Table 1 Open in new tab Main...

System

Leak classification

Grade

Signs and symptoms (or definition)

Management

Bruce et al., 2001^*

Radiological

−

• Detected only on routine imaging; no clinical signs

• No change

Clinical minor

−

• Luminal contents through the drain or wound site (local inflammation)
• Fever (>38°C) or leukocytosis (>10,000/L)
• Leak may also be detected on imaging studies

• Prolonged hospital stay and/or delay in resuming oral intake

Clinical major

−

• As clinical minor with severe disruption to anastomosis
• Leak may also be detected on imaging studies

• Intervention required

Lerut et al., 2002^†

Radiological

−

• No clinical signs

• No change

Clinical minor

−

• Local inflammation cervical wound
• X-ray contained leak (thoracic anastomosis)
• Fever, > WBC, > CRP

• Drain wound
• Delay oral intake
• Antibiotics

Clinical major

−

• Severe disruption on endoscopy
• Sepsis

• CT-guided drainage or reintervention

Conduit necrosis

−

• Endoscopic confirmation

• Reintervention

Price et al., 2013^‡

Radiological

• No clinical signs or symptoms
• Purely radiological diagnosis

• No change in management

Clinical minor

• Minor clinical signs (e.g. cervical wound inflammation or drainage)
• Radiographically contained intrathoracic leak
• Fever, leukocytosis

• Delay oral intake
• Antibiotics
• Wound drainage
• CT-guided drain placement

Clinical major

III

• Significant anastomotic disruption requiring surgical—revision
• Minor anastomotic disruption with systematic sepsis

• Esophageal stent placement
• Surgical debridement
• Anastomotic revision

Conduit necrosis

• Conduit necrosis necessitating esophageal diversion

• Conduit resection with esophageal diversion

Low et al., 2015^§

Anastomotic leakage

• Local defect

• No change in therapy or medical treatment or dietary modification

• Local defect

• Interventional radiology drain
• Stenting or bedside opening
• Packing of incision

III

• Local defect

• Surgical therapy

Conduit necrosis

• Focal (identified endoscopically)

• Additional monitoring or nonsurgical therapy

• Focal (identified endoscopically, not associated with free anastomotic or conduit leakage)

• Surgical therapy without esophageal diversion

III

• Extensive

• Surgical therapy: conduit resection with diversion

Table 1

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Main classification systems of anastomotic leakage

System	Leak classification	Grade	Signs and symptoms (or definition)	Management
Bruce et al., 2001^*	Radiological	−	• Detected only on routine imaging; no clinical signs	• No change
	Clinical minor	−	• Luminal contents through the drain or wound site (local inflammation) • Fever (>38°C) or leukocytosis (>10,000/L) • Leak may also be detected on imaging studies	• Prolonged hospital stay and/or delay in resuming oral intake
	Clinical major	−	• As clinical minor with severe disruption to anastomosis • Leak may also be detected on imaging studies	• Intervention required
Lerut et al., 2002^†	Radiological	−	• No clinical signs	• No change
	Clinical minor	−	• Local inflammation cervical wound • X-ray contained leak (thoracic anastomosis) • Fever, > WBC, > CRP	• Drain wound • Delay oral intake • Antibiotics
	Clinical major	−	• Severe disruption on endoscopy • Sepsis	• CT-guided drainage or reintervention
	Conduit necrosis	−	• Endoscopic confirmation	• Reintervention
Price et al., 2013^‡	Radiological	I	• No clinical signs or symptoms • Purely radiological diagnosis	• No change in management
	Clinical minor	II	• Minor clinical signs (e.g. cervical wound inflammation or drainage) • Radiographically contained intrathoracic leak • Fever, leukocytosis	• Delay oral intake • Antibiotics • Wound drainage • CT-guided drain placement
	Clinical major	III	• Significant anastomotic disruption requiring surgical—revision • Minor anastomotic disruption with systematic sepsis	• Esophageal stent placement • Surgical debridement • Anastomotic revision
	Conduit necrosis	IV	• Conduit necrosis necessitating esophageal diversion	• Conduit resection with esophageal diversion
Low et al., 2015^§	Anastomotic leakage	I	• Local defect	• No change in therapy or medical treatment or dietary modification
		II	• Local defect	• Interventional radiology drain • Stenting or bedside opening • Packing of incision
		III	• Local defect	• Surgical therapy
	Conduit necrosis	I	• Focal (identified endoscopically)	• Additional monitoring or nonsurgical therapy
		II	• Focal (identified endoscopically, not associated with free anastomotic or conduit leakage)	• Surgical therapy without esophageal diversion
		III	• Extensive	• Surgical therapy: conduit resection with diversion

System	Leak classification	Grade	Signs and symptoms (or definition)	Management
Bruce et al., 2001^*	Radiological	−	• Detected only on routine imaging; no clinical signs	• No change
	Clinical minor	−	• Luminal contents through the drain or wound site (local inflammation) • Fever (>38°C) or leukocytosis (>10,000/L) • Leak may also be detected on imaging studies	• Prolonged hospital stay and/or delay in resuming oral intake
	Clinical major	−	• As clinical minor with severe disruption to anastomosis • Leak may also be detected on imaging studies	• Intervention required
Lerut et al., 2002^†	Radiological	−	• No clinical signs	• No change
	Clinical minor	−	• Local inflammation cervical wound • X-ray contained leak (thoracic anastomosis) • Fever, > WBC, > CRP	• Drain wound • Delay oral intake • Antibiotics
	Clinical major	−	• Severe disruption on endoscopy • Sepsis	• CT-guided drainage or reintervention
	Conduit necrosis	−	• Endoscopic confirmation	• Reintervention
Price et al., 2013^‡	Radiological	I	• No clinical signs or symptoms • Purely radiological diagnosis	• No change in management
	Clinical minor	II	• Minor clinical signs (e.g. cervical wound inflammation or drainage) • Radiographically contained intrathoracic leak • Fever, leukocytosis	• Delay oral intake • Antibiotics • Wound drainage • CT-guided drain placement
	Clinical major	III	• Significant anastomotic disruption requiring surgical—revision • Minor anastomotic disruption with systematic sepsis	• Esophageal stent placement • Surgical debridement • Anastomotic revision
	Conduit necrosis	IV	• Conduit necrosis necessitating esophageal diversion	• Conduit resection with esophageal diversion
Low et al., 2015^§	Anastomotic leakage	I	• Local defect	• No change in therapy or medical treatment or dietary modification
		II	• Local defect	• Interventional radiology drain • Stenting or bedside opening • Packing of incision
		III	• Local defect	• Surgical therapy
	Conduit necrosis	I	• Focal (identified endoscopically)	• Additional monitoring or nonsurgical therapy
		II	• Focal (identified endoscopically, not associated with free anastomotic or conduit leakage)	• Surgical therapy without esophageal diversion
		III	• Extensive	• Surgical therapy: conduit resection with diversion

^*Bruce, J., Krukowski, Z. H., Al-Khairy, G., Russell, E. M. & Park, K. G. M. Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery. British Journal of Surgery (2001) doi:10.1046/j.0007-1323.2001.01829.x.

^†Lerut, T. et al. Anastomotic complications after esophagectomy. in Digestive Surgery (2002). doi:10.1159/000052018.

^‡T.N., P. et al. A comprehensive review of anastomotic technique in 432 esophagectomies. Ann. Thorac. Surg. (2013).

^§Low, D. E. et al. International consensus on standardization of data collection for complications associated with esophagectomy: Esophagectomy Complications Consensus Group (ECCG). Ann. Surg. (2015) doi:10.1097/SLA.0000000000001098.

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