Analysis Of Risk Factors Of Anastomotic Leakage After Minimally Invasive Esophagectomy For Esophageal Carcinoma

Objective To analyze the risk factors of anastomotic leakage(AL)after minimally invasive esophagectomy(MIE),in order to propose preventive measures with clinical significance for AL after MIE for esophageal carcinoma.Methods Clinical data of 407 esophageal squamous cell carcinoma patients who underwent MIE in department of thoracic surgery of The Fist Affiliated Hospital Of Anhui Medical University from December 2014 to November 2015 were analyzed retrospectively according to the inclusive criteria.With regard to the surgical procedures,thoracolaparoscopic esophagectomy with cervical anastomosis(TLE-Neck)and thoracolaparoscopic esophagectomy with thoracic anastomosis(TLE-Chest)were performed in 242 and 165 patients respectively.80 cases thoracolaparoscopic Ivor-Lewis and 85 cases thoracolaparoscopic esophagectomy with thrasorally placed anvil(Or Vil)were included in the TLE-Chest group.Firstly,univariate analysis was used in 19 factors including gender,age,history of smoking,history of alcohol,history of hypertension,history of diabetes mellitus,chronic disease of upper gastrointestinal tract,Body Mass Index,tumor location,maximum diameter of tumor,pathological stage,operation time,whether to do gastric tube,whether to do anastomotic reinforce and embedding,whether to do suspension around anastomosis,location of anastomosis,postoperative day 2 serum albumin,postoperative nutrition approach,postoperative pulmonary complications for the 407 patients.Multivariate analysis were used for those with statistical difference to find out independent risk factors of AL after MIE.Secondly,the patients were divided into TLE-Neck group and TLE-Chest group depending on the location of anastomosis.Univariate analysis and multivariate analysis were used for both groups to find out independent risk factors of AL after TLE-Neck and TLE-Chest.All analysis were performed by using SPSS software(version16.0).Student's t-test was used to compare the mean of continuous data,Pearson's ?2 test and Fisher's exact test were used to compare categorical data.Multivariate Logistic Regression was used for multivariate analysis of the independent risk factors of AL after MIE.P<0.05 was considered statistically significant.Results Among the 407 patients,postoperative anastomotic leakage occurred in 42 patients,the overall anastomotic leakage rate was 10.32%(42/407),33 patients of the242 patients who underwent TLE-Neck experienced AL,while 9 patients of the 165 patients who underwent TLE-Chest experienced AL.AL rate of the TLE-Neck group was higher than that of the TLE-Chest group with statistical significance(13.64%vs.5.45%,P=0.008).The average time of diagnosis of anastomotic leakage was9.24 ± 4.568 days.One patients of the TLE-Neck group was dead of AL,and the leak-associated mortality was 3.03%(1/33).While one patients of the TLE-Chest group was dead of AL,and the leak-associated mortality was 11.11%(1/9).The overall leak-associated mortality was 4.76%(2/42).As to AL rate,univariate analysis showed statistical significance betwen patients with different operative time and anastomosis locations,and between patients with and without a gastric tube,with and without suspension around anastomosis,with and without plasma albumin level lower then35g/L the 2nd day after MIE and with and without postoperative pulmonary complications(P=0.015?0.007?0.008?0.004?<0.001?<0.001).Multivariate analysis showed that plasma albumin level lower then 35g/L the 2nd day after MIE(P=0.001,OR=5.345,95%CI=1.998 ~ 14.301)and postoperative pulmonary complications(P=0.002,OR=4.904,95%CI=1.833~13.118)were the independent risk factors of AL after MIE.Univariate analysis of the TLE-Neck group showed statistical difference betwen patients with different operative time,with and without plasma albumin level lower then 35g/L the 2nd day after operation and with and without postoperative pulmonary complications(P=0.036?<0.001?0.028).Multivariate Logistic analysis showed that plasma albumin level lower then 35g/L the 2nd day after operation(P=0.001,OR=5.914,95%CI=2.730~12.815)and postoperative pulmonary complications(P=0.045,OR=3.496,95%CI=1.028~11.884)were the independent risk factors of AL after TLE-Neck.Univariate analysis of the TLE-Chest group showed statistical difference betwen patients with and without suspension around anastomosis,and with and without postoperative pulmonary complications(P=0.012 ?0.002).Multivariate Logistic analysis showed that without suspension around anastomosis(P=0.028,OR=11.457,95%CI=1.300~100.942),and postoperative pulmonary complications(P=0.001,OR=14.279,95%CI=2.840~71.801)were the independent risk factors of AL after TLE-Chest.Conclusion1.Because of high tension and poor blood supply of the cervical anastomosis,the current postoperative anastomotic leakage rate of TLE-Neck approach was higher than that of the TLE-Chest approach.2.As for all cases,plasma albumin level lower then 35g/L the 2nd day after operation and postoperative pulmonary complications were the independent risk factors of AL after MIE.Plasma albumin level lower then 35g/L the 2nd day after operation and postoperative pulmonary complications were the independent risk factors of AL after TLE-Neck.Without suspension around anastomosis and postoperative pulmonary complications were the independent risk factors of AL after TLE-Chest.2.Strengthening perioperative respiratory management to reduce the occurrence of postoperative pulmonary complications,and early detection and supplementation of albumin were of great significance in preventing the occurrence of cervical anastomotic leakage.Intraoperative anastomotic suspension and strengthen the perioperative respiratory management to reduce the occurrence of pulmonary complications were of great significance in preventing the occurrence of intrathoracic anastomotic leakage.