P1.221. Radiological Classification System for Anastomotic Leakage After Esophagectomy; ESO-RADS

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Anastomotic leakage remains a major complication after esophagectomy and is associated with increased mortality and need for re-intervention. Although computed tomography is routinely used for diagnosis, a standardized CT-based assessment of anastomotic leakage severity is lacking; this study aimed to develop such scoring system. Imaging features were selected through multidisciplinary consensus to develop a CT-based scoring system; ESO-RADS. All CT scans performed between January 1st 2022 and January 1st 2025 for suspected anastomotic leakage after esophagectomy were independently reviewed and scored by five radiologists blinded to the original reports. Interobserver agreement for probability scores of anastomotic leakage was assessed using the intraclass correlation coefficient (two-way random effects model, absolute agreement). Scans rated as inadequate (score 0) were excluded from this analysis. In total, 109 scans were re-assessed by five radiologists. Interobserver agreement among the five radiologists was reasonable, given the subjective nature of ordinal probability scoring, with an intraclass correlation coefficient (ICC) of 0.65 (95% CI 0.56–0.73). The AUC for detecting anastomotic leakage ranged from 0.72 to 0.85 among the five radiologists, reflecting good discriminative performance (Radiologist 1: 0.72 [95% CI 0.61–0.83]; Radiologist 2: 0.78 [0.68–0.87]; Radiologist 3: 0.85 [0.77–0.92]; Radiologist 4: 0.83 [0.75–0.91]; Radiologist 5: 0.77 [0.66–0.87]). The average score across all radiologists yielded an AUC of 0.83 (0.75–0.92). At a clinically relevant cut-off of ≥3 to indicate a positive result, individual radiologist performance showed moderate to high sensitivity (71–91%) and specificity (53–71%). Using the mean score, sensitivity and specificity improved to 80.0% and 77.8%, respectively. The scoring system adds value in detecting anastomotic leakage on CT. Interobserver agreement among the five radiologists was acceptable and scoring allowed reliable discrimination between patients with and without leakage,. Averaging scores further improved sensitivity and specificity, supporting its use to enhance diagnostic consistency.