LEAKAGE OF INTRATHORACIC OESOPHAGOVISCERAL ANASTOMOSES IN ADENOCARCINOMA OF THE GASTRIC CARDIA - CHANGES IN SERIAL APACHE-II SCORES AND THEIR PROGNOSTIC-SIGNIFICANCE

Objective: To evaluate changes in serial Acute Physiology and Chronic Health Evaluation (APACHE) II scores in patients with intrathoracic oe sophageal anastomotic leaks and to assess their prognostic significanc e. Design: Retrospective study. Setting: Teaching hospital, Taiwan. Su bjects: 18 patients (4%) who developed intrathoracic oesophageal anast omotic leaks in a total of 491 patients who underwent oesophagogastrec tomy for adenocarcinoma of the gastric cardia between 1980 and 1994. M ain outcome measure: APACHE II scores in those that survived (n = 10) compared with those who died (n = 8). Results: Of the 18 patients, 8 ( 44%) died. The preoperative general condition, biochemical data, and p erioperative APACHE II scores were similar in the two groups. Leakage from the oesophageal anastomoses caused similar degrees of sepsis in t he two groups in terms of APACHE II scoring, but the APACHE II scores of survivors started to decline within a week of initial management. I n contrast, the APACHE II scores of those who died had increased one w eek after the leak had been diagnosed despite initial management. Ther e were significant differences in the APACHE II scores of survivors an d those who died from one week after leakage until discharge or death (p < 0.001). Only one patient (1/9) survived if the APACHE II score on e week after diagnosis of the leak was more than 10. None died of the leak if the APACHE II scores were equal to or less than 10 after a wee k. Conclusions: Adequate surgical drainage, antibiotic cover according to the microbiological picture, and nutritional support are essential in the management of intrathoracic oesophageal fistulas. Early reoper ation to close early leaks by simple suture or secondary wrapping and to improve local drainage is recommended. The APACHE II scoring system is valuable in evaluating the severity of sepsis caused by intrathora cic oesophagovisceral anastomosis leaks and may serve as an indicator of adequate management. Aggressive surgical measures should be conside red if APACHE II scores rise during initial management.