Leak grading and percutaneous transanastomotic drainage for the treatment of cervical anastomotic leakage after esophagectomy

Anastomotic leakage, a major complication of esophagectomy, can be fatal. However, there is no consensus on treatment strategy for this critical complication. Percutaneous trans-anastomotic drainage (PTD) refers to intraluminal trans-fistula vacuum drainage for cervical anastomotic leakage. This study aims to evaluate the efficacy of this form of treatment according to leak grade. The severity of leakage in the 117 of 647 consecutive postesophagectomy patients with cervical anastomosis leaks was graded according to esophagogram findings as follows: Grade I, linear extravasation; Grade II, localized obvious cavity; and Grade III, large cavity extending into the mediastinum or thoracic cavity. Treatment tended to be allocated according to grading, PTD being performed in most patients with Grades II and III. Three cases with conduit necrosis requiring immediate surgical intervention were excluded. Leakage was detected by radiologic evaluation in 117 (18.2%) of the remaining 644 patients, over half being Grade II (51%). Patients with Grade II leaks who underwent PTD required significantly shorter treatment (PTD: 16.8 days/non-PTD: 22.3 days; P= 0.02). Moreover, patients who underwent PTD within 3 days of diagnosis (n= 29) required significantly shorter treatment than those who underwent it 4+ days after diagnosis (n= 14) (earlyPTD: 14.9 days/late-PTD: 20.6 days; P = 0.01). It is useful to assign treatment strategy according to leak grading. Additionally, PTD promotes early healing and is considered a valuable treatment option for cervical anastomotic leakage.