Fluoroscopically guided nose tube drainage of mediastinal abscesses in post-operative gastro-oesophageal anastomotic leakage

Objective

The aim of this study was to retrospectively evaluate the technical success rates and clinical effectiveness of fluoroscopically guided nose tube drainage of mediastinal abscesses and a nasojejunum feeding tube in post-operative gastro-oesophageal anastomotic leakage (GEAL).

Methods

From January 2006 to June 2011, 18 cases of post-operative GEAL with mediastinal abscesses after oesophagectomy with intrathoracic oesophagogastric anastomotic procedures for oesophageal and cardiac carcinoma were treated by insertion of a nose drainage tube and nasojejunum feeding tube under fluoroscopic guidance. We evaluated the feasibility of two-tube insertion to facilitate leakage site closure and complete resolution of the abscess, and the patients’ nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube.

Results

The two tubes were placed successfully under fluoroscopic guidance in 18 patients (100%). The procedure time for two-tube insertion ranged from 20 to 40 min (mean 30 min). 17 patients (94%) achieved leakage site closure after two-tube insertion and had a good tolerance of two tubes in the nasal cavity. The serum albumin level was significant, increased from pre-enteral feeding (2.49±0.42 g dl⁻¹) to the post-enteral feeding (3.58±0.47 g dl⁻¹) via the feeding tube (p<0.001). The duration of follow-up ranged from 1 to 49 months (mean 19 months).

Conclusion

The insertion of nose tube drainage and a nasojejunum feeding tube under fluoroscopic guidance is safe, and it provides effective relief from mediastinal abscesses in GEAL after oesophagectomy. Moreover, our findings indicate that two-tube insertion may be used as a selective procedure to treat mediastinal abscesses in post-operative GEAL.

Advances in knowledge

Directive drainage of mediastinal abscesses in post-operative GEAL may be an effective treatment.Mediastinal leakage occurs in about 7% of distal oesophageal resections and is associated with a mortality rate of up to 60% [1,2]. Although the amounts of post-operative anastomotic leakage can be rather slight, the leakage is a major source of mortality and morbidity [3]. The leading causes of death in patients with mediastinal abscesses are infection and nutritional deficiency [4,5]. Mediastinal abscesses form a potentially devastating condition in gastro-oesophageal anastomotic leakage (GEAL). Historically, intravenous antibiotics combined with surgical debridement have been the mainstay of therapy [6]. Rethoracotomy extended procedure, however, carries considerable risks for a critically ill patient [5]. Han et al [7] treated patients with mediastinal abscess with stent placement and nasal–oesophagal drainage, while percutaneous drainage was applied under the guidance of CT [8,9] or endoscopy [10,11]. Drainage may be a promising treatment for mediastinal abscess in GEAL. In this study, we determined the feasibility and effectiveness of using two-tube insertion under fluoroscopic guidance in the treatment of mediastinal abscess in GEAL. The effect of treatment was evaluated by time interval of the leaks’ closure and the effect on nutritional status was evaluated by serum albumin level.