Intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy for carcinoma.

BACKGROUND: A purported advantage of the cervical esophagogastrostomy is that drainage is easily accomplished should anastomotic dehiscence occur after esophagectomy. However, support for this statement stems mainly from studies of transhiatal esophagectomy, with little data published when a transthoracic resection is performed. The purpose of this study was to determine the incidence and clinical significance of intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy.

METHODS: A retrospective analysis of a prospectively collected esophageal carcinoma database (1988 to 2004) was performed at a single institution. Operative and pathologic data were collected, as well as details concerning the incidence, clinical features, treatment, and outcome of anastomotic leaks. Patients with leaks were further analyzed on the basis of whether or not intrathoracic manifestations of anastomotic leakage were present.

RESULTS: Two hundred, forty-two patients underwent transthoracic esophagectomy with a cervical anastomosis during the study period. There were 27 (11.1%) anastomotic leaks. Of these, 14 patients (52%) had intrathoracic manifestations of their cervical leaks, with empyema being the most common. Patients with intrathoracic spread of sepsis had significantly longer in-hospital (p < 0.001) and anastomotic healing times (p < 0.05) and required more drainage procedures (including reoperation; p < 0.005) than those with leaks confined to the neck. However, no difference in operative mortality or long-term survival was appreciated.

CONCLUSIONS: Intrathoracic manifestations of cervical anastomotic leaks are more common after transthoracic esophagectomy than what has historically been reported for transhiatal esophagectomy. This discrepancy may be due to anatomical or technical differences, or both, between the two procedures. Early diagnosis and aggressive drainage are necessary for achieving a favorable outcome.