The role of early endoscopy in the management of post-esophagectomy patients

Abstract

Background: Major complications after esophagectomy include anastomotic leak, ischemic conduit, conduit mal-rotation, and delayed gastric emptying. Accurate and timely detection of complications is challenging. Upper endoscopy is increasingly used to detect and manage complications. This study looks into the indications, timing, and accuracy of early post-operative upper endoscopy in the diagnosis of the above complications. Different endoscopic therapeutic procedures were also investigated. Method: Records of all patients who underwent esophagectomy between January 2014 and December 2016 in a tertiary referral center were reviewed. Early post-operative upper endoscopy was defined as upper endoscopy performed within the same admission. Results: A total of 114 patients underwent esophagectomy. Forty-four patients (38.6%) had early post-operative upper endoscopy. The most common indications were atrial fibrillation (33.3%), sinus tachycardia (17.9%), and fever (17.9%). Fifteen out of these 44 patients (34.1%) had abnormal findings. Upper endoscopy detected 7 anastomotic leaks *(Sn: 70.0%, Sp: 100%, PPV: 100%, and NPV: 92.3%), 3 ischemic conduits *(Sn: 100%, Sp: 100%, PPV 100%, and NPV 100%), 2 conduit mal-rotation, and 3 delayed gastric emptying. Contrast study and computed tomography had inferior sensitivity and specificity for anastomotic leaks. No complications from endoscopy were reported. The post-operative day of diagnosis of ischemic conduit was on days 1, 2, and 5. The median post-operative day for diagnosis of anastomotic leak was 9.5 (4–27). Feeding tube/decompression tube insertion (n = 20) and stenting (n = 3) were the most performed endoscopic therapeutic procedures. There was no in-hospital mortality. The two patients who had conduit malrotation required re-exploration, while the three with delayed gastric emptying were treated conservatively. Conclusion: Early post-operative upper endoscopy is safe, sensitive, and specific in the diagnosis of anastomotic leak and ischemic conduit. Appropriate timing and careful case selection may reduce unnecessary endoscopies. *Sn = sensitivity; Sp = specificity; PPV = positive predictive value; NPV = negative predictive value.