{"id":7293,"date":"2020-02-13T15:00:08","date_gmt":"2020-02-13T14:00:08","guid":{"rendered":"https:\/\/www.endoscopy-campus.com\/klassifikationen\/die-caes-klassifikation-der-oesophagusanastomosen-insuffizienz\/"},"modified":"2020-02-24T12:59:36","modified_gmt":"2020-02-24T11:59:36","slug":"die-caes-klassifikation-der-oesophagusanastomosen-insuffizienz","status":"publish","type":"klassifikationen","link":"https:\/\/www.endoscopy-campus.com\/en\/classifications\/die-caes-klassifikation-der-oesophagusanastomosen-insuffizienz\/","title":{"rendered":"The CAES classification of anastomotic insufficiency in the esophagus"},"content":{"rendered":"\n

The Surgical Working Group on Endoscopy\nand Ultrasound (Chirurgische\nArbeitsgemeinschaft f\u00fcr Endoskopie und Sonographie,<\/em> CAES) has developed and\nvalidated a classification of anastomotic insufficiency in the esophagus, which\nwas published in December 2018 [1].<\/p>\n\n\n\n

Background<\/h2>\n\n\n\n

Intrathoracic anastomotic insufficiency\nfollowing esophageal or cardial resection continues to be a feared\ncomplication, in view of the significant morbidity and increased mortality\nassociated with it. In addition to restrictions of pulmonary function as a\nresult of pleural effusions and empyema, mediastinitis may also lead to septic\norgan failure. Minimally invasive surgical techniques and improvements in\nperioperative management have led to a substantial reduction in the mortality\nrate [2,3], despite perioperative oncological therapy. Since endoscopy has\nbecome established, particularly in Germany, as the primary diagnostic measure when\nanastomotic insufficiency is suspected [4], the CAES has developed and\nvalidated a definition and classification of severity for anastomotic\ninsufficiency following esophageal resection. The classification is based on\nthe endoscopic findings.<\/p>\n\n\n\n

Definition and validation<\/h2>\n\n\n\n

The CAES classification is based on the\nfollowing criteria. Independently of the diagnostic method used, intrathoracic anastomotic\ninsufficiency following resection of the esophagus or cardia is defined as a\ncommunication between the intraluminal and extraluminal compartments through a\ndefect in the integrity of the intestinal wall at the anastomosis between the\nesophagus and stomach, small bowel or colon, or conduit (including the suture\nor stapler row at the conduit\/stomach\/small bowel\/colon). Every patient with\nfever, rising infection parameters, and\/or clinical deterioration, with or\nwithout abnormal drainage secretion during the postoperative course, should\nundergo endoscopy if possible.<\/p>\n\n\n\n

In addition to describing\ndegrees of severity of the insufficiency, the classification also evaluates\ntheir relevance for clinical management. The classification was validated on\nthe basis of 459 patients at the university hospitals in Heidelberg and\nT\u00fcbingen, among whom a total of 92 cases of intrathoracic anastomotic\ninsufficiency occurred. The classification was correlated with the length of\nthe intermediate care\/intensive-care unit stay, with the Clavien\u2013Dindo general\nclassification of postoperative complications (P<\/em> < 0.0143), and also with postoperative mortality (P<\/em> < 0.001).<\/p>\n\n\n\n

<\/p>\n\n\n\n

Table CAES classification of the severity of anastomotic insufficiency in the esophagus <\/h2>\n\n\n\n
Insufficiency type<\/th>Endoscopic description<\/th>Clinical findings<\/th>Treatment<\/th><\/tr><\/thead>
Type I<\/strong><\/td>Insufficiency of any size, vital gastric graft, small bowel, colon<\/td>Clinically stable<\/td>Conservative, fasting, antibiotics if appropriate, endoscopic placement of a feeding tube if appropriate, endoscopic clip application if appropriate<\/td><\/tr>
Type II<\/strong><\/td>Insufficiency of any size, vital gastric graft, small bowel, colon<\/td>Clinical deterioration<\/td>Interventional: endoscopic (SEMS, endoscopic vacuum therapy), and\/or imaging-guided drainage (US\/CT-guided)<\/td><\/tr>
Type IIIa<\/strong><\/td>Insufficiency of any size, vital gastric graft, small bowel, colon<\/td>Clinical deterioration \/ pre-sepsis<\/td>Surgical: surgical revision (of any type except discontinuity resection)<\/td><\/tr>
Type IIIb<\/strong><\/td>Insufficiency of any size, vital gastric graft, small bowel, colon
Graft necrosis<\/td>		Pre-sepsis \/ sepsis <\/td>Surgical: Discontinuity resection<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n

CAES, Chirurgische Arbeitsgemeinschaft f\u00fcr Endoskopie und Sonographie;
CT, computed tomography; SEMS, self-expanding metal stent; US, ultrasonography<\/p>\n\n\n\n

Conclusions for practice<\/h2>\n\n\n\n

The CAES has successfully developed and\nvalidated a classification of insufficiencies in intrathoracic anastomoses. The\nclassification is easy to use and shows significant correlations with the\nClavien\u2013Dindo classification and mortality. The CAES recommends that this\nclassification and its categories for degrees of severity should be used in\nfuture studies.<\/p>\n\n\n\n

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.<\/p>\n\n\n\n

Example illustrations<\/h2>\n\n\n\n
\n
\n
\"\"
Type I
<\/strong>\u25cb A small insufficiency in the esophagogastrostomy<\/figcaption><\/figure>\n<\/div>\n\n\n\n
\n
\"\"
Type II
<\/strong># Mediastinal insufficiency cavity
** Access to the gastric tube graft<\/figcaption><\/figure>\n<\/div>\n<\/div>\n\n\n\n
\n
\n
\"\"
Type IIIa
<\/strong># Mediastinal insufficiency cavity
** Access to the gastric tube graft<\/figcaption><\/figure>\n<\/div>\n\n\n\n
\n
\"\"
Type IIIb
<\/strong>++ Esophagus, vital anastomosis
\u2193\u2193 Ischemic gastric graft<\/figcaption><\/figure>\n<\/div>\n<\/div>\n\n\n\n
<\/div>\n\n\n\n

References<\/h2>\n\n\n\n
  1. 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 <\/li>
  2. 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<\/li>
  3. 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<\/li>
  4. 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<\/li><\/ol>\n\n\n\n

    <\/p>\n","protected":false},"excerpt":{"rendered":"

    The Surgical Working Group on Endoscopy and Ultrasound (Chirurgische Arbeitsgemeinschaft f\u00fcr Endoskopie und Sonographie, CAES) has developed and validated a classification of anastomotic insufficiency in the esophagus.<\/p>\n","protected":false},"featured_media":7283,"template":"","categories":[94,93],"tags":[1896,1890,1893,889,1894,1895],"ec-magazin-ausgaben":[],"sponsoren-erwaehnung":[],"autor":[],"class_list":["post-7293","klassifikationen","type-klassifikationen","status-publish","has-post-thumbnail","hentry","category-classifications","category-upper-gi-tract","tag-anastomotic-insufficiency-in-the-esophagus","tag-caes","tag-caes-en","tag-insuffiency","tag-oesophagusanastomosen-en","tag-oesophagusanastomosen-insuffizienz-en"],"_links":{"self":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/klassifikationen\/7293","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/klassifikationen"}],"about":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/types\/klassifikationen"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/media\/7283"}],"wp:attachment":[{"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/media?parent=7293"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/categories?post=7293"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/tags?post=7293"},{"taxonomy":"ec-magazin-ausgaben","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/ec-magazin-ausgaben?post=7293"},{"taxonomy":"sponsoren-erwaehnung","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/sponsoren-erwaehnung?post=7293"},{"taxonomy":"autor","embeddable":true,"href":"https:\/\/www.endoscopy-campus.com\/en\/wp-json\/wp\/v2\/autor?post=7293"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}