Prof. Simon LAW
Professor, Gastrointestinal Surgery, University of Hong Kong, Hong Kong
Simon Law graduated from the University of Cambridge. He is currently Cheung Kung-Hai Professor in Gastrointestinal Surgery, and Chair Professor and Chief of Esophageal and Upper Gastrointestinal Surgery at The University of Hong Kong.
Professor Law is Vice-President of the International Society of Diseases of the Esophagus, and co-chairman of the Education Committee of the same society. He is Secretary of the Hong Kong China Chapter of the American College of Surgeons, honorary fellow of the American Surgical Association as well as the European Surgical Association.
He has published near to 300 articles and 40 book chapters. He is associate editor of Diseases of the Esophagus, and member of the editorial board in 15 other journals. He has been invited as visiting professor and to deliver keynote and plenary lectures worldwide. He has spoken nationally and internationally on over 300 occasions.
Anastomotic leak after esophagectomy remains significant morbidity. Despite the improvement in surgical techniques, its incidence remains high even among specialist centres. According to Esodata.org database (an international database currently including over 3000 patients worldwide), the leak rate is still over 10%.
Many factors are contributory to leaks. Blood supply of the conduit, tension, and the actual surgical techniques are likely most important, but other systemic factors may also be responsible. Aside from ensuring a conduit of adequate length (avoiding tension), and careful construction of the anastomosis, gastric perfusion is very important. The blood supply of the gastric fundus relies on the right gastroepiploic arcade and intramural plexus. Ischaemic conditioning as a method to improve fundal perfusion has not made a big impact on the outcome. Recently intraoperative assessment of perfusion using fluorescent angiography with Indocyanine Green has received much attention. It allows intraoperative assessment of perfusion and surgical methods can be tailored to such findings. Early experience showed that leak rates can be reduced.
Perioperatively, anaesthetic and postoperative care are important. Combinations of factors potentially affect visceral (gastric) perfusion: systemic mean arterial pressure (MAP), epidural analgesia, use of vasopressors, intraoperative and perioperative fluid management are all interacting to affect perfusion. Current evidence seems to suggest conservative fluid administration to prevent overload, avoidance of epidural boluses (lessen the chance of hypotension), judicious use of vasopressors to titrate MAP are important.
Despite all efforts, leaks can still happen. Early diagnosis is essential; liberal use of endoscopy and imaging ensures timely treatment before sepsis takes hold. Treatments include control of sepsis, drainage (by simply opening a neck wound, interventional radiology, endosponge treatment, or even surgery), nutritional support, endoscopic stenting are all employed method. Treatment should be individualized.