Mortality secondary to esophageal anastomotic leak.

BACKGROUND: Esophageal anastomotic leak is a potentially life threatening complication of esophagectomy and esophagogastrectomy. We reviewed our experience with this complication and tried to identify factors predictive of mortality after esophageal anastomotic leak. METHODS: Records of patients undergoing esophagectomy and esophagogastrectomy for benign or malignant disease over a 10-year period (1989-1999), who developed esophageal anastomotic leaks, were reviewed. RESULTS: Three-hundred and seven patients underwent esophagectomy or esophagogastrectomy. Twenty-three (7.5%) developed esophageal anastomotic leaks. Eight of these patients (35%) died. Four of 23 (17%) patients had seemingly normal postoperative contrast studies. Factors potentially predictive of death included age (died, 72.8+/-8.3 years; survived, 65.3+/-8.8 years; p=0.063), location of anastomosis (cervical, 3/9 died; thoracic, 5/14 died; p=0.91), leak presentation (clinical, 6/12 died; contrast study, 2/11 died; p=0.11), time of leak (<7 days, 3/5 died; > or =7 days, 5/18 died; p=0.18), presence of gastric necrosis (necrosis, 3/3 died; no necrosis, 5/20 died; p=0.019), and treatment (surgical, 4/4 died; conservative, 4/19 died; p=0.005). CONCLUSIONS: Postoperative esophageal anastomotic leaks prove fatal in a significant number of cases. The lethal potential of cervical anastomotic leaks should not be underestimated. Gastric necrosis is an important predictor of subsequent death. Advanced age, early postoperative (<7 days) leakage, and clinically apparent signs of leakage may be predictive of death but these factors did not reach statistical significance in our study. Surgical treatment of esophageal anastomotic leaks is associated with subsequent death, but this relationship is unlikely to be causal; severely ill patients tend to be treated surgically.     

Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis

BACKGROUND: Although the acute postoperative complications of a cervical esophagogastric anastomosis are less than those with an intrathoracic esophageal anastomosis, the long-term sequelae of a cervical anastomotic leak are not as minor as initially reported. Nearly 50% of cervical anastomotic leaks result in an anastomotic stricture, and the subsequent need for chronic dilatations negates the merits of an operation intended to restore comfortable swallowing. OBJECTIVE: This study was undertaken to determine whether construction of a side-to-side stapled cervical esophagogastric anastomosis after transhiatal esophagectomy could reliably eliminate the majority of anastomotic leaks. METHODS: In 114 consecutive patients undergoing transhiatal esophagectomy, a functional side-to-side cervical esophagogastric anastomosis was constructed with the Auto Suture Endo-GIA II stapler (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn) applied directly through the cervical wound. This side-to-side stapled anastomosis has 3 rows of staples. Early postoperative anastomotic morbidity, subsequent need for anastomotic dilatations, and patient satisfaction with swallowing were evaluated. RESULTS: Before the side-to-side stapled anastomosis, the incidence of cervical esophagogastric anastomosis leak in over 1000 patients undergoing transhiatal esophagectomy having a manually sewn anastomosis varied from 10% to 15%. Among the 111 survivors of transhiatal esophagectomy and a side-to-side stapled anastomosis, there were 3 (2.7%) clinically significant anastomotic leaks. This lowered incidence of leaks has contributed to reduction in the average length of stay after an uncomplicated transhiatal esophagectomy to 7 days and has provided more comfortable swallowing, ease of subsequent esophageal dilatations, and greater patient satisfaction. CONCLUSIONS: Construction of the cervical esophagogastric anastomosis with a side-to-side stapled anastomosis greatly reduces the frequency of anastomotic leaks and later strictures. The side-to-side stapled anastomosis is a major technical advance in the progression of refinements of transhiatal esophagectomy and a cervical esophagogastric anastomosis.     

Factors affecting leakage following esophageal anastomosis

Esophageal anastomotic leaks remain the most serious problem following extirpative procedures for esophageal carcinoma. We conducted a retrospective analysis of 352 patients with carcinoma in the thoracic esophagus who had undergone esophageal anastomosis following esophagectomy at the Kurume University Hospital between 1981 and 1990. Of these, 94 patients (27%) developed anastomotic leaks, and out of this subgroup, 21 (6%) died as a direct result of the leak. A further 20 patients (6%) underwent repair of the leak, after which they were able to tolerate oral intake. The anastomotic leak healed spontaneously in the other 53 patients (15%). The risk factors predisposing to leaks from esophageal anastomoses were determined as: (1) the anastomosis being performed via a retrosternal or subcutaneous route as opposed to an intrathoracic route, (2) the use of colonic interposition as opposed to a gastric pedicle, (3) performing a manual anastomosis as opposed to a mechanical anastomosis, and (4) employing an end-to-end anastomosis, as opposed to an end-to-side anastomosis, using a mechanical method. By introducing an anastomotic stapling device, a microvascular technique, a staged operation based on the preoperative risk analysis, and improvement in pre- and postoperative management, the incidence of anastomotic leakage could be decreased from 35% to 14%, and that of consequent hospital mortality, from 9% to 2%.     

Modified Nissen fundoplication combined with Ivor Lewis esophagogastrectomy

Esophageal carcinoma is a difficult neoplasm to treat, with a reported overall 5-year survival of about 15%. The role of chemotherapy and radiation has yet to be defined, making surgical resection the standard treatment. Postoperative esophageal leak remains a significant contributor to morbidity and mortality, especially after an intrathoracic anastomosis. We propose a modification of the Ivor Lewis esophagogastrectomy that has resulted in two anastomotic leaks in a series of more than 500 patients.     

Collare Anastomosenstenosen nach Magenhochzug beim Ösophaguskarzinom

Common late complications after esophagectomy and gastric tube reconstruction for esophageal carcinoma are symptomatic, benign fibrotic stenoses of the cervical anastomosis, which require dilatation. Since the prognosis of esophageal carcinoma still remains poor, bad functional results such as dysphagia affect quality of life. In a retrospective analysis, our patients were evaluated with regard to the underlying effects of cervical anastomotic stenosis after esophagectomy and gastric tube reconstruction. From 1 January 1989 to 31 July 1995, 173 patients with carcinoma of the esophagus were operated in our institution. Transhiatal esophageal dissection was performed in 133 patients; 40 patients underwent transthoracic en bloc resection. The 30-day mortality rate was 7.5% (13 patients). Postoperative fibrotic stenosis of the cervical anastomosis requiring dilatation occurred in 36.4% (63 patients) 6–12 weeks after operation. Fibrotic stenosis of the cervical anastomosis did not develop in 97 patients. There was a significant difference concerning the incidence of anastomotic leaks within both groups: whereas in 23.8% of the 63 patients who developed a fibrotic stricture of the cervical anastomosis an anastomotic leak preceded this event (P<0.001), no anastomotic leak occurred in the group of 97 patients with normal healing of the cervical anastomosis. In addition, significantly (P<0.01) more patients (37.5%,n=23) with preexisting diabetes mellitus could be found among the 63 patients who developed a fibrotic stricture of the cervical anastomosis, in contrast to the 97 patients without anastomotic stenosis.     

Diagnostik und Definition der Nahtinsuffizienz aus chirurgischer Sicht

The leak rates of different gastrointestinal anastomoses vary considerably but despite this there are common and general concepts for diagnosis and management. Early diagnosis and timely consistent therapy must guide management to prevent harm to the patients. Diagnosis of anastomotic leaks is coupled to clinical signs of the patients and should be initiated promptly. Dependent on the localization of the leak, computed tomography with administration of oral or rectal contrast dye and endoscopy are of high diagnostic value. Both procedures guarantee the option of drainage or stenting through interventional drains or stent placement. Only the implementation of uniform definitions of anastomotic leaks enables surgeons to compare and to improve surgical treatment. Over recent years consensus definitions of postoperative complications including bile leak, pancreatic fistula and colorectal leak have been formulated. These definitions are based on a 3-fold increase of bilirubin (bile leak) or amylase levels (pancreatic fistula) in abdominal drainage fluid compared to serum levels or on an intestinal wall defect with communication of the intraluminal and extraluminal compartments (colorectal anastomosis). The definitions each describe three severity grades A?CC. A change of clinical management is required in grade B whereas grade C usually requires a re-operation. Comparable consensus definitions for anastomotic leaks following esophagogastrostomy or esophagojejunostomy or following small bowel anastomosis have not been established. The authors strongly recommend implementation of the presented consensus definitions into clinical and academic daily practice.     

The esophageal anastomotic leak

Sixty-three esophageal anastomoses were performed on adult patients with esophageal or gastric cancer. A total of thirteen anastomotic leaks occurred, resulting in death in seven patients and serious morbidity in an additional patient. Twelve patients had esophagocolostomy, with five anastomotic leaks. Four leaks occurred in the cervical region and were easily managed by local drainage and irrigation, while the other patient had an intrapleural leak resulting in sepsis and death. Twenty-eight patients had esophagogastrostomy, with a total of five leaks. All anastomoses were intrapleurally located, and death ensued in four patients. Fourteen Roux-en-Y and three loop esophagojejunostomies were performed, with no leaks. Two additional deaths occurred from leakage in the pleural cavity and left upper abdomen after jejunal interposition (3 patients) and esophagoduodenostomy (3 patients). In this study, impaired blood supply of the anastomotic end appeared to be the major cause of anastomotic failure. In addition, postoperative shock appeared to predispose to anastomotic leakage, whereas microscopic tumor at the line of resection, duration of operation and operations for palliation did not appear to increase the leakage rate. The high mortality with esophageal anastomotic leak occurs when diagnosis is delayed and when the site of leakage is in the pleural cavity or left upper abdomen. Conservative treatment is uniformly fatal, whereas operative intervention offers the only chance for survival.     

Do We Really Know Why Colorectal Anastomoses Leak?

Introduction

Colorectal anastomotic leak, a feared complication, results in significantly increased patient morbidity, mortality, and hospital resource utilization. The overall incidence of colorectal anastomotic leak is approximately 11 % with increasing rate the closer the anastomosis is to the anal verge. Because surgeons are unable to reliably predict which anastomosis would fail, most will construct a diverting ileostomy for low colorectal anastomosis to circumvent the devastating complications of anastomotic failure. Despite extensive investigations on technical considerations of anastomosis construction, anastomotic leaks continue to occur at an unacceptably high rate.

Discussion

In this review, we examine the major known risk factors and technical considerations that have been implicated as factors in leakage. Although surgical technique has evolved over the past several decades with the advent of newer surgical staplers, laparoscopy, and robotics, we have not witnessed a decrease in the incidence of colorectal anastomotic leaks suggesting that the fundamental pathogenesis of anastomotic leak remains unknown. Among the factors contributing to anastomotic healing, intestinal bacteria remains largely overlooked even though compelling evidence exist that intraluminal microbes could play a major role in pathogenesis of anastomotic leak. Further investigation focusing on intestinal microbes could be one such avenue for uncovering the elusive cause of colorectal anastomotic leak.     

Unifying concepts in treatment of esophageal leaks

We treated 75 patients with esophageal trauma, perforation, or anastomotic leak. Several factors were shown to be associated with an increased mortality, including delayed treatment, presence of severe underlying esophageal disease, total parenteral nutrition catheter infection, the necessity for major extirpative procedures to treat the perforation, and the use of exclusion and diversion in the continuity procedure. The use of local muscle flaps to buttress suture line closure has led to excellent results in the 19 patients so treated. Delayed treatment of perforation or an anastomotic leak is a major problem, but the treatment protocol described herein has led to the survival of 12 of 16 patients treated. The use of primary muscle flap closure for extensive esophageal defects or delayed treatment of nonhealing leaks was evaluated in five patients. All five had healing of the defect, with one resultant esophageal stricture.     

Incidence and management of anastomotic leakage following laparoscopic prostatectomy with implementation of a new anastomotic technique incorporating posterior bladder neck tailoring

In laparoscopic prostatectomies, vesicourethral anastomotic leaks may result in significant morbidity because of the chemical and metabolic derangements created by urine within the peritoneal cavity. To date, minimal data are available on this problem. Herein we present our experience with urine leaks after RALP. Over a period of 24 months, 135 men underwent RALP. Any drainage creatinine greater than two times the serum creatinine was considered as an anastomotic leak. According to our criteria, 20% of the first 110 patients developed an anastomotic leak. The patients were analyzed in two groups, those with and without leaks. In the two groups, there was no statistically significant difference in age, height, weight, prostate volume and pre-op hemoglobin. The patients with leaks did have higher rate of prior abdominal surgery (50 vs. 36%), higher average pre-operative PSA values (7.6 vs. 6.1), higher rates of multiple biopsies (27 vs. 17%) and a higher average BMI (29.6 vs. 27.8). Intraoperative differences included an average of 30 min longer operative time and 66 cm³ higher average EBL in patients with leaks. The transfusion rate was higher in the leak group at 18 vs. 1% in the no leak group. Recovery tended to be longer in patients with leaks, with hospital stays of an average of 3.6 days longer. The most common indication for prolonged hospitalization was ileus, which 55% of patients with leaks developed. Management included placing the catheter on mild traction, continuous antibiotics and taking the drain-off suction with caution to monitor the signs of a worsening ileus. In the last 25 patients, we revised our anastomotic technique. We now include posterior tailoring of the bladder neck prior to the vesicourethral anastomosis when the bladder neck is enlarged. This facilitates a water-tight anastomosis. Using this technique, we have yet to see the anastomotic leak. In RALPs, anastomotic leaks can lead to ileus formation and longer hospital stays. These leaks are associated with a higher average blood loss and transfusion rate. Management should focus on prevention. Since we have incorporated posterior bladder neck tailoring with the anastomosis, the problem has been markedly reduced.     

The management and outcome of anastomotic leaks in colorectal surgery

Purpose  Anastomotic leaks in colorectal surgery are associated with significant morbidity and mortality and may result in poor functional and oncological outcomes. Diagnostic difficulties may delay identification and appropriate management of leaks. The aim of this study was to look at the diagnosis, clinical management and outcomes of anastamotic leaks in our department.
Method  A retrospective audit and case note review of all patients who underwent the formation of a colorectal anastomosis between January 1996 and December 2002 ( n  = 1421) was performed. An anastomotic leak was defined as sepsis identified to have arisen from an anastomosis that subsequently required surgery, radiological drainage or intravenous antibiotics. Forty-one patients (25 male, 16 female) with a median age of 60 years (range 7–89 years) were identified as having suffered an anastomotic leak.
Results  The median time to diagnosis of an anastomotic leak following surgery was 7 days (range 3–29). At re-operation, 21 patients (51%) underwent formation of a stoma, and any who required the anastomosis to be formally taken down have been left with a 'permanent' stoma. Currently only four of 12 patients (33%) who required a stoma for an anastomotic leak following anterior resection have undergone stoma reversal. Eleven of 16 patients (69%) who had received a stoma following another colorectal procedure had undergone stoma reversal. The mortality associated with an anastamotic leak in this series was 5% ( n  = 2).
Conclusion  Although anastomotic leaks following colorectal surgery are associated with significant morbidity and stoma formation, early and aggressive management should result in a low overall mortality. If an anastomosis is taken down following an anastomotic leak after anterior resection, this will usually result in a 'permanent' stoma.     

Treatment of intrathoracic esophageal anastomotic leaks by means of endoscopic stent implantation

Intrathoracic anastomotic leakage in patients with esophagectomy is associated with high morbidity and mortality. Until recently surgical reexploration was the preferred way of dealing with this life-threatening complication. But mortality remained significant. After the first successful reports we adopted endoscopic stent implantation as a primary treatment option. The aim of this study was to investigate the feasibility and the results of endoscopic stent implantation. Between January 2004 and December 2009, 167 patients underwent an esophageal resection. Surgery was mainly the result of esophageal cancer. An intrathoracic esophageal anastomotic leak was endoscopically verified in 17 patients. Twelve patients received an implantation of a self-expanding stent as a primary treatment. An endoscopic stent placement was accomplished in all 12 patients. In nine patients a definitive closure of the leak was achieved and the stent could subsequently be removed. Two patients died due to severe sepsis in spite of sufficient stent placement. Because of early recurrence of very malign small cell cancer the stent remained in situ in one patient. In conclusion, stent implantation for intrathoracic esophageal anastomotic leaks is feasible and compares favorable with the results of surgical reexploration. It is an easily available minimally-invasive procedure which may reduce leak-related mortality and morbidity.     

Use of decellularized human skin to repair esophageal anastomotic leak in humans.

Multiple surgical techniques have been described for repair of esophageal leaks. None of the repairs are optimal, and the morbidity and mortality of an esophageal leak remains high. To our knowledge, this is the first case report of use of AlloDerm (Lifecell Corp, Brachburg, NJ) to successfully repair a thoracic anastomotic esophageal leak.     

Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy

Background In patients with esophagectomy and gastric pull up for esophageal carcinoma anastomotic leaks are a well-known complication and a major cause of morbidity and mortality. Objective We evaluated stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Methods 269 patients with esophageal cancer (adenocarcinoma n = 212, squamous cell carcinoma n = 57) had undergone esophagectomy and gastric pull up with an intrathoracic anastomosis between January 1998 and December 2005. A thoracic anastomotic leak was clinically and endoscopically proven in 12 patients (4.5%). Endoscopic insertion of a self-expanding covered metal stent at the site of the anastomotic leak was performed in 10 patients; two patients were treated with fibrin glue. Results Stents were successfully placed in all patients without complications. In all but one patient (n = 9) radiological examination showed complete closure of the leakage. In one patient the stent was endoscopically corrected and complete closure could be achieved thereafter. The stent could be removed after six weeks in five patients. Stent migration occurred in four patients. In all but one patient (n = 7) definitive leak occlusion was achieved. Two patients died during their hospital stayfor reasons not related to the stent placement. Conclusion Stent implantation in patients with thoracic anastomotic leaks after esophagectomy is an easily available and effective treatment option with low morbidity, but stent migration does occur.     

Esophagogastric anastomoses: the value of fibrin glue in preventing leakage

Disruption of an esophagogastric anastomosis can result in a high mortality despite aggressive treatment. The efficacy of fibrin "glue" to seal esophagogastric anastomoses was evaluated as a means of preventing this complication. A left thoracotomy was performed in 25 adult mongrel dogs. After esophagogastric resection, a standardized esophagogastrostomy was performed and eight interrupted sutures were used to completely close the posterior wall. The anterior wall was approximated with only three sutures, leaving four large holes between sutures. The dogs were then randomized into the control group (n = 14; no attempt to seal the leaks) or into the fibrin glue-treated group (n = 11). An average of 3.3 ml of glue was applied to the anterior wall of the anastomosis in the treated group. In the control group, 13 of 14 dogs (92.9%) died of anastomotic leak a median of 3 days after operation. In the fibrin glue-treated group, only four of 11 dogs (36.4%) died of anastomotic leaks (p less than 0.01). Dogs that survived were put to death at 14 days. Postmortem examination in all dogs revealed no deleterious effects or complications related to the glue. Postmortem examination of the one surviving control dog and the seven fibrin glue-treated dogs that did not die of sepsis revealed a healed anastomosis without abscess formation. We conclude that fibrin glue is effective in lessening the incidence of esophagogastric anastomotic leaks as employed in this experimental model.     

Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks

Background  Esophageal perforations and extensive anastomotic leaks after esophageal resection or gastrectomy are surgical emergencies with high mortality rates. In recent years, the use of self-expanding metallic stents (SEMS) has emerged as a promising treatment alternative for bridging and sealing the damage. This study aimed to evaluate the role of covered SEMS for the management of esophageal perforations and anastomotic leaks. Methods  All esophageal stent placement procedures (174 procedures for 157 patients) at the authors’ unit between January 1999 and April 2008 were assessed by a retrospective chart review. Of the 157 patients, 10 (6.4%) were treated with SEMS for sealing of an iatrogenic esophageal perforation (n = 4), a spontaneous esophageal rupture in Boerhaave’s syndrome (n = 4), or an anastomotic leakage (n = 2). Results  The median time from perforation or anastomotic leak to stent insertion was 13 days (range, 2 h to 48 days). The esophageal leak was totally sealed for 8 (80%) of 10 patients. The overall mortality rate was 50% (n = 5), and three (30%) of the five deaths were related to the perforation (n = 2) or leakage (n = 1). In both of the perforation cases, the diagnosis and treatment were substantially delayed. One patient with an anastomotic leak after gastrectomy died of the complication despite successful operative and SEMS treatment. Two of the deaths were unrelated to the perforation. In both cases, the cause of death was a disseminated malignant disease. Conclusions  Traumatic perforations and anastomotic leaks can be treated effectively with covered SEMS together with adequate drainage of the thoracic cavity even in cases of severely ill patients with inveterate esophageal perforations and leaks.     

先天性食管闭锁的外科治疗

目的 总结32例先天性食管闭锁手术治疗经验。方法 手术均采用食管上盲端前壁肌层U形翻转，即经胸膜外入路充分游离食管上端及瘘管，近气管侧缝扎切断瘘管。用剪刀将远端食管前壁纵行剪开5min，吻合前距吻合口上方10min处行食管上下两端浆肌层缝合3针，然后距吻合口上方15～20min处将食管前壁肌层切开，从切开处向吻合口方向从两侧纵行切开肌层至吻合口约5mm，轻轻分离前壁肌瓣，形成U形向下翻转，缝合在食管远端浆肌层上。结果 32例中17例采用此方法未发生吻合口瘘，1例吻合口狭窄。2例成功行一期胃代食管术。结论 食管上盲端前壁肌瓣U形翻转能有效预防吻合口瘘及狭窄。Ⅰ、Ⅱ型食管闭锁采用一期胃代食管术，可避免二次手术。     

Salvage esophagectomy after definitive chemoradiotherapy

Salvage surgery is the sole curative-intent treatment option for patients with esophageal cancer after definitive chemoradiotherapy. The most significant factor associated with long-term survival appears to be RO resection. Patients who undergo salvage esophagectomy have high morbidity and mortality rates. Extended three-field lymphadenectomy should be limited in salvage surgery. Ischemic tracheobronchial lesions are serious complications of salvage esophagectomy. The right posterior bronchial artery should be preserved, and neck dissection should be avoided to preserve the blood supply from the inferior thyroidal artery to the trachea. The anastomotic leak rate is also significantly increased after salvage esophagectomy. Irradiation of the esophagus and stomach may affect the blood supply, which may then contribute to leakage. Gastric conduit necrosis in the posterior mediastinum can cause mortal mediastinitis, necessitating surgical modifications to reduce the impact of leaks into the thoracic cavity. The reconstruction route was changed to the anterior mediastinum with cervical anastomosis. Long-term or late cardiopulmonary toxicity cannot be ignored in patients who undergo salvage esophagectomy. A high morbidity rate is acceptable in view of the potential for long-term survival after salvage esophagectomy. Patients should be carefully selected for salvage esophagectomy after high-dose chemoradiotherapy at referral centers that specialize in esophageal cancer treatment.     

Role of Fibrin Glue as a Sealant to Esophageal Anastomosis in Cases of Congenital Esophageal Atresia with Tracheoesophageal Fistula

Objective The aim of this study was to characterize a successful approach for the management of infants with long-gap esophageal atresia (EA) with tracheoesophageal fistula (TEF). The goal was to preserve the native esophagus and minimize the incidence of esophageal anastomotic leaks using fibrin glue as a sealant over the esophageal anastomosis. Method A total of 52 patients were evaluated in this study. Only patients in whom, gap between the two ends of the esophagus was ≥ 2 cm were selected during January 2005 to January 2007. Patients were divided in two groups on the basis of block randomization. Group A comprised the patients in whom fibrin sealant was used as reinforcement on a primary end-to-end esophageal anastomosis; in group B, fibrin glue was not used. The two groups were compared in terms of esophageal anastomotic leak (EL), postoperative esophageal stricture (ES), and mortality. The statistical analysis was done using Fisher’s exact test and the chi-squared test. Result The number of anastomotic leaks in group A (glue group) was about one-fifth that in group B (no glue group). The incidence of ES was almost twice as high in group B as in group A. The mortality rate was almost threefold higher in group B (no-glue group). The higher incidence of EL and ES in group B compared to group A was statistically significant. Conclusion Thus, fibrin glue when used as an adjunct to esophageal anastomosis for primary repair of long-gap EA with TEF appears safe in the clinical setting and may lower the chances of esophageal leak and anastomosis-site strictures. Hence, it can diminish the mortality and morbidity of these patients.     

Selective management of intrathoracic anastomotic leak after esophagectomy

OBJECTIVE: We sought to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy. METHODS: All patients who had intrathoracic anastomotic leaks after esophagectomy were reviewed. Management and factors affecting outcome were analyzed. RESULTS: From March 1993 through February 2003, 761 patients had esophagectomy with intrathoracic anastomosis at our institution. Forty-eight (6.3%) patients had an anastomotic leak; one refused authorization to review his medical record and was excluded from further analysis. Twenty-four (51.1%) patients had a contained leak. Twenty-seven (57.4%) patients were managed nonoperatively. Twenty (42.6%) patients required surgical intervention that included primary anastomotic repair in 14 patients, reinforcement of the anastomosis with viable tissue in 6 patients, and esophageal diversion in 2 patients. A single reoperation was done in 15 patients, and 5 patients had 2 reoperations. Median hospitalization in the reoperative group was 31 days (range, 15-97 days) and 20 days (range, 10-42 days) in the nonoperative group ( P = .0037). Four (8.5%) patients died. Cause of death was sepsis in 2 patients and multiorgan failure and myocardial infarction in 1 patient each. At follow-up (median, 8 months; range, 1-120 months), 10 (58.8%) patients in the reoperative group were eating a normal diet and 5 (29.4%) patients required at least one dilatation compared with 20 (76.9%) patients in the nonoperative group who were eating a normal diet and 9 (34.6%) who required at least one dilatation. A noncontained leak had an adverse effect on long-term survival ( P = .04). CONCLUSION: Intrathoracic anastomotic leak after esophagectomy is associated with significant morbidity and mortality. Contained leaks often can be managed nonoperatively. When surgical management is required, esophagogastric continuity can often be maintained in the majority of patients. Long-term functional results are satisfactory and similar in both the reoperative and nonoperative groups. However, a noncontained leak adversely affected long-term survival.