The American Journal of Surgery (2014) 208, 536-543

Association of Women Surgeons Optimal approach to the management of intrathoracic esophageal leak following : a systematic review

Lara Schaheen, M.D.a, Shanda H. Blackmon, M.D., M.P.H.b, Katie S. Nason, M.D., M.P.H.a,* aDivision of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA; bDivision of General Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA

KEYWORDS: Abstract Esophagectomy; BACKGROUND: Recently, endoscopic interventions (eg, esophageal stenting) have been success- Postoperative fully used for the management of intrathoracic leak. The purpose of this systematic review was to assess complications; the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak. Anastomotic leak; DATA SOURCES: We performed a systematic review of MEDLINE, EMBASE, and PubMed to iden- Review; tify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy. Systematic; CONCLUSIONS: Intraoperative anastomotic drain placement was associated with earlier identifica- Assessment; tion and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the Outcomes anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endo- scopic placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persis- tent leak require surgical intervention. Ó 2014 Elsevier Inc. All rights reserved.

Esophagectomy is the mainstay of therapy in the man- 30% to 60%.2–4 Compared with cervical anastomosis, intra- agement of patients with locoregionally advanced esopha- thoracic anastomoses have a lower incidence of anasto- geal cancer, but carries significant risk of associated motic leak and stricture rate. Presentation ranges from morbidity and mortality. The incidence of anastomotic asymptomatic and clinically silent to overwhelming sepsis leak varies widely in the current literature but has been and death; patient prognosis after intrathoracic anastomotic reported to be up to 50%,1 with mortality rates as high as leak depends on the extent of contamination and time inter- val to diagnosis. Regardless of the severity, the presence of Supported by the National Cancer Institute of the National Institutes of an anastomotic leak following esophagectomy has a sub- Health under award numbers 5K07CA151613 (K.S.N.). The content is stantial impact on postoperative length of stay, overall solely the responsibility of the authors and does not necessarily represent morbidity, stricture formation, and dysphagia.5,6 the official views of the National Institutes of Health. The treatment of anastomotic leak remains controversial, * Corresponding author. Tel.: 11-412-623-2025; fax: 11-412-623-0329. as the indications for surgical, conservative, and endoscopic E-mail address: [email protected] 7,8 Manuscript received February 3, 2014; revised manuscript May 10, therapy remain non-standardized Strategies described in 2014 the literature include conservative management (consisting

0002-9610/$ - see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2014.05.011 L. Schaheen et al. Management of thoracic anastomotic leak 537 of strict nil per oral, initiation of intravenous antibiotics, and leaks were also excluded. To further limit the scope of the drainage), early and late surgical exploration, endoscopic systematic review, we excluded articles focused on cervical management with stenting, as well as prophylactic omental anastomotic leaks, approach to anastomosis and leak, and reinforcement. Determining the optimal therapy for such pa- ischemic preconditioning and leak. Additional references tients requires examining all available options as there are from article bibliographies were included as appropriate. A few retrospective and prospective studies comparing these total of 51 articles were included in the final review. techniques. To determine the optimal management of intrathoracic Prophylactic management of anastomotic leak anastomotic leak, we performed a systematic review of the after esophagectomy: the role for intraoperative literature analyzing endoscopic approaches to management and published outcomes. Specifically, we sought to deter- drain placement and pedicled omental mine: (1) whether intraoperative drain placement at the reinforcement of the anastomosis anastomosis impacts leak rate and/or duration; (2) whether reinforcement of the esophagogastric anastomosis after Because of the high mortality and morbidity associated esophagectomy with omentoplasty reduces leak rate or with anastomotic leak, several authors have argued for the use the need for reintervention; and (3) the safety, efficacy, and of prophylactic interventions to reduce the impact and/or indications for endoscopic interventions (stenting and incidence of anastomotic leak. These include ischemic negative pressure therapy) in leak management. preconditioning, debates regarding the location (thoracic vs cervical) and approach to anastomosis (handsewn vs stapled), type of conduit (, jejunum, or colon), intraoperative Data Sources drain placement, and vascularized tissue reinforcement of the anastomosis at the time of initial operation. For this systematic Eligible studies for inclusion were identified using a review, we focused our question on whether intraoperative systematic search strategy (Table 1). Titles and abstracts of drain placement at the anastomosis impacts leak rate and/or 465 articles were reviewed and all English language studies duration and whether reinforcement of the esophagogastric examining intrathoracic esophageal anastomotic leak after anastomosis after esophagectomy with omentoplasty reduces esophagectomy were identified for inclusion. Articles were leak rate or need for reintervention. excluded if they were published in abstract only, reported It is widely accepted that adequate drainage is a critical leaks predominately for operations other than esophagec- principles guiding management of anastomotic leak, with tomy and esophagogastric anastomosis, were case reports mortality rates as high as 80% in the setting of uncontrolled, with less than 3 patients, or did not include anastomotic inadequately drained leak.9 Despite wide acceptance of the leak as a major focus of the article. Review articles other role for prophylactic intraoperative perianastomotic drain than systematic reviews and meta-analysis were also placement, the available literature analyzing the role for excluded. If more than one publication was found from the this approach is limited. Only 1 article was identified that same institution, only the largest series was included. focused on the role of intraoperatively placed drains in the Because the outcomes of interest are leak resolution and evaluation and management of anastomotic leak. Tang leak-related mortality, articles that did not report success et al, in a retrospective review of 414 patients who underwent rate or mortality rate after use of a stent to treat anastomotic esophagectomy with intrathoracic anastomosis, analyzed the

Table 1 Systematic literature search for management of anastomotic leaks Search terms Number of articles 1. ’esophagectomy’ AND (anastomosis OR anastomotic) AND leak AND (’complication’/exp/mj 326 OR complication) AND [humans]/lim AND [english]/lim AND [2000–2014] 2. ’esophagectomy’/exp AND (’anastomosis’/exp OR anastomotic) AND leak AND ’stent’/exp 70 AND [humans]/lim AND [english]/lim AND [2000–2014] 3. ’esophagectomy’/exp AND (’anastomosis’/exp OR anastomotic) AND oment* AND [humans]/lim 28 AND [english]/lim AND [2000–2014] 4. ’’ AND (’resection’/exp/mj OR ’resection’) AND ’anastomosis dehiscence’ 98 Total number of articles 522 Total number after removal of duplicates 465 Final number after review for inclusion and exclusion criteria and addition of articles 51 from review of references* *Exclusion criteria: abstract only; operations other than esophagectomy; anastomotic leak not a major focus of article; not published in English; case reports with ,3 patients; review articles other than systematic reviews and meta-analysis; other than esophagogastric anastomosis. 538 The American Journal of Surgery, Vol 208, No 4, October 2014 role of prophylactic placement of a drainage tube adjacent to the anastomosis at the time of surgical resection in addition to standard tube thoracostomy. A prophylactic drain adjacent to 15.2 6 the anastomosis was placed in 112 patients and leaks were SD) 6 6 identified in this group through detection of increased drain 6 volume, odor, and turbidity and were no longer able to hold suction. Confirmation of leak was achieved upon suspicion of leak at the bedside with methylene blue ingestion and im-

mediate discoloration of the drain. In contrast, 5 of the 11 pa- 11.5 23.1 6 523 tients with leaks without prophylactic drain required further 6 assessment with computed tomography and oral contrast to 6 6 establish the diagnosis. Of the remaining 6 patients, methy- lene blue with drainage into the chest tube ultimately estab- lished the diagnosis, although one patient required 3 doses before the methylene blue reached the chest tube. Eight pa- tients in the no drain group required placement of additional

drains to control the leak compared with none in the prophy- (%) Length of stay (days lactic drain group. Resolution of anastomotic leak was signif- n icantly faster in the prophylactic drain group (mean 23.4 vs 80.7 days; P , .05) as was return to oral intake (mean 32.2 vs 98 days).10 Perianastomotic drain placement permitted bedside assessment for leak using methylene blue and mini- mized the time delay in diagnosis that accompanies radio- graphic imaging. Use of drain amylase levels for confirmation of leak may be another advantage of perianasto- motic drain placement, but only one abstract (not published in manuscript form) was identified in the systematic review.11 It is important to note, however, that intraluminal migration of surgical drains can occur after esophagectomy.12 Wilmot et al reviewed 254 patients who underwent esophagectomy; 57 patients had anastomotic leak postoperatively and all 57 had perianastomotic drains in place at the time of leak diag- nosis. Four of the 57 patients had radiographic evidence of in- (%) Stricture formation, n traluminal migration of the surgical drain, either at or near the anastomosis an average of 19 days after esophagectomy. Proper drain position had previously been documented in Leak rate, all 4 patients, but only 2 of the 4 patients had previously docu- Omental flap No omental flap Omental flap No omental flap Omental flap No omental flap mented leaks before migration of the drain into the anasto- motic defect. Healing of the leak in all 4 patients was achieved after withdrawing the drain. Given these findings, perianastomotic drain placement likely facilitates earlier diagnosis and reduces the need for subsequent intervention

in some patients with low risk of drain-associated complica- Anastomotic technique tions, but the quality of data supporting the use of intraoper- ative perianastomotic drain placement is weak. The use of perianastomotic drainage may facilitate diagnosis and management of anastomotic leak but does Number of patients not minimize the occurrence of the leak. In contract, 194255607184 Handsewn Circular stapled Stapled Handsewn 1/128 (1) 3/97 (3) 7/127 10/215 3/92 (6) (5) (3) 14/97 (14) 41/392 (11) 9/92 (10) 8/128 (6) 10/97 (10) Not reported 20/127 7/97 (16) (7) 4/92 (4) 9 20.4 2/92 (2) 22 11 21 pedicled omental reinforcement of the thoracic esophago- gastric anastomosis has been proposed by several authors as 15 17

a means to decrease the incidence of anastomotic leak 13 (Table 2). During formation of the gastric conduit, a 2 or 14

3 vessel segment of omentum is retained on the greater Review of omental reinforcement following esophagectomy curvature near the anticipated location of the anastomosis. standard deviation. This segment is used to encircle the anastomosis, providing 5 a buttress for the staple line and containing endoluminal SD Author, reference Table 2 Bhat et al (2006) Dai et al (2011) Zheng et al (2013) contents in the event of anastomotic dehiscence. Sepesi et al (2012) L. Schaheen et al. Management of thoracic anastomotic leak 539

Systematic review revealed 3 randomized controlled trials, the setting of mediastinitis or empyema, surgical debride- a retrospective review, and a Cochrane database review, ment was used. Recently, however, endoluminal therapy which compared anastomotic complications in cases with with stenting and negative pressure therapy has been used omentoplasty reinforcement with those without reinforce- successfully for management of intrathoracic anastomotic ment.13–17 In 2006, Bhat et al13 published their experience leak. Systematic review for use of stent in the management of 184 patients randomized to receive omental reinforce- of anastomotic leaks revealed 25 articles, of which none ment of the esophageal anastomosis versus no reinforce- were randomized controlled trials; there was 1 systematic ment, and demonstrated a decrease in leak rate from review focusing on comparisons between types of . 3.4% vs 14.4%. The authors reported no complications Five articles described the use of negative pressure therapy related to omental pedicle mobilization. Dai et al reported for leak management. their experience with 255 patients, 127 of whom were ran- Endoscopic placement of stents for management of domized to receive anastomotic omental reinforcement. anastomotic leak was successful in 72% of patients, This study demonstrated a leak rate of 1% compared with aggregating results from the 25 articles (299/414 cases). 6% in patients without omental reinforcement.14 Neither Overall mortality was 15% when stents were used the Bhat trial nor the Dai trial demonstrated significant dif- compared with 3.3% to 11.6% for surgical repair. Data ferences in postoperative complication rates, hospital mor- for each series are summarized in Table 3. The types of tality, or length of stay or incidence of anastomotic stents used included partially and completely covered strictures. In 2010, Sepsi et al published a retrospective re- self-expanding metal stents (SEMS), self-expanding plastic view of their experience with thoracic transposition of an stents (SEPS), and Montgomery salivary tubes. A system- omental flap; the incidence of leak with omentoplasty atic review of 25 studies, including 267 patients, was per- was 4.7% versus 10.5% without omentoplasty. The need formed by van Boeckel et al to assess the clinical for reintervention was also decreased in the omentoplasty effectiveness and safety of temporary placement of stents cohort. Mobilization of the omentum from the transverse for anastomotic leak. They performed a pooled analysis colon and creation of the pedicle added approximately of clinical outcomes, complications and survival comparing 20 minutes to the operative time, and did not demonstrate fully and partially covered SEMS with SEPS. Clinical suc- any additional morbidity.15 cess was reported in 85% of patients and did not differ by The trials by Bhat and Dai were included in the Cochrane stent type. The average time for SEPS to remain in place review on the topic, published in 2012, which concluded that was 8 weeks, whereas SEMS remained for only 6 weeks. omentoplasty after esophagectomy may provide benefit with Stent-related complications, including migration, bleeding, regard to decreasing the incidence of anastomotic leak. The perforation, and tissue ingrowth, occurred in 34% of pa- review indicated that more randomized trials were needed.16 tients. Migration was more common with SEPS and fully In keeping with this finding, the most recent randomized trial covered SEMS than with partially covered SEMS (31% on the topic was published in 2013 by Zheng et al17 with 184 and 26% vs 12%, respectively), resulting in significantly patients randomized to omentoplasty (n 5 92) or non- higher rates of endoscopic reintervention for the former 2 omentoplasty (n 5 92). Similar to Bhat and Dai, they observed stents compared with the partially covered SEMS.18 a significant reduction in leak rate (9.8% vs 3.3%; P , .05). While it was not possible to separate the intrathoracic Uncontrollable leak with empyema and mediastinitis with anastomotic leaks from the other esophageal leaks reported subsequent death occurred in 2 patients in the non- in the 25 articles with regard to the reporting of compli- omentoplasty group experienced compared with none in the cations, they are important to note; serious complications omentoplasty group; this difference was not significantly included 11 patients with erosion of the stent into large different because of small numbers. Hospital stay was signif- vessels (eg, aorta) with hemorrhage that was usually icantly longer (21 vs 23 days; P 5 .01). Taken together, these fatal,19–24 and 6 patients who suffered extension of the studies suggest that routine reinforcement of the thoracic anas- anastomotic dehiscence with worsening of the tomosis with pedicled omental flap may reduce the incidence leak.20,23,25,26 Perforation of the stent through the conduit of anastomotic leak; recommendations based on this data can into the trachea was noted in 1 patient,27 airway obstruction be made with moderate strength, but further studies are needed from the stent in 2 patients,20 and left atrial compression in to determine which patients and surgical approaches are most 1 patient.28 Stent erosion, not otherwise specified, was re- likely to benefit from the additional intervention. ported in 3 patients,23,28 esophageal necrosis at the prox- imal stent resulting in patient death in another.29 Stent migration was a common problem, requiring repeat endo- Analysis of data regarding the safety, efficacy, scopic intervention and resulting in 2 reported bowel ob- and indications for endoscopic interventions structions without perforation.28 (stenting and negative pressure therapy) in leak These data suggest that stenting for esophageal anasto- management motic leaks is potentially beneficial but not without signif- icant potential risk. In general, endoscopic stenting is Historically, the approach to anastomotic leak has been limited to leaks involving less than 30% of the anastomotic to control drainage, nil per oral, and antibiotic therapy. In circumference and without extensive necrosis of the gastric 540 The American Journal of Surgery, Vol 208, No 4, October 2014

Table 3 Analysis of outcomes after stent placement for management of anastomotic leak after esophagectomy Number of Anastomotic Heal success, Author Year Type of stent patients technique n (%) Mortality, n (%) Doniec et al34 2003 pcSEMS 10 Not reported 8 (80) 1 (10) Evrard et al35 2004 SEPS 4 Not reported 4 (100) 0 Gelbmann et al25 2004 SEPS 5 Not reported 3 (60) 2 (40) Hu¨nerbein et al36 2004 SEPS 9 Stapled 9 (100) 0 Langer et al26 2005 SEPS 24 Not reported 16 (67) 3 (13) Schubert et al37 2005 SEPS 12 Circular stapled 11 (92) 0 Han et al22 2006 cSEMS 8 Not reported 6 (75) 2 (25) Kauer et al38 2008 cSEMS 10 Not reported 7 (70) 2 (20) Kim et al21 2008 MSBT 4 Not reported 4 (100) 0 Pennathur et al20 2008 SEPS 5 Not reported 2 (40) Not reported Tuebergen et al39 2008 cSEMS 19 Not reported 14 (74) 1 (5) Zisis et al40 2008 cSEMS 9 Not reported 7 (78) 2 (22) Kotzampassakis et al24 2009 Not reported 3 Not reported 3 (100) 0 Leers et al41 2009 cSEMS 15 Not reported 13 (87) 1 (7) Bona et al42 2010 cSEMS 3 Not reported 2 (67) 0 Dai et al30 2011 fcSEPS 18 Not reported 16 (89) 2 (11) David et al28 2011 cSEMS 5 Not reported 4 (80) 1 (20) D’Cunha et al23 2011 cSEMS or SEPS 22 Not reported 13 (59) 4 (18) Feith et al27 2011 fcSEMS 115 Not reported 81 (70) 10 (9) Freeman et al31 2011 SEPS and cSEMS 17 Not reported 16 (94) 0 Nguyen et al43 2011 cSEMS 9 Not reported 9 (100) 0 Schweigert et al19 2013 cSEMS 22 Stapled 17 (77) 5 (23) Brangewitz et al29 2013 cSEMS or SEPS 39 Not reported 21 (54) 11 (28) Leenders et al44 2013 SEMS-mix 15 Handsewn 11 (73) 5 (33) Schniewind et al45 2013 SEMS and SEPS 12 Not reported 2 (17) 10 (83) Total 414 299 (72) 62 (15) Heal success means that the stent is reported to heal the leak and not just seal with radiograph. The seal rate will always be higher than the actual heal rate. bd 5 biodegradable stent; cSEMS 5 covered self-expanding metal stent; fcSEMS 5 fully covered self-expanding metal stent; MSBT 5 Montgomery salivary bypass tube; pcSEMS 5 partially covered self-expanding metal stent; SEPS 5 self-expanding plastic stent.

conduit. Patients with extensive devitalization of esopha- shorter time to oral intake. Freeman et al31 demonstrated geal anatomy, large leaks, or a nonviable conduit are not that 82% of patients were able to resume oral intake within suitable for endoscopic management with stent placement. 72 hours of stent placement. If para-anastomotic and pleural drainage with existing Although multiple studies have demonstrated the suc- thoracostomy tubes is inadequate, insertion of additional cessful use of endoscopic stenting for the management of drains under thoracoscopic or computed tomography guid- anastomotic leaks, these studies are limited by small study ance may be required. A significant caveat of is populations with heterogeneous patient selection, lack of that it carries the risk of exacerbating an anastomotic randomized trials, use of a variety of stent types, varying defect. Because of the risk of mediastinal contamination management algorithms and, importantly, different under- during endoscopy, it is recommended that esophageal stents lying pathology. Limiting factors for the use of endoscopic be placed at the time of initial endoscopic diagnosis.30 The stenting may include the extent of the defect, delay in morbidity associated with endoscopic management and diagnosis and treatment, clinical condition of the patient, stenting extends to the required follow-up and often the and underlying malignant disease. Unfortunately, deter- need for repeat interventions. Serial surveillance chest radi- mining the efficacy of endoscopic stenting is difficult as no ography is required to monitor for stent migration, and standardized reporting system or clinical trials exist. Many when detected, repeat endoscopy is required to reposition studies report the ability of a stent to seal but not heal the the stent. Finally, endoscopic removal of the stent is the leak and mortality associated with anastomotic leak, even only definitive method to assess healing of the defect. Dai when managed with early endoscopic stenting, continues to et al30 demonstrated that in their series, repeat stenting be substantially higher than mortality for esophagectomy in was necessary in 33 of 40 patients, the mean number of general. For now, endoscopic stenting for the management stents per patient was 3.2, and the mean time to healing of intrathoracic leak remains experimental therapy and was 30 days. The principle advantage of endoscopic stent- providers should be fully aware of the associated risks and ing is immediate coverage of the anastomotic defect with inform their patients accordingly. L. Schaheen et al. Management of thoracic anastomotic leak 541

The goal of endoscopic stenting is to eliminate extra- anastomotic contamination of the mediastinum and pleura, while the dehiscence heals by secondary intention. Another option that may prove viable for achieving this same goal is to use endoscopically placed transluminal vacuum therapy. This technique was reported in 5 articles (2 were updates of the (%) previous experience at the same institution and the most Stricture formation noted on endoscopy, n recent, largest report was included), an adjunct to surgical management of anastomotic leak (Table 4). Similar to wound

(%) vacuum, which has been used with great success for abdom- n inal wound dehiscence and other large wounds with cavitary components, transluminal vacuum therapy involved place- ment of a sponge into the anastomotic defect cavity with suc- Post-treatment outcomes Symptomatic dysphagia, Not reported tion provided by a transnasal catheter. In the 3 articles included in this systematic review, 37 of 40 (93%) patients were suc- cessfully managed with endoscopic vacuum therapy. There were no episodes of significant bleeding or erosion reported. The wound vacuum sponge was changed at varying intervals, but on average between 2 and 3 times per week. While still experimental and not yet available in the United States, Schorsch et al argue that endoscopic vacuum drainage can be used for a wide range of defect sizes within the entire length 2 times per week

Week 1: 3 timesSubsequent per weeks: week of the esophagus and provides an opportunity for direct visu- alization of the inner wound at each vacuum system change.

Conclusions 2cm

, Early recognition and appropriate management of intra- thoracic anastomotic leaks have decreased leak-associated

cavity mortality, yet morbidity associated with the complication remains significant. Over the past several decades, there has been a shift in management of anastomotic leaks from aggressive surgical intervention to conservative manage- ment, and more recently to increasing utilization of (%) Duration of therapy Exchange interval

Treatment success, n endoscopic interventions. The basic principles of these management strategies remain the same, including closure or coverage of the defect, containment of the leak, and drainage of the contaminated paraesophageal and medias- tinal space. Based on a systematic review of the available literature, there appears to be weak evidence supporting

Anastomotic technique prophylactic drain placement for early identification and control of the leak and omental reinforcement to reduce the incidence and minimize contamination of the mediastinum. There is moderate evidence for the efficacy of endoluminal stents in appropriate patients, but the safety of stent use 6 Circular stapled 6 (100) 13.5 days 48–72 hours Not reported Number of patients 1717 Not reported 15 (88) Not reported Once 16 diameter of (94) wound remains 12 days in question and 1–7 days further research Not is reported needed 1 (6) to better understand the appropriate use of endoscopic stents for 47

45 management of intrathoracic anastomotic leaks. Negative

46 pressure wound vacuum therapy may become an important tool in the management of anastomotic leaks, but further study is needed and both stenting and wound vacuum should continue to be regarded as experimental therapy at Outcomes of endoscopic vacuum sponge therapy for anastomotic leak this time. To date, there are no guidelines for endoscopic stent selection nor treatment window for stenting. The patient’s clinical presentation, time to diagnosis, Table 4 Author, year Schniewind et al (2013) Schorsch et al (2013) Weidenhagen et al (2010) etiology, and size of the anastomotic defect should each be 542 The American Journal of Surgery, Vol 208, No 4, October 2014 considered in the clinician’s choice of management 7. Raju GS, Tarcin O. Endoscopic management of anastomotic esopha- strategy. All patients with loss of anastomotic integrity geal leaks. Tech Gastrointest Endosc 2006;8:66–71. should be treated with intravenous antibiotics, adequate 8. Pross M, Manger T, Reinheckel T, et al. Endoscopic treatment of clin- ically symptomatic leaks of thoracic esophageal anastomoses. Gastro- drainage, and nutritional support. Patients with leaks intest Endosc 2000;51:73–6. diagnosed early, absence of significant mediastinal 9. Cassivi SD. Leaks, strictures, and necrosis: a review of anastomotic contamination, smaller defects, and asymptomatic presen- complications following esophagectomy. Semin Thorac Cardiovasc tation may be amenable to endoscopic management with Surg 2004;16:124–32. stent placement. 10. Tang H, Xue L, Hong J, et al. A method for early diagnosis and treat- ment of intrathoracic esophageal anastomotic leakage: prophylactic Because of the high morbidity and mortality associated placement of a drainage tube adjacent to the anastomosis. with a second operation, surgical intervention should be J Gastrointest Surg 2012;16:722–7. reserved for patients with symptomatic or uncontained 11. Hill JS, Hanna EM, Hurley SC, et al. Relationship of drain amylase intrathoracic anastomotic leaks and those in whom conser- and anastomotic leak after esophagectomy. J Clin Oncol 2013;31. vative or endoscopic management has failed. It is important 12. Wilmot AS, Levine MS, Rubesin SE, et al. Intraluminal migration of sur- gical drains after transhiatal esophagogastrectomy: radiographic find- for the esophageal surgeon to be familiar with the options ings and clinical relevance. AJR Am J Roentgenol 2007;189:780–5. for surgical management. It is equally important that 13. Bhat MA, Dar MA, Lone GN, et al. Use of pedicled omentum in endoscopic management be quickly abandoned in a patient esophagogastric anastomosis for prevention of anastomotic leak. who is not thriving after endoscopic therapy, as this is likely Ann Thorac Surg 2006;82:1857–62. an indication that the leak is not controlled. Options for 14. Dai JG, Zhang ZY, Min JX, et al. 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