Post-Surgical Leaks of the Upper Digestive Tract – The Importance of an Early Endoscopic Approach

Aims To analyze the factors associated with the success of endoscopic treatment of anastomotic dehiscence in the upper digestive tract.

Methods Prospective analysis of patients from 3 tertiary hospitals who underwent endoscopic treatment for upper digestive tract anastomotic dehiscence (DAC) between January 2016 and September 2024. The primary outcomes were defined as 'clinical success' (closure of the dehiscence with resolution of symptoms and/or imaging abnormalities) and the presence of complications. Secondary outcomes included the identification of predictive factors for clinical success and complications (univariate analysis and multivariate logistic regression). Kaplan-Meier curves were used to estimate survival rates [1].

Results Thirty-two patients were included [71.9% male, n=23], with a median age of 71.5 years [48-88], and the majority had comorbidities [19/32 (59.4%) with ASA≥3; 25/32 (78.1%) with a Charlson Comorbidity Index (CCI)≥5]. Most surgeries were performed electively (n=29; 90.6%) and had a median duration of 4 hours [2-8 hours], with gastric adenocarcinoma being the most common indication (19/32, 59.4%). Total gastrectomy (n=21) and subtotal gastrectomy (n=6) were the most frequently performed surgeries, and the most common site of dehiscence was the esophagojejunal anastomosis (n=21, 65.6%). A median of 5 days [2-24] elapsed from surgery to diagnosis, with fever being the most common manifestation (15/32, 46.9%). Endoscopic treatment was first-line in a minority of cases (12/32, 37.5%) and was performed after a median of 17 days post-surgery [2-98]. Technical success was achieved in 90.6% of cases (29/32), and clinical success (CS) was 71.9% (23/32), mostly in a single session (20/32, 62.5%). The most common treatment was metal stent placement [20/32, 62.5%], followed by OTS-clip [8/32, 25.0%]. Nine patients (28.1%) experienced complications, with stent migration being the most frequent (n=5). Oral diet was resumed at a median of 10 days after the endoscopic procedure. Eighteen patients (56.3%) died during follow-up, though none as a result of endoscopic treatment complications. Selection of endoscopic treatment as the first-line option was the only variable with a statistically significant impact on CS (p=0.0150); older age, higher ASA, or CCI seemed to have a negative impact on CS. Complications also tended to occur more frequently in patients with a higher CCI and in cases where endoscopic treatment was not the first-line option.

Conclusions The findings reinforce that endoscopic treatment should increasingly be prioritized as the primary and early approach in patients with anastomotic dehiscence, as delaying its implementation may be associated with worse outcomes.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025

• References

• 1 Medas R., Rodrigues-Pinto E.. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clinical Endoscopy 2023; 56 (6): 693