P1.224. An Imaging-Guided Multidisciplinary Framework for Cervical Anastomotic Leak Management

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer – early outcomes and complications Cervical anastomotic leaks after esophagectomy are heterogeneous and potentially life-threatening complications. Their impact depends not only on leak rate, but also on early recognition, adequate source control, and coordinated rescue strategies. Despite expanding therapeutic options, management remains highly variable. We propose an imaging-guided multidisciplinary framework to support therapeutic decision-making. A previously proposed imaging-based classification of cervical esophagogastric anastomotic leaks was expanded into a multidisciplinary institutional management framework through retrospective analysis of a prospective database and ongoing protocol refinement. Leaks were stratified according to radiologic presentation: type A, exclusive cervical manifestation; type B, contained mediastinal extension; type C, communication with an apical pleural collection; and type D, diffuse or loculated pleural empyema. Management was guided by clinical, endoscopic, and radiologic evolution. Core principles included early suspicion, standardized diagnostic work-up, nutritional support, luminal defect management, and mediastinal and pleural source control. Therapeutic strategies ranged from conservative treatment to endoscopic vacuum therapy and/or stenting, image-guided drainage, thoracoscopic lavage or decortication according to empyema stage. Coordination between surgery, gastroenterology, radiology, intensive care, nutrition, and rehabilitation teams was incorporated throughout management. The proposed framework standardized communication and therapeutic escalation in a complex postoperative complication. Different radiologic phenotypes were associated with distinct patterns of septic extension and required tailored treatment strategies. Exclusive cervical manifestations were predominantly managed conservatively, while mediastinal and pleural involvement more frequently required multimodal and sequential interventions. Dynamic reassessment allowed treatment adaptation according to clinical evolution. In patients with pleural contamination, management was guided by empyema stage and source-control principles, ranging from image-guided drainage to thoracoscopic lavage or decortication. Institutional adoption strengthened multidisciplinary coordination and supported reproducible management strategies while allowing ongoing protocol refinement and future interinstitutional discussion. Cervical anastomotic leaks after esophagectomy are heterogeneous and dynamic complications that require coordinated multidisciplinary management.This framework integrates imaging phenotype and patterns of septic extension to support standardized therapeutic escalation and reproducible decision-making. Ongoing refinement, prospective evaluation, and international collaboration are essential to improve management strategies and advance collective experience in the treatment of anastomotic leaks.