Addressing Anastomotic Leak After Esophagectomy: Insights from a Specialized Unit

<b>Background/Objectives:</b> Anastomotic leakage is one of the most frightening and potentially fatal complications after esophagectomy. The collaboration between the surgical team, interventional gastroenterologists, and radiologists has the potential to improve the hospital stay, as well as morbidity and mortality. The aim of this study is to present our experience and evaluate the results of the multimodal management of anastomotic leak following esophagectomy in our unit. <b>Methods:</b> This is a retrospective study analyzing a single referral center's prospectively maintained database of all patients diagnosed with anastomotic leak between March 2019 and March 2025 using the definition of the Esophageal Complications Consensus Group. The treatment pathways and the patient outcomes are presented. The primary endpoint was 90-day mortality and in-hospital mortality. <b>Results:</b> A total of 241 esophageal resections were performed between March 2019 and March 2025. Lymphadenectomy of the mediastinum was performed in 88.4% of the patients. Cervical and intrathoracic anastomosis were performed in 143 (59.3%) and 98 (40.7%) cases, respectively. Twenty-nine patients (12%) with a mean age of 59.1 years developed anastomotic leak. Anastomotic leak occurred in 14.3% of intrathoracic anastomoses and 10.5% of cervical anastomoses. The median day of leak diagnosis was the sixth postoperative day. Leak management involved conservative strategies, wound exploration, endoscopic stent placement or vacuum therapy, drainage of effusions under radiologic guidance, and reoperation. The 90-day and in-hospital mortality rate was 3.4%. No cases of conduit necrosis or mediastinitis were reported. Endoscopic management was employed in 18 patients (62.1%) as a first- or second-line treatment, while reoperation was required in 6 patients (20.7%). The median interval from diagnosis to anastomosis healing was 21 days and the median duration of hospital stay 32 days. The management was successful in 27 patients (93.1%) except for 1 who developed tracheoesophageal fistula and 1 who died due to hemorrhagic complication of anticoagulant treatment. <b>Conclusions:</b> Anastomotic leak after esophagectomy is considered a complex, diversified, and morbid clinical entity. The evolving potential of multidisciplinary management encompassing surgical and interventional radiological and endoscopic treatment addresses the mortality rates and heralds a new era of minimizing morbidity.