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Page 2 of 10 Latorre-Rodríguez et al. Mini-invasive Surg 2023;7:6 https://dx.doi.org/10.20517/2574-1225.2022.104

The reduction and management of perioperative complications includes three main strategies: (1) risk
assessment and prevention through the appropriate selection of procedures and patients; (2) timely and
early diagnosis of perioperative anastomotic complications; and (3) the adoption of less invasive endoscopic
and radiological techniques to replace traditional major surgical interventions.

This paper aims to present the most recent information on fundamental concepts, including the definition,
epidemiology, diagnosis, and management principles of esophageal ALs, and to introduce novel
management techniques for this condition.

DEFINITION
Although ALs are widely regarded as the Achilles heel of esophageal resections, until recently, there was no
uniform definition or grading. Recently, the Esophagectomy Complications Consensus Group (ECCG)
defined ALs as a discontinuity in the anastomosis, staple lines, or conduits of the esophagus . In other
[1]
words, ALs are a failure of the anastomosis and may be caused by the surgical technique or intrinsic patient
factors.

EPIDEMIOLOGY
ALs after esophageal surgery are believed to be the leading cause of postoperative morbidity, mortality, and
[2]
prolonged hospitalization . ALs can be associated with mediastinitis, sepsis, and acute respiratory distress
[3]
syndrome ; however, it is difficult to know the precise incidence of ALs and their outcomes because, until
recently, there was no accepted definition or standard method for recording, tracking, and defining
complications . More recently, the multicenter perioperative data collection platform for
[1,4]
esophagectomies, ESODATA.org, was developed by the ECCG , and 79 surgical centers currently use it in
[5]
more than 16 countries. Of 2704 esophagectomies registered on ESODATA.org between 2015 and 2016,
ALs were the third most frequent complication with an incidence of 11.4%, preceded only by pneumonia
[5]
(14.6%) and atrial arrhythmia (14.5%) .

The mortality rate among patients with ALs is higher (7.2%) than that of patients without this complication
[2]
(3.1%) , and the incidence of ALs varies by the surgical anatomical location, being higher at the
[6]
intracervical level (13.64%) than at the intrathoracic level (2.96%) . In oncology patients, esophageal ALs
are correlated with a significant reduction in overall survival and disease-free survival, as well as a greater
[7]
likelihood of locoregional recurrences . An important factor that may contribute to higher AL rates is
surgeon inexperience , suggesting that the AL rate could be considered a key indicator of individual
[8]
surgical expertise.

ETIOLOGY, RISK FACTORS, AND PREVENTION
Esophageal ALs can occur spontaneously with delayed clinical presentation, and a delay in diagnosis and
management increases morbidity and mortality. Etiology is multifactorial; a clear or specific cause can rarely
[9]
be established . The recognized causes and risk factors of anastomotic leaks in the GI tract are classified
into four groups: (1) intrinsic patient factors; (2) microbiota of the gastrointestinal tract; (3) tissue
perfusion; and (4) technical or mechanical factors [2,9-12] .

Some risk factors that have been shown to have statistically significant associations with the development of
ALs in the gastrointestinal tract include male sex, obesity, smoking, hypertension, vascular and coronary
diseases, type 2 diabetes mellitus, chronic renal disease, chronic obstructive pulmonary disease, use of
steroids, non-steroidal anti-inflammatory drugs or bevacizumab, previous abdominal surgery, or previous
thoracic radiotherapy [2,9,10] . Adequate preoperative management and control of these risk factors through