Clinical Presentation, Diagnosis and Management of Early, Average and Late Onset Anastomotic Leakage After Esophagectomy

Background Anastomotic leakage (AL) is a common and severe complication after esophagectomy. The moment of AL diagnosis and its clinical presentation is diverse, thereby complicating subsequent diagnosis and management. Current literature suggest early and late AL may be distinct clinical entities, but robust data supporting these suggestions is lacking. The objective of this study was to explore differences in clinical presentation, diagnosis and management of AL after esophagectomy in relation to moment of AL diagnosis. Methods The TENTACLE—Esophagus is an international multicenter retrospective cohort study including patients with AL after esophagectomy for esophageal cancer. Patients with AL were grouped based on moment of AL diagnosis (early ≤ postoperative day (POD) 3, and late ≥ POD 11). Differences in clinical presentation, diagnosis and management of these groups were explored using descriptive statistics. Results Of 1508 patients, 166 (11.0%) had an early, 919 (60.9%) had an average and 284 (18.8%) had a late AL. An omental wrap was performed in 28.9%, 27.5% and 37.3% of patients with early, average and late AL (P = 0.019), respectively. Aberrant drain output diagnosed AL in 24.7%, 18.6% and 12.0% (P < 0.001), and gastric tube ischemia/necrosis was present in 18.7%, 9.2% and 9.5% (P = 0.006) of patients with early, average, and late AL, respectively. Initial treatment of early AL was predominantly surgical (39.8%), whereas average and late AL were primarily managed with endoscopic or radiologic intervention (41.2%, 51.8%, P < 0.001). Conclusion In this large multinational cohort, patients with early AL were more likely to be diagnosed based on aberrant drain output, to present with gastric tube ischemia/necrosis and to undergo initial surgical treatment. Patients with late AL were more likely to undergo initial endoscopic or radiologic intervention. The late diagnosis of AL may be attributed to omental wrapping of the anastomosis as this was more often performed in patients with late AL.