OUTCOMES OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY BEFORE AND AFTER IMPLEMENTATION OF ENDOSCOPIC VACUUM THERAPY IN A TERTIARY REFERRAL CENTER

Background
Anastomotic leakage (AL) after esophagectomy is associated with severe morbidity and a high mortality. Endoscopic vacuum therapy (EVT) has recently been established as a promising endoscopic treatment option for AL, with success rates of higher than 80%. The aim of this study was to compare outcomes of AL after esophagectomy, before and after implementation of EVT.

Methods
For this cohort study, consecutive patients with AL after transthoracic esophagectomy with gastric conduit reconstruction with cervical or thoracic anastomosis from two different time periods (before the implementation phase of EVT [2013 – 2017, pre-EVT], and after the implementation phase of EVT [2020 – 2023, post-EVT]) were included. Data was collected from a prospectively maintained database. Outcome measures included initial treatment modality, re-operation, intensive care unit (ICU) admission, hospital stay, and complications, classified according to Clavien-Dindo.

Results
In total, 100 patients with AL were included, with 50 patients in the pre-EVT group and 50 patients in the post-EVT group. In the pre-EVT group, initial treatment of AL consisted of conservative therapy (n = 20, 40%), endoscopic stenting (n = 13, 26%), endoscopic drainage (n = 6, 12%) or surgery (n = 11, 22%). In the post-EVT group, initial treatment of AL consisted of conservative therapy (n = 5, 10%), surgery (n = 2, 4%) or EVT (n = 43, 86%). Baseline characteristics showed no differences. The post-EVT group had a significantly lower initial surgical treatment rate compared to the pre-EVT group (respectively 2 [4%] vs. 11 [22%], p = 0.03). Furthermore, the post-EVT group had a significantly lower ICU admission rate than the pre-EVT group (respectively 16 [32%] vs. 35 [70%], p < 0.001). Clavien-Dindo classification differed significantly between the two groups (p = 0.033), with less Grade IIIa and more Grade IVa in the pre-EVT group, compared to the post-EVT group. Reoperations occurred in 17 patients (34%) in the pre-EVT group and 9 (18%) in the post-EVT group, which was not statistically significant. No statistically significant difference was observed in length of hospital stay.

Conclusion
The implementation of EVT as treatment option for AL after esophagectomy in this tertiary referral center led to a lower ICU admission rate. Taking this into consideration, EVT may be associated with long term health benefits for the patient and reduced healthcare costs.