IS Case 95: Post Esophagectomy Anastomotic Leak
Imaging Sciences URMC 2008
Publication Date: 2009-05-20
Esophagram. AP and oblique projections (A-D) (Fig. 1) demonstrate irregularity and progressive contrast leak at the level of the esophagogastric anastomosis (arrows). Compare with a normal post-operative esophagram (Fig .2).
Leak at the esophagogastric anastomosis is one of the most common complications following esophagectomy with gastric pull through, reported to occur in up to 50% of patients. Anastomotic leak can occur early (2-3 days) due to technical failure or late (3-7 days) due to ischemic changes at or just below the anastomosis due to necrosis of the proximal gastric conduit.
Early detection is crucial for timely management and avoiding significant morbidity and mortality. Common post-surgical protocols call for an upper GI series on postoperative day 7, if not sooner, to evaluate for anastomotic leak. The findings are readily evident as contrast leak outside of the expected luminal contour. Computed tomography (CT) is of limited utility in initial diagnosis, but may identify associated complications such as mediastinitis. Patients with anastomotic leak are at increased risk of stricture and fistula formation.
Treatment depends upon the size and extent of leak at imaging in conjunction with the severity of clinical symptoms. Contained leaks (limited to the mediastinum) are managed conservatively with antibiotics, nasogastric tube placement, TPN, and percutaneous drainage, if necessary. Leaks with pleural extension require surgical revision.
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