Risk Factors Related to Anastomotic Leak and Incidence of Atrial Fibrillation in Minimally Invasive Transhiatal Esophagectomy

Abstract

Research Question: What are the pre-operative risk factors connected with increased incidence of anastomotic leak in minimally invasive transhiatal esophagectomy, and are these risk factors also associated with increased morbidity and mortality?

Background and Significance: The amount and number of esophagectomies performed for the treatment of adenocarcinoma and squamous cell carcinoma of the esophagus has grown substantially largely due to the improvement in modern therapy regimens and surgical operative techniques. Post-operative outcomes in patients with an esophageal cancer diagnosis is pertinent to the process of disease progression as well as related to the outcomes of the surgery itself. Approximately 40% of postoperative mortality after esophagectomy is related to anastomotic leak and this is a significant source of post-operative mortality and morbidity. Additionally, atrial fibrillation (AF) has been associated with leak in the current literature. The purpose of the present study at our institution was to determine possible risk factors associated with the incidence of post-operative leak after transhiatal esophagectomy (THE).

Materials and Methods: This retrospective study was approved by the institution¿s IRB at Methodist Richardson Medical Center. A retrospective detailed chart review was performed between the years of 2012 and 2020. All patients who underwent robotic-assisted transhiatal esophagectomy with perioperative course detailed in the available electronic medical record were included in the detailed retrospective chart review. Patient comorbidities, demographics, operative times, and perioperative outcomes such as anastomotic leak development and atrial fibrillation were confirmed through either computed tomography (CT) or upper gastrointestinal series (UGI). A detailed univariate analysis was then completed between study groups to initially identify possible factors associated with anastomotic leak. Following the univariate analysis a multivariate logistic regression was then undertaken.

Results: There was no difference of significance in patient demographics between those who developed a leak and those who did not upon initial analysis of univariance. The patients who did develop an anastomotic leak had a significantly higher rate of chronic obstructive pulmonary disease diagnosis (COPD) (p = 0.006) as well as a history of prior gastric surgery (p = 0.002). Additionally, prior gastric surgery (OR = 6.9, p = 0.005) and COPD (OR = 4.9, p = 0.002) continued to remain significantly correlated with development of a leak.

Conclusion: Prior gastric surgery and COPD are significantly associated with higher rates of postoperative anastomotic leak development in esophageal cancer patients who undergo transhiatal esophagectomy. Subsequent work should aim to assess reasonable processes of preoperative risk reduction in patients with a history of prior gastric surgery and COPD diagnosis.