Diagnosis and management of a mediastinal leak following radical oesophagectomy

Background: The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a s tapled intrathoracic anastomosis. Methods: Some 291 consecutive patients underwent two-phase subtotal oesopha gectomy with gastric interposition for malignancy. Patients with clinical s uspicion of a leak were investigated with contrast radiology and flexible u pper gastrointestinal endoscopy. Results: Nineteen patients (6.5 per cent) developed a proven mediastinal le ak at a median of 8 (range 3-30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had wide spread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology wa s normal. In six patients the diagnosis of leakage followed an apparently n ormal routine contrast examination on day 5-8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intr avenous antibiotics and antifungal therapy, nasogastric decompression and e nteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical p icture; the), were managed with repeat thoracotomy and either revision of t he conduit or resection and exclusion. Despite early intervention four of t he six patients died. Conclusion: Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology a nd endoscopic evaluation. Isolated anastomotic leaks can be managed success fully with non-operative treatment, whereas more extensive leaks from the g astric conduit require revisional surgery which carries a high mortality ra te.