Endoscopic Dilation for Treatment of Anastomotic Leaks Following Transhiatal Esophagectomy

Background and Study Aims: Anastomotic leak is a known complication after transhiatal esophagectomy (THE) and cervical esophagogastric anastomosis. Conservative management takes a long time to heal such leaks. We assessed the role of endoscopic dilation in patients with anastomotic leak following THE.

Patients and Methods: Eight consecutive patients (seven men, one woman; mean age 51) with anastomotic leak following THE were subjected to endoscopic dilation using Savary Gilliard dilators of 7 - 15 mm diameter. The mean interval between surgery and detection of leak was 9 days (range 5 - 22 days) and dilation was performed at a mean interval of 11.4 days (range 1 - 20 days) after detection of the leak.

Results: Drainage from fistulas stopped completely after 1 - 8 days (mean 3 days). X-ray with water soluble contrast showed closure of the fistula in all cases. Duration of follow-up ranged from 2 to 12 months. Anastomotic strictures developed in three patients. These patients required three sessions each of repeat dilation, and were alive at follow-up periods of 2, 4, and 12 months, respectively. One patient developed recurrence of growth at an anastomotic site. Four patients died because of distant metastasis.

Conclusions: Bougie dilation of anastomotic sites is a safe and effective technique for the healing of anastomotic leaks following THE. However there is a need for a prospective randomized trial comparing endoscopic dilation with no dilation in patients with anastomotic leaks following THE.

References

• 1 Urschel J D. Esophagogastrotomy anastomotic leaks complicating esophagectomy: a review.  Am J Surg. 1995;  169 634-640
• 2 Dewar L, Gelfand G, Finley R J, et al. Factors affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition.  Am J Surg. 1992;  163 484-489
• 3 Tam P C, Fok M, Wong J. Re-exploration for complications after esophagectomy for cancer.  J Thorac Cardiovasc Surg. 1989;  98 1122-1127
• 4 Orringer M B, Lemmer J H. Early dilatation in the treatment of esophageal disruption.  Ann Thorac Surg. 1993;  56 1432-1433
• 5 de Lange E E, Schaffer H A Jr, Holt P D. Esophagogastric anastomotic leaks: treatment with fluoroscopically guided balloon dilation.  Am J Roentgenol. 1994;  162 51-54
• 6 Trentino P, Pampeo E, Nofroni I, et al. Predictive value of early postoperative esophagoscopy for occurrence of benign stenosis after cervical esophagogastrostomy.  Endoscopy. 1997;  29 840-844
• 7 Dhir V, Santi Swaroop V, Deshpande R K. Esophagocutaneous fistula from cancer esophagus: management by esophageal endoprosthesis.  Am J Roentgenol. 1995;  90 172