Incidence and treatment of mediastinal leakage after esophagectomy: Insights from the multicenter study on mediastinal leaks

Table 1 Patients’ characteristics and perioperative information

	Number of patients	Patients with ML n (%)	P value
Total	501	59 (11.8)
ASA score			0.43
1-2	266	32 (12.0)
3-4	158	24 (15.2)
Histology			0.96
Adenocarcinoma	385	44 (11.4)
Squamous carcin.	101	12 (11.8)
Other	7	2 (28.5)
T			0.34
1-2	212	34 (16.0)
3-4	280	34 (12.1)
N			0.098
0	200	36 (18.0)
+	274	31 (11.3)
Neoadjuvant chemotherapy			0.89
Yes	314	37 (11.8)
No	187	22 (11.8)
Pyloric procedure			0.14
Yes	53	10 (18.9)
No	448	49 (10.9)
	Patients with no ML	Patients with ML	P value
Median body mass index (range)	25 (15-33.3)	27.5 (17.7-35)	0.0328
Median surgery duration (range)	360 (127-700)	330 (173-615)	0.6707

ML: Mediastinal leakage.

Table 2 Number of esophagectomies and leaks by center

Center	1	2	3	4	5	6	7	All
Number of esophagectomies	64	66	16	127	62	151	15	501
Number of leaks	1	3	1	10	11	30	3	59
Leak/esophagectomies (%)	1.6	4.5	6.3	7.9	17.7	19.9	20.0	11.8

Centers 1, 2, 4, 5, and 6 are high-volume centers, whereas centers 3 and 7 are low- volume centers.

Table 3 Mediastinal leaks and mortality rates in the multicenter study on mediastinal leaks

	TEG	30-d mortality		90-d mortality		Post-op day of diagnosis1
		Leak n (%)	All n (%)	Leak n (%)	All n (%)
Patients	501	3 (0.6)	7 (1.4)	9 (1.8)	16 (3.2)
Leaks2	59 (11.8)	3 (5.1)		6 (10.2)		3 (1-58)
Necrosis2
Type I	5			0		8 (4-8)
Type II	30			2 (6.7)	2 (6.7)	4 (1-28)
Type III	24	3 (12.5)		7 (29.2)	10 (41.7)	7 (4-58)
P value		0.038		< 0.001

¹Median values for the postoperative day on which the mediastinal leak was diagnosed;

²Mediastinal leak was defined according to the taxonomy recently proposed by the Esophageal Complications Consensus Group[11]. TEG: Transthoracic esophagectomy with intrathoracic anastomosis.

Table 4 Mediastinal leakage rate by surgical technique

	Surgical technique			Total	P value
	Open IL	Hybrid IL	MIIL1
Number of TEG	152	244	105	501
Number of leaks	16	22	21	59
Leakage rate (%)	10.5	9.0	20.0	11.8
Necrosis - type I	1	4	0	5
Necrosis - type II	9	10	11	30
Necrosis - type III	6	8	10	24
Hybrid vs MI					0.0072
Open vs MI					0.0520
Open + hybrid vs MI					0.0560

¹Minimally invasive Ivor Lewis (MIIL) procedure performed in 4 of the 7 surgical centers. Anastomoses in MIIL are mainly semi-mechanical (highest leaking rate compared to manual and mechanical). TEG: Transthoracic esophagectomy with intrathoracic anastomosis; MIIL: Minimally invasive Ivor Lewis; IL: Ivor Lewis; MI: Minimally invasive.

Table 5 Treatment of mediastinal leaks

	Conservative	Endoscopic			Surgical
	NGT antibiotics	NED	ES	Other	Deb	Redo A	Dem
Primary, n	81	11	12	62	6	10	6
Primary, %	13.6	49.2			37.3
Retreat, n	1	2	1	2	2
Retreat, %	12.5	17.2			9.1
Secondary	1 stent	2 end stent	1 restent	1 surg+stent; 1 stent	1 redo A 1 restent
Tertiary		1 reanast		1 reanast; 1 restent	1 dem
Total leaks	7	26			26
Mortality	2		2			3	2
Mortality (%)	25	6.9			22.7

¹Eight patients: radiologically guided drainage (pleural/mediastinal collections).

²One patient transferred to another hospital. NED: Naso-esophageal extraluminal drainage. ES: Endoscopic stent; Other: Other endoscopic treatment (clip, glue); Deb: Surgical debridment with or without stent; Redo A: Redo anastomosis; Dem: Demontage.

Table 6 Mediastinal leakage and mortality rates: Multicenter study on mediastinal leaks and other studies

	Patients	Mortality rates		Leakage rates	Leak-related mortality rates
Price’s in 2013	268	3.71		5.9
Dent et al[28] 2016	377	01		7.2	0
Van Daele et al[9] 2016	412			2.9
Guo et al[15] 2014	1867			1.8	18.2
		30-d	90-d		30-d	90-d
Rutegård et al[8] 20122	559		6.2	7.9
Kassis et al[16] 20133	1559	3.6		9.3
MuMeLe study4	501	1.4	3.2	11.8	5.0	15.3

¹Operative mortality rate;

²Multicenter prospective study;

³Multicenter retrospective study;

⁴Multicenter retrospective study. MuMeLe: Multicenter study on mediastinal leaks.

Table 7 Mediastinal leakage and mortality rates by minimally invasive technique: Multicenter study on mediastinal leaks and other studies

Technique	Study	Patients	Operative mortality rate	Mediastinal leakage rate
MIIL	van Workum et al[23] 2019	646	2.3	14.4
	Schmidt et al[13] 2017	49	6.1	6.1
	Zhang’s in 2017	15		0.0
	Mungo et al[25] 2016	52	3.8	14.0
	MuMeLe study	105	5.9	20.0
Hybrid	Woodard’s in 2017	143	2.5	2.5
	MuMeLe study	244	1.8	9.0

MIIL: Minimally invasive Ivor Lewis; Hybrid: Hybrid Ivor Lewis; MuMeLe: Multicenter study on mediastinal leaks.