Prognostic Value of Chest-Tube Amylase Versus C-Reactive Protein as Screening Tool for Detection of Early Anastomotic Leaks After Ivor Lewis Esophagectomy.

INTRODUCTION: Intrathoracic anastomotic leaks after esophagectomy are a significant cause of morbidity and death. Early detection and timely management are crucial. This study evaluates the effectiveness of daily drain amylase levels in detecting early leaks after esophagectomy compared with C-reactive protein (CRP). MATERIALS AND METHODS: Between June 2015 and September 2017, 126 esophagectomies were performed in our department. Amylase levels were collected in 80 of these patients, as long right-sided chest tubes were in place. Mostly, chest tubes were removed before postoperative day (POD) 5. CRP levels were measured daily. Early leaks were defined as occurring with the chest tubes in place. According to the obtained receiver operating characteristics curves, amylase levels >335 U/L, and CRP >30 mg/dL were considered positive. Sensitivity and specificity for both drain amylase and CRP were calculated. RESULTS: Overall anastomotic leak rate was 7.5% (6/80). An early disruption occurred in 4 of 80 patients (5%). Three patients had a positive amylase level and none a positive CRP on POD 1. These 3 patients had on POD 2 a positive CRP. The fourth patient presented at POD 2 bilious secretion in the chest tubes. He showed normal amylase and CRP levels on POD 1. Sensitivity and specificity for amylase level and CRP within the first 3 PODs were 0.75 and 0.98 versus 0.75 and 0.85, respectively. The patients with leak were reoperated at POD 2. They were all discharged between PODs 15 and 19. CONCLUSIONS: Amylase level after esophagectomy is a more accurate screening tool for detection of early leaks than CRP. It could facilitate their detection up to 24 hours earlier than CRP.

Pancreaticopleural fistula-induced empyema thoracis: principles and results of surgical management.

OBJECTIVE: Pancreaticopleural fistula is a very uncommon complication of pancreatitis resulting from pancreatic duct disruption with leakage of pancreatic secretions into the pleural cavity. Fistulization occurs either through the esophageal hiatus or straight through the diaphragm. Pleural effusion with dyspnea is the main presenting symptom, and delayed diagnosis is frequent. Initial conservative treatment fails in a significant number of cases. Ascending infection via the fistulous tract results in empyema and life-threatening sepsis. METHODS: All patients who underwent surgery for pancreaticopleural fistula-induced empyema thoracis at a tertiary referral hospital from 2008 to 2011 were included in a retrospective case study. RESULTS: Altogether six patients with pancreaticopleural fistula and associated pleural empyema were identified. All patients suffered from pancreatitis and received initial medical and endoscopic treatment. Despite all nonsurgical treatment efforts, superinfection led to left-sided pleural empyema in four and bilateral empyema in two cases. The contagious spread took place through the fistulous tract connecting the pancreatic duct with the pleural cavity. The patients were referred for surgery with considerable delay and already advanced pleural empyema. Minimally invasive thoracic surgery with pleural debridement was performed in all cases. Furthermore, left pancreatic resection was mandatory in five cases and cystostomy in one case. All patients recovered well and upon follow-up there were no further complications. CONCLUSION: Surgical management combining minimally invasive thoracic surgery and removal of the fistulous tract is highly effective. If initial medical treatment fails, surgery should be considered early to prevent severe sepsis. Further improvement seems achievable by reducing the time between fruitless conservative efforts and surgical intervention.