F-097 * ELIMINATING THE CERVICAL ANASTOMOTIC LEAK WHILE REDUCING COSTS AND IMPROVING OUTCOMES

Abstract

Objectives: The oesophageal anastomotic leak (EAL) results in long-term strictures and chronic dysphagia in over 1/3 of patients with an EAL. EAL is as high as 30% following neoadjuvant therapy (NAT). A change in postoperative care has dramatically reduced the rate of EAL. Methods: A prospective change related to oral intake was applied to all patients undergoing transhiatal oesophagectomy (THE) for any reason. Historically oral intake after THE was resumed on POD 3 at our institution. Because of this relatively high rate of EAL following NAT, no patient was allowed to resume oral intake until POD 15. Patients were discharged on POD 5 with only j-tube feedings until POD 15. Results: One hundred and twenty-nine patients underwent THE from June 2008 to November2013. Five EALs (3.9%) occurred, which was much lower than our EAL rate of 15% prior to 2008. Of these 5 EALs 1 had a residual tumour at the anastomosis, and 1 had a stent in place prior to NAT crossing the gastro-oesophageal junction with severe gastric damage upon removal at surgery. In those without a stent at the time of surgery or residual tumour at the anastomosis our leak rate was 2.3% (n = 3) of which all 3 had NAT. Dysphagia requiring dilatation was seen in 12.4% compared to 28% of our control group prior to 2008. This reduction in EAL has resulted in a reduction in cost as well as a return to normal activity sooner. The cost reduction due to the need for serial dilations was $3233 per patient. Conclusions: By increasing the time to postoperative oral feeding, we have been able to markedly improve on both the immediate and long-term outcomes of THE patients. Almost eliminating the EAL has resulted in significantly better long-term results with respect to swallowing, stricture formation, and reduction in the need for serial dilations.