Drain amylase aids detection of anastomotic leak after esophagectomy

Abstract

Background: Anastomotic leak following esophagectomy is associated with significant morbidity and mortality. As hospital length of stay decreases, the timely diagnosis of leak becomes more important. We evaluated CT esophagram, white blood count (WBC), and drain amylase levels in the early detection of anastomotic leak.

Methods: The diagnostic performance of CT esophagram, drain amylase >800 IU/L, and WBC >12,000/µL within the first 10 days after surgery in predicting leak at any time after esophagectomy was calculated.

Results: Anastomotic leak occurred in 13 patients (13%). CT esophagram performed within 10 days of surgery diagnosed six of these leaks with a sensitivity of 0.54. Elevation in drain amylase level within 10 days of surgery diagnosed anastomotic leak with a sensitivity of 0.38. When the CT esophagram and drain amylase were combined, the sensitivity rose to 0.69 with a specificity of 0.98. WBC elevation had a sensitivity of 0.92, with a specificity of 0.34. Among 30 patients with normal drain amylase and a normal WBC, one developed an anastomotic leak.

Conclusions: Drain amylase adds to the sensitivity of CT esophagram in the early detection of anastomotic leak. Selected patients with normal drain amylase levels and normal WBC may be able to safely forgo CT esophagram.

Keywords: Esophagectomy; amylase; anastomotic leak.

Conflict of interest statement

Conflicts of Interest: A portion of this work was presented as a poster presentation at the Society of Surgical Oncology 2013 and ASCO GI 2013.

Figures

Figure 1

A 68-year-old woman (patient #21) with T1aN0M0 adenocarcinoma of the gastroesophageal junction treated with minimally invasive esophagectomy. Significant elevation of drain amylase (>800 IU/L) was noted on postoperative day 6. CT esophagram on postoperative day 6 showed evidence of a leak. She was treated with intraluminal stent. Note that drain amylase level appears on a semi-logarithmic scale.

Figure 2

A 58-year-old woman (patient #61) with adenocarcinoma of the gastroesophageal junction treated with preoperative carboplatin, paclitaxel, and radiation therapy followed by minimally invasive esophagectomy. Transient elevation in drain amylase levels peaked at 2,464 IU/L on postoperative day 11 and subsequently normalized. CT esophagrams performed postoperative day 7 and postoperative day 13 were normal. Patient was discharged postoperative day 17 without clinical signs of anastomotic leak. She was treated with NPO status and jejunostomy feedings until her drain amylase declined. Note that drain amylase level appears on a semi-logarithmic scale.

Figure 3

Proposed diagnostic pathway for postoperative evaluation for anastomotic leak and outcomes after esophagectomy, based upon the study population. Elevated WBC is defined as exceeding 12,000/µL and elevated drain amylase as exceeding 800 IU/L. WBC, white blood count.