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Perioperative Risk Factors for Anastomotic Leakage After Esophagectomy^*

Influence of Thoracic Epidural Analgesia

Pierre Michelet, MD; Xavier-Benot D’Journo, MD; Antoine Roch, MD, PhD; Laurent Papazian, MD, PhD; Jacques Ragni, MD; Pascal Thomas, MD, PhD and Jean-Pierre Auffray, MD

^* From the Département d’Anesthésie Réanimation (Drs. Michelet, Roch, Ragni, and Auffray), Service de Chirurgie Thoracique (Drs. D’Journo and Thomas), and Service de Réanimation Médicale (Dr. Papazian), Hôpitaux Sud, Marseille, France.

Correspondence to: Pierre Michelet, MD, Département d’Anesthésie Réanimation, Hôpital Sainte-Marguerite, 13274 Marseille Cedex 9, France; e-mail: pierre.michelet{at}mail.ap-hm.fr

Study objectives: Anastomotic leakage after esophagectomy is associated with high postoperative morbidity and mortality. The most important predisposing factors for anastomotic leaks are ischemia of the gastric conduit and low blood oxygen content. The aim of this study was to evaluate the influence of thoracic epidural analgesia (TEA) on the incidence of anastomotic leakage after esophagectomy.

Design: Retrospective study.

Setting: A thoracic surgery and anesthesia department in a teaching hospital.

Patients: Two hundred seven patients who underwent one-stage esophagectomy between 1998 and 2003.

Interventions: The effects of perioperative factors and postoperative complications on the incidence of anastomotic leakage were analyzed. Leakage was defined as an anastomotic disruption detected by an ionic x-ray contrast study and confirmed by upper endoscopy in the postoperative period. Analyzed factors included effective TEA placed before the surgical procedure.

Measurements and results: Anastomotic leakage occurred in 23 patients (11%). This complication was associated with a significant increase in length of stay in the ICU and in the hospital (mean, 19 ± 16 days vs 9 ± 7 days [± SD], p = 0.008; and 43 ± 27 days vs 23 ± 11 days, respectively; p < 0.001). Mortality in patients presenting anastomotic leakage was 26%, compared with 5.4% in the remainder (p = 0.002). Factors independently associated with the incidence of leakage included estimated blood loss per milliliter during the surgical procedure (odds ratio [OR], 1.004; 95% confidence interval [CI], 1.001 to 1.007), the cervical location for anastomosis (OR, 5.4; 95% CI, 1.3 to 22.9), and the development of an ARDS in the postoperative period (OR, 4.1; 95% CI, 2.6 to 176.5). Ninety-three patients benefited from an effective TEA for 4.4 ± 0.8 days. The use of TEA was independently associated with a decrease in the incidence of anastomotic leakage (OR, 0.13; 95% CI, 0.02 to 0.71).

Conclusions: The results of this retrospective study suggest that TEA is associated with a decrease in occurrence of anastomotic leakage.

Key Words: anastomotic leakage • esophagectomy • surgical complication • thoracic epidural analgesia

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