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Anastomotic leakage is a dreaded complication of surgery for esophageal cancer. PhD research by Sander Ubels from Radboud university medical center allows healthcare providers to predict which patients are at high risk of a serious course of anastomotic leakage. He also shows that for this complication, a more expectant policy probably leads to better outcomes than aggressive treatment.
Every year, around eight hundred esophageal cancer patients in the Netherlands undergo major surgery. The surgeon removes part or all of the esophagus and makes a new connection with the stomach. The problem is that that connection regularly leaks. In some cases, the consequences of such an anastomotic leak are relatively mild, but a serious course is also relatively common. Such a course is associated with significantly increased mortality. Sander Ubels investigated factors that contribute to a favorable or serious course of an anastomotic leak and how they are best treated.
Online prediction model
Ubels developed a new score that predicts the severity of anastomotic leakage. He used data from more than 1,500 patients obtained in 71 hospitals from all over the world. The score is based on twelve factors, including an early or late diagnosis of anastomotic leakage, the extent of leakage, and problems with the heart, kidneys or lungs.
At a later stage he also added patient factors to the score, such as age, general condition and other health problems. ‘This allows doctors to predict the risk of death even better’, says Ubels. 'Using this score, they can identify patients with an increased risk and tailor treatment accordingly. Our prediction model is freely available online, so that everyone can use it.'
International guideline
No one actually knows the optimal treatment approach for anastomotic leaks. As such, there is huge variation worldwide. Historically, the preference has been for aggressive treatment: an operation during which the surgeon repairs the damage. Ubels' research shows that this is probably not the best option. Patients seem better off with a more cautious, expectant policy. This could, for instance, involve placement of a drain to remove the leaked fluid. The study shows that anastomotic leakage heals faster in these cases, and patients spend less time in the hospital.
‘We are going to write an international guideline based on this research’, says Camiel Rosman, a professor of minimally invasive surgery who supervised the PhD project. 'The guideline details how to deal with an anastomotic leak, both in terms of diagnosis and treatment. Subsequently, we will implement this guideline in the Netherlands and investigate whether this indeed leads to better patient outcomes.'
More information about this PhD thesis defense
PhD thesis defense of Sander Ubels on April 12th at 12.30 p.m. Title of dissertation: Anastomotic leak after esophagectomy; Towards evidence-based treatment (available online after April 12th). (Co-)supervisors: prof. dr. C. Rosman, dr. B.R. Klarenbeek, dr. F.T.W.E. van Workum, and dr. G.J. Hannink. The defense can be followed via this livestream.
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