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Ann Thorac Surg 2006;82:383
© 2006 The Society of Thoracic Surgeons
Union Memorial Hospital, J. P. B. 3333 N Calvert, Suite 610, Baltimore, MD 21218-2895
(Email: richard.heitmiller{at}medstar.net).
Korst and colleagues [1] published a single institution review of 242 patients who underwent transthoracic esophagectomy with cervical anastomosis. The incidence of anastomotic leak was 11.1%. Over half (52%) of these patients had an intrathoracic manifestation of the cervical leak. They conclude that compared with transhiatal esophagectomy, cervical anastomotic leaks are more common with transthoracic esophagectomy methods. The authors hypothesize that the reasons for this finding could include transmediastinal infection of the pleural space while constructing the cervical anastomosis, chest tube suction, or size (larger) of the leak.
I believe that the reason cervical leaks are higher with transthoracic esophagectomy is secondary to ipsilateral pleural space air (pneumothorax). At the time of thoracotomy, a chest tube is used to drain the pleural space and re-expand the lung. Postoperatively, the chest tube is usually removed on day 4 or 5 depending on drainage. Small apical pneumothorax after chest tube removal is not uncommon; with time this air will be resorbed. However, before it is removed, the air will try to track in a cephalad direction. In a closed pleural space, the air is contained at the chest apex. With an open mediastinal pleura, the air tracks along the esophageal conduit to come in contact with the cervical anastomosis. A bowel anastomosis exposed to air (such as one that is exteriorized) will leak.
Transmediastinal pleural infection as a cause of leak should occur early after surgery and be associated with more evident pleural space changes. Suction applied to the chest tubes should not significantly affect the cervical anastomosis and would also lead to early postoperative leaks. In fact, Korst and colleagues [1] report that intrathoracic evidence of leak occurred at a mean of 6.9 days after surgery. This should be at a time when the initial chest tube has already been removed. Crestanello and colleagues [2] reported on their experience with intrathoracic anastomotic leaks after esophagectomy. I had the opportunity to discuss this article when it was presented [[2, see Discussion]. In their series, a number of patients had anastomotic leaks develop late, after contrast swallow showed no leakage, and after the initial chest tube had been removed. I believe the explanation of post-chest tube removal pneumothorax could account for these late leaks as well.
Selective opening of the mediastinal pleura, keeping intact the mediastinal pleura cephalad to the azygos vein, may help to insulate the cervical anastomosis from the effect of a post-chest tube removal pneumothorax. Admittedly this can not always be accomplished to achieve complete tumor removal or lymph node dissection; however, it is something to consider. Conservative chest tube management and aggressive treatment of pneumothorax may also help minimize the incidence of cervical leaks when transthoracic esophagectomy techniques are used.
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  R. J. Korst Reply. Ann. Thorac. Surg., July 1, 2006; 82(1): 383 - 384. [Full Text] [PDF]
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