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Latorre-Rodríguez et al. Mini-invasive Surg 2023;7:6 https://dx.doi.org/10.20517/2574-1225.2022.104 Page 3 of 10

pre-habilitation with physiotherapy and clinical follow-up is essential to decrease the likelihood of
esophageal ALs after esophagectomy.

DIAGNOSIS
An early and timely diagnosis of esophageal ALs is critical in limiting deleterious outcomes. Delayed
[13]
recognition and treatment of ALs lead to higher mortality and morbidity . To date, there is no consensus
on the best diagnostic modality. The clinical manifestations of ALs vary widely and range from
asymptomatic presentation to complex scenarios such as sepsis or acute respiratory distress syndrome.

Common symptoms of esophageal ALs are fever, supraventricular tachyarrhythmias, dyspnea, chest pain,
cough, peri-incisional erythema, cervical induration (cervical anastomosis), and symptoms related to
mediastinitis or sepsis such as purulent discharge or enteric contents in the drains [4,14] . Several biomarkers
have been studied for the diagnosis of esophagus ALs (e.g., c-reactive protein, calcitonin, erythrocyte
sedimentation rate, and white blood cell count), but their systematic use is not standardized [4,15] . Depending
on the availability and the specific scenario of each patient, the surgeon may use esophagography, computed
tomography (CT), or endoscopy as diagnostic or confirmatory tools. However, in recent years CT plus
[4]
endoscopy has become the standard method .
PRINCIPLES OF ESOPHAGEAL AL MANAGEMENT
The basic principles of managing esophageal ALs can be reduced to addressing sepsis (adequate drainage
and broad-spectrum antibiotics), ameliorating the anastomotic defect, and providing nutritional support
[Figure 1]. It is important to note that esophageal AL management must be individualized. First, it is
imperative to determine the diagnosis and whether the patient needs to be transferred to an intensive care
unit or supported in some way (e.g., ventilator, vasopressors). Second, the surgeon must determine if an
intervention is required.

One of the most important challenges in the management of ALs is the control of sepsis or infectious
complications that may lead to fatal outcomes. Infection control is based on two fundamental pillars: (a)
drain any collection from the AL and limit continued leaking through the anastomotic defect, either by
open surgery or minimally invasive procedures (endoscopic or percutaneous) ; and (b) provide early and
[4]
correct broad-spectrum antibiotic treatment including anti-fungal coverage [4,16,17] . It is highly recommended
to perform microbiological cultures, including blood cultures, to direct antibiotic therapy.

Another main goal during AL management is nutritional support. The key point is to determine the best
type of nutritional support depending on the patient’s condition. The preferred route is enteral and distal to
the AL; some available options are the use of a nasojejunal, gastrostomy, or jejunostomy tube [4,13] . In
addition, proton pump inhibitors, anticholinergics, and prokinetics are recommended to reduce salivary
and leakage volume [4,18] . Nutritional support should be provided until the successful closure of the AL and
the resumption of adequate oral intake [13,16,19] .

SURGICAL MANAGEMENT
It is suitable and acceptable to perform an open or laparoscopic surgical intervention to correct both
cervical and intrathoracic anastomotic defects in the following situations: (1) esophageal ALs detected
within the first 72 h after surgery; (2) esophageal ALs in critically ill patients or those that are life-
threatening; (3) in cases of necrotic or ischemic conduit; or (4) when previous endoscopic/radiological
treatment has failed [4,13] .