Diagnosis And Treatment For The Intrathoracic Anastomotic Leak In Postoperative Esophageal And Gastric Cardial Carcinoma

The Morbility of esophageal and gastric cardial carcinoma is high in china, and so do the rate of esophageal and cardial carcinoma in thoracic surgery.Intrathoracic anastomotic leak is one of the main complications in postoperative esophageal and cardial carcinoma. The presence of anastomotic leak after esophagectomy has continued to plague surgeons and pa-tients for decades, despite continuing advances in operative technique and postoperative care. The combination of conduit necrosis and anastomotic leak between the esophagus and selected esophageal substitute almost always results in significant morbidity and mortality(50%). How to avoid and manage these leaks when we occur is very important.Between april 2001 and april 2006, 317 patients underwent esophagectomy for esophageal and gastric cardial carcinoma at the Department of Thoracic Surgery,First Hospital of JinLin University.There are 9 patients of the anastomotic leak after operation in five years.The leak rate was 2.84%.The patients consisted of 6 males and 3 females with the middle age of 63 (range 55-72). All the patients pathological diagnosis was SqCa, 2 patients underwent placement of self-expanding covered metallic stents. 1 patient underwent operative intervention.The clinical manifestation including: (1) Fever; (2) Signs of systemic sepsis; (3) Chest distress and pain; (4) Cardiopalmus and accelerated breathing; (5) Methylene was seen from the drainage after drinking by patients; (6) The percussion of chest was flatness ; (7) Infection of incisional wound; (8) Foul chest tube drainage or a large intrathoracic fluid collection; (9) Phenomenon of furcation could be seen in contrast esophagogram. The presence of mediastinal air or loculated fluid in CT can suggest the presence of an occult leak. The time of diagnosis:3-13 days.There are two main treatments of anastomotic leak: expectant treatment and operation.It was useless to repair the anastomotic leak by reoperation in serious infection of acute stage, and It was always aggravate pathogenetic condition. Initial management for an anastomotic leak includes intravenous fluid resuscitation,broad spectrum antibiotics, nutritional support.Very small intrathoracic leaks that are asymptom-atic and discovered incidentally on routine esophagography require no specific therapy. Contained moderate-sized leaks that are asymptomatic and drain spontaneously back into the esophagus can also be treated expectantly, although this approach should be used cautiously because fistulization into vital medias-tinal structures can occur. Two recent series reported considerable success with nonoperative management of contained intrathoracic leaks, If symptoms intervene or there is concern regarding erosion into adjacent organs, these contained fluid collections should be drained. In these cases, institution of broad-spectrum antibiotics should be considered. Microbiological surveillance and specific antibiotic therapy ensure that a complication does not cause a septic cascade leading to multiorgan failure.Some surgeons have attempted internal drainage by place-ment of a nasogastric tube (under fluoroscopic guid-ance) through the anastomotic defect, although this technique risks further disruption of the anastomosis. Successful drainage of the abscess can often be established percutaneously under CT guidance, which leads to spontaneous healing of the leak over 1 to 3 weeks. If the patient's condition does not improve rapidly, open drainage should be under-taken. Open drainage will allow direct inspection of the anastomotic site, and often direct repair of the leak will be possible, buttressed with a vascularized tissue flap of transposed muscle, omentum, or pericardial fat. Debridement of devitalized tissue and establishment of adequate drainage complete the pro-cedure. In poorly or noncontained leaks, attempts at conservative management should be abandoned in favor of prompt reexploration.1 patient has shorten the course of disease obviously after reoperation.There has been renewed interest in the literature in the endoscopic treatment of contained anastomotic leaks with the placement of self-expanding silicone or covered metallic stents. Stent placement usually results in occlusion of the leak and often is combined with percutaneous drainage of the adjacent contained mediastinal abscess. In small published reports, most leaks close satisfactorily, with occasional prob-lems with stent migration requiring reintervention. The stents often are left in place for several months to minimize the occurrence of subsequent stricture formation. There are 2 patient has underwent the placement of self-expanding silicone or covered metallic stents, and there were not stricture of anastomotic leaks in one year follow-up visit.Nutritional support is one of most important composition in expectant treatment.hemophthisis and malnutrition should be addressed before surgery. There are mainly three approaches to complete nutritional support: PPN, EN, CVN. Comparatively, EN is cheap,polytrophic and convenience. Blood plasm and fresh blood were helpful to anti-infection,healing the Anastomotic leaks and improve General body state.Anastomotic leaks continue to be a source of con-siderable morbidity and mortality after esophageal resection. Careful attention to the contributing factors to the development of a leak, particularly conduit ischemia and anastomotic technique, can reduce the incidence of anastomotic complications postoperatively. Selective management of leaks, including non-operative treatment when indicated, will maximize the chance for a successful outcome.