The CAES classification of anastomotic insufficiency in the esophagus

Classifications Upper GI tract

The Surgical Working Group on Endoscopy and Ultrasound (Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonographie, CAES) has developed and validated a classification of anastomotic insufficiency in the esophagus, which was published in December 2018 [1].

Background

Intrathoracic anastomotic insufficiency following esophageal or cardial resection continues to be a feared complication, in view of the significant morbidity and increased mortality associated with it. In addition to restrictions of pulmonary function as a result of pleural effusions and empyema, mediastinitis may also lead to septic organ failure. Minimally invasive surgical techniques and improvements in perioperative management have led to a substantial reduction in the mortality rate [2,3], despite perioperative oncological therapy. Since endoscopy has become established, particularly in Germany, as the primary diagnostic measure when anastomotic insufficiency is suspected [4], the CAES has developed and validated a definition and classification of severity for anastomotic insufficiency following esophageal resection. The classification is based on the endoscopic findings.

Definition and validation

The CAES classification is based on the following criteria. Independently of the diagnostic method used, intrathoracic anastomotic insufficiency following resection of the esophagus or cardia is defined as a communication between the intraluminal and extraluminal compartments through a defect in the integrity of the intestinal wall at the anastomosis between the esophagus and stomach, small bowel or colon, or conduit (including the suture or stapler row at the conduit/stomach/small bowel/colon). Every patient with fever, rising infection parameters, and/or clinical deterioration, with or without abnormal drainage secretion during the postoperative course, should undergo endoscopy if possible.

In addition to describing degrees of severity of the insufficiency, the classification also evaluates their relevance for clinical management. The classification was validated on the basis of 459 patients at the university hospitals in Heidelberg and Tübingen, among whom a total of 92 cases of intrathoracic anastomotic insufficiency occurred. The classification was correlated with the length of the intermediate care/intensive-care unit stay, with the Clavien–Dindo general classification of postoperative complications (P < 0.0143), and also with postoperative mortality (P < 0.001).

Table CAES classification of the severity of anastomotic insufficiency in the esophagus

Insufficiency type	Endoscopic description	Clinical findings	Treatment
Type I	Insufficiency of any size, vital gastric graft, small bowel, colon	Clinically stable	Conservative, fasting, antibiotics if appropriate, endoscopic placement of a feeding tube if appropriate, endoscopic clip application if appropriate
Type II	Insufficiency of any size, vital gastric graft, small bowel, colon	Clinical deterioration	Interventional: endoscopic (SEMS, endoscopic vacuum therapy), and/or imaging-guided drainage (US/CT-guided)
Type IIIa	Insufficiency of any size, vital gastric graft, small bowel, colon	Clinical deterioration / pre-sepsis	Surgical: surgical revision (of any type except discontinuity resection)
Type IIIb	Insufficiency of any size, vital gastric graft, small bowel, colon Graft necrosis	Pre-sepsis / sepsis	Surgical: Discontinuity resection

CAES, Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonographie;
CT, computed tomography; SEMS, self-expanding metal stent; US, ultrasonography

Conclusions for practice

The CAES has successfully developed and validated a classification of insufficiencies in intrathoracic anastomoses. The classification is easy to use and shows significant correlations with the Clavien–Dindo classification and mortality. The CAES recommends that this classification and its categories for degrees of severity should be used in future studies.

The Working Group believe that they have made a substantial contribution to future research, making it possible to generate comparable criteria for insufficiency rates after esophageal and cardial resections with intrathoracic anastomoses.

Example illustrations

**Type I**
○ A small insufficiency in the esophagogastrostomy

**Type II**
# Mediastinal insufficiency cavity
** Access to the gastric tube graft

**Type IIIa**
# Mediastinal insufficiency cavity
** Access to the gastric tube graft

**Type IIIb**
++ Esophagus, vital anastomosis
↓↓ Ischemic gastric graft

References

Schaible A, Schmidt T, Diener M, Hinz U, Sauer P, Wichmann D, Konigsrainer A (2018) [Intrathoracic anastomotic leakage following esophageal and cardial resection : Definition and validation of a new severity grading classification]. Chirurg 89:945-951
Glatz T, Marjanovic G, Zirlik K, Brunner T, Hopt UT, Makowiec F, Hoeppner J (2015) [Surgical treatment of esophageal cancer : Evolution of management and prognosis over the last 3 decades]. Chirurg 86:662-669
Kjaer DW, Larsson H, Svendsen LB, Jensen LS (2017) Changes in treatment and outcome of oesophageal cancer in Denmark between 2004 and 2013. Br J Surg 104:1338-1345
Palmes D, Bruwer M, Bader FG, Betzler M, Becker H, Bruch HP, Buchler M, Buhr H, Ghadimi BM, Hopt UT, Konopke R, Ott K, Post S, Ritz JP, Ronellenfitsch U, Saeger HD, Senninger N, German Advanced Surgical Treatment Study G (2011) Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group. Langenbecks Arch Surg 396:857-866