the patient’s consent. AL, anastomotic leak; CAL, cervical anastomotic leak; CT, computed tomography; DT, drainage tube; IDT, irrigation and drainage treatment; IT, irrigation tube.

Figure 3

Changes in inflammatory markers in patients with CALs (A, WBC; B, CRP; C, PCT; D, IL-6). Graphs were created using Python 3.12, presenting box plots (with whiskers representing 1.5 IQR) and scatter plots for two groups of data. The comparison between the two groups was conducted using the Wilcoxon rank-sum test. P values with significance were annotated. CALs, cervical anastomotic leaks; CRP, C-reactive protein; DC, dressing changes; IDT, irrigation and drainage treatment; IL, interleukin; IQR, interquartile range; PCT, procalcitonin; WBC, white blood cell count.