The CAES classification of anastomotic insufficiency in the esophagus
A. Schaible, A. Königsrainer, D. Wichmann
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 .
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 , 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|
|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.
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