Abstract： Objective To investigate diagnosis and treatment of concealed intrathoracic anastomotic leak of the esophagus. Methods We retrospectively analyzed the clinical data of 32 patients who presented with unexplained sepsis （temperature＞38 ℃ and elevated white blood cell count） after esophagectomy and intrathoracic anastomosis for esophageal carcinoma or gastric cardia carcinoma in Affiliated Hospital, Medical College of Qingdao University from January 2006 to December 2010. All the patients underwent oral water-soluble contrast esophagogram and oral water-soluble contrast computerized tomography of the chest. None of the patients had any sign of contrast leak in these diagnostic examinations, but their chest computerized tomography all showed peri-anastomotic bubble and encapsulated effusion. Fifteen patients were treated as concealed intrathoracic anastomotic leak of the esophagus, including fasting, broad spectrum antibiotic treatment, prolonged gastrointestinal decompression and enteral nutrition via naso-intestinal feeding tube. The other 17 patients were not treated as anastomotic leak of the esophagus and only received broad spectrum antibiotic treatment. Results None of the 15 patients who were treated as concealed intrathoracic anastomotic leak finally developed anastomotic leak proved by oral water-soluble contrast esophagogram and computerized tomography of the chest （0%, 0/15）. Among the 17 patients who were not treated as anastomotic leak, fourteen patients developed anastomotic leak later （82.4%, 14/17）, 2 patients died of aorto-esophageal fistula and 3 patients died of multiple organ dysfunction syndrome. Conclusion Peri-anastomotic bubble and irregular encapsulated effusion in oral water-soluble contrast esophagogram and computerized tomography of the chest should be considered as specific signs of concealed intrathoracic anastomotic leak of esophagus after esophagectomy and intrathoracic anastomosis. Patients with such signs should be treated as anastomotic leak.
ObjectiveTo systematically review the efficacy and safety between intrathoracic anastomosis (IA) and cervical anastomosis (CA) after esophagectomy using gastric tube. MethodsWe electronically searched databases including PubMed, EMbase, The Cochrane Library (Issue 11, 2014), Web of Knowledge, CNKI, CBM, and WanFang Data for randomized controlled trials (RCTs) of IA vs. CA after esophagectomy using gastric tube from inception to Nov, 2014. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted data and assessed the risk of bias of included studies. Then, meta-analysis was performed by RevMan 5.2 software. ResultsA total of 10 RCTs involving 1 138 patients were included, of which, 570 patients were in the IA group and the other 568 patients were in the CA group. The results of meta-analysis showed that the incidences of anastomotic leak (RR=2.72, 95%CI 1.67 to 4.45, P<0.05) and injury of recurrent laryngeal nerve (RR=5.64, 95%CI 2.41 to 13.18, P<0.05) in the IA group were significantly lower than those in the CA group, but the IA group had a higher rate of positive margins (RR=0.25, 95%CI 0.09 to 0.67, P<0.05). There were no significant differences between two groups in postoperative anastomotic stricture (RR=1.12, 95%CI 0.73 to 1.74), pulmonary complications (RR=1.10, 95%CI 0.60 to 2.01), operation mortality (RR=1.03, 95%CI 0.55 to 1.94), tumor recurrence (RR=1.57, 95%CI 0.72 to 3.44) and chylothorax (RR=0.76, 95%CI 0.24 to 2.36). ConclusionIA after esophagectomy using gastric tube has lower rates of anastomotic leak and injury of recurrent laryngeal nerve than CA but with a higher rate of positive margins. There are no significant differences between the two surgical operations in operation mortality, postoperative anastomotic stricture and pulmonary complications. IA could reduce the incidence of postoperative complications and is an effective and safe surgical operation for digestive tract reconstruction after esophagectomy. Due to limited quality and quantity of included studies, more high quality studies are needed to verify the conclusion for long-term efficacy and the quality of life.
ObjectiveTo explore the effect of mediastinal drainage tube placed after the esophageal cancer resection with intrathoracic anastomosis on postoperative complications such as anastomotic fistula. MethodsLiterature on the application of mediastinal drainage tubes in esophageal cancer surgery published in databases such as PubMed, EMbase, CNKI, China Biomedical Literature Database, VIP, and Wanfang were searched using English or Chinese, from the establishment of the databases to December 31, 2023. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included retrospective studies, the Cochrane Handbook bias risk tool was used to assess the bias risk of randomized controlled trials (RCT), and Review Manager 5.4 software was used for meta-analysis. ResultsA total of 19 retrospective studies and 8 RCT involving 6320 patients were included, with 3257 patients in the observation group (mediastinal drainage tube+closed thoracic drainage tube) and 3063 patients in the control group (closed thoracic drainage tube or single mediastinal drainage tube). The NOS score of the included literature was≥6 points, and one RCT had a low risk of bias and the other RCT had a moderate risk of bias . Meta-analysis results showed that compared with the control group, the observation group had fewer postoperative lung complications [OR=0.44, 95%CI (0.36, 0.53), P<0.001], fewer postoperative cardiac complications [OR=0.40, 95%CI (0.33, 0.49), P<0.001], earlier average diagnosis time of anastomotic fistula [MD=−3.33, 95%CI (−3.95, −2.71), P<0.001], lower inflammation indicators [body temperature: MD=−1.15, 95%CI (−1.36, −0.93), P<0.001; white cell count: MD=−5.62, 95%CI (−7.29, −3.96), P<0.001], and shorter postoperative hospital stay [MD=−15.13, 95%CI (−18.69, −11.56), P<0.001]. However, there was no statistically significant difference in the incidence of postoperative anastomotic fistula between the two groups [OR=0.85, 95%CI (0.70, 1.05), P=0.13]. ConclusionPlacing a mediastinal drainage tube cannot reduce the incidence of anastomotic fistula, but it can effectively reduce the incidence of postoperative respiratory and circulatory system complications in patients and improve patients’ prognosis. It can early detect teh anastomotic fistula and fully drain digestive fluid to promote rapid healing of the fistula, alleviate the infection symptoms of postoperative anastomotic fistula, and shorten the hospital stay.