Evaluation And Study On The Risk Factors Of Esophagogastric Anastomotic Leakage After Esophageal Cancer Surgery In The Perioperative Period

Part Ⅰ Risk factors of esophagogastric anastomotic leakage after esophageal cancer surgery:a meta-analysisObjectiveThis study aimed to systematically review the risk factors of esophagogastric anastomotic leakage(EGAL)after esophageal cancer surgery for surgeons and provide a theoretical foundation for the clinical prevention and treatment on EGAL.MethodsEmbase,PubMed,The Cochrane Library,Web of Science,CBM,VIP,WanFang Data,and CNKI were searched from the beginning of database building to January 2020 to collect cohort studies and case-control studies about risk factors of EGAL after esophagectomy.Two individuals conducted independently literature screening,extracted data and evaluated methodological quality of included studies according to the Newcastle-Ottawa Scale(NOS),then,meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 33 articles were included with 26636 patients,including 20283 males and 6353 females,and there were 9587 cases in China and 17049 cases abroad.The results of meta-analysis showed that the following factors(P<0.05)can increase the risk of EGAL,including patients own factors:age,sex,hypertension,body mass index(BMI),alcohol history,smoking history,smoking index(≥400 cigarette-year),digestive tract ulcer,respiratory disease,lower FEV1%,COPD,diabetes,arrhythmia,coronary atherosclerosis,peripheral vascular disease,celiac trunk calcification and descending aortic calcification.Preoperative factors included abnormal liver function,renal insufficiency,ASA grading,neoadjuvant radiotherapy and preoperative albumin<35g/L,preoperative lower albumin.Intraoperative factors included cervical anastomosis,upper segment tumor,retrosternal route,tubular stomach,thoracoscopic surgery,splenectomy,operation time≥4.5h.Postoperative factors included arrhythmia,respiratory failure,pulmonary infection,use of fiberoptic bronchoscopy,deep venous thrombosis.Neoadjuvant chemotherapy could reduce the risk of postoperative EGAL(P<0.05).However,age≥60 years,upper gastrointestinal inflammation,DLCO%,thoracic surgery history,abdominal surgery history,cerebrovascular disease,glucocorticoid drugs history,neoadjuvant chemoradiotherapy,anastomotic embedding,end-to-end anastomosis,hand anastomosis,intraoperative blood loss and other factors were not significantly correlated with EGAL(P≥0.05).Part Ⅱ The risk factors and primary prediction model of esophagogastric anastomotic leakage after esophageal cancer surgery in the perioperative periodObjectiveTo analyze the risk factors of EGAL after esophageal cancer surgery and establish a risk prediction model for early prevention and treatment of EGAL.MethodsWe collected clinical data of 303 patients undergoing esophagectomy in the 940th Hospital of Joint Logistics Support Force of Chinese People’s Liberation Army(The former Lanzhou General Hospital,Lanzhou Military Area Command)from January 2013 to October 2020.According to whether anastomotic fistula occurred after operation,the patients were divided into anastomotic fistula group and non-anastomotic fistula group.The independent risk factors of postoperative anastomotic leakage were analyzed by univariate analysis and multivariable logistic regression analysis(LR method),and a clinical nomogram prediction model was established.ResultsIn all the 303 patients included,46 patients(15.18%)developed anastomotic leakage.Multivariate logistic regression indicated that hypertension,chronic bronchitis,peptic ulcer disease,type of surgery,tumor location,anastomotic methods,the number of dissected lymph nodes,the number of intraoperative chest drainage tube,no-supplementing albumin in the first three days after surgery,postoperative pulmonary infection,postoperative using bronchoscope were significantly correlated with EGAL after esophagectomy(P<0.05).Based on these factors,a predictive nomogram was established to predict the occurrence of EGAL with the area under receiver operating characteristic curves of 0.954(95%CI:0.924～0.975),indicating a significant predictive value.Conclusions(i)The Meta-analysis evidence showed that the risk factors of patients themseleves andperioperative period causing EGAL included age,sex,smoking index,BMI,hypertension,alcohol history,peptic ulcer,lower FEV1%,COPD,diabetes,ASA grading,neoadjuvant radiotherapy,preoperative albumin<35g/L,cervical anastomosis,thoracoscopic surgery,operation time ≥4.5h,tubular stomach,upper segment tumor,intraoperative splenectomy,postoperative respiratory failure,postoperative arrhythmia and other risk factors.Neoadjuvant chemotherapy may be the protection factor of EGAL.Due to limited study quality,higher quality studies are needed to verify the conclusion.(ii)Combined with the medical records of our hospital,univariate analysis and multivariable logistic regression analysis showed that hypertension,chronic bronchitis,peptic ulcer disease,type of surgery,tumor location,anastomotic methods,the number of dissected lymph nodes,the number of intraoperative chest drainage tube,no-supplementing albumin in the first three days after surgery,postoperative pulmonary infection,postoperative using bronchoscope were the independent risk factors of EGAL after esophageal cancer surgery.(iii)The prediction model in this study had a good evaluation efficiency,which could effectively identify individuals at high risk of anastomotic fistula,promote the early detection,diagnosis and treatment of postoperative EGAL with certain clinical application value.