How to manage a patient with anastomotic leakage after total gastrectomy and Oesophagojejunostomy (total removal of stomach and surgical connection between esophagus and jejunum) without signs of sepsis, confirmed by Gastrografin (contrast agent) study, on the 4th postoperative day?

Management of Anastomotic Leak After Total Gastrectomy and Oesophagojejunostomy

Conservative management with nasogastric suction, appropriate local drainage, antibiotics, and jejunal feeding is the recommended first-line approach for this patient with a confirmed anastomotic leak without sepsis on the 4th postoperative day. 1

Assessment of the Current Situation

The patient has:

• Total gastrectomy with Oesophagojejunostomy performed 4 days ago
• Confirmed anastomotic leak by Gastrografin study
• No signs of sepsis
• Ongoing drainage from the leak site

Management Algorithm

First-line Management: Conservative Approach

1. Maintain existing drainage

   • Ensure proper positioning of existing drain
   • Monitor drainage output and characteristics

2. Nasogastric decompression

   • Place nasogastric tube if not already present
   • Maintain on continuous suction to decrease pressure at the anastomotic site

3. Nutritional support

   • Implement jejunal feeding (via feeding jejunostomy if available)
   • Consider parenteral nutrition if enteral feeding is not feasible

4. Antibiotic therapy

   • Administer broad-spectrum antibiotics to prevent infection
   • Adjust based on culture results if available

5. Close monitoring

   • Monitor vital signs, laboratory values, and clinical status
   • Watch for development of sepsis or peritonitis

Second-line Management (If Conservative Management Fails)

If the patient deteriorates or the leak persists:

1. Endoscopic stenting 1

   • Consider fully covered self-expanding metal stent (FCSEMS)
   • Ensure proper positioning to cover the leak site
   • May be combined with percutaneous drainage if needed

2. Surgical intervention (Only if the above measures fail or patient deteriorates)

   • Re-exploration with repair
   • Omental patch reinforcement
   • Consider diversion in severe cases

Rationale for Conservative Management

The Gut guidelines clearly state that "the majority of anastomotic leakages, whether in the neck or the chest, can be managed conservatively with nasogastric suction, appropriate local drainage, antibiotics, and jejunal feeding" 1. This approach is particularly appropriate for this patient who:

1. Has a confirmed leak but is hemodynamically stable
2. Shows no signs of sepsis
3. Has a functioning drain in place
4. Is only 4 days post-operation (early leak)

Important Considerations and Pitfalls

• Early vs. Late Disruption: The guidelines distinguish between early disruption (within 72 hours) and later disruptions. This patient's leak at day 4 falls into the later category, which typically reflects local ischemia and/or tension at the anastomotic site rather than technical error 1.

• Monitoring for Deterioration: Despite conservative management, close monitoring is essential as the patient could develop sepsis or peritonitis, which would necessitate more aggressive intervention 2.

• Drainage Position: Ensure the drain is properly positioned to effectively drain the leak. Inadequate drainage can lead to collection formation and sepsis 1.

• Avoid Premature Closure of Drain: Keep the drain in place until output decreases significantly and repeat imaging confirms improvement 1.

• Nutritional Support: Adequate nutrition is crucial for healing. Jejunal feeding is preferred if a feeding jejunostomy was placed during the initial surgery 1.

• Endoscopic Options: If conservative management fails, endoscopic stenting should be considered before resorting to surgical intervention, as it has shown good success rates in stable patients 1.

The conservative approach is supported by systematic reviews showing that conservative management can achieve complete resolution of leakage within 7-28 days with lower mortality compared to surgical intervention 3.

By following this algorithm, you maximize the chance of successful management while minimizing additional surgical trauma to the patient.