Anatomy of an oesophagojejunostomy leak: a surgical perspective to identify Achille’s heel after total gastrectomy

Objective This study aimed to describe the location, treatments and postoperative outcomes of patients with anastomotic leak (AL) after total gastrectomy for gastric cancer (GC). Methods A retrospective review was conducted of patients who experienced AL after total gastrectomy for GC, treated at a high-volume European institution between 2019 and 2024. Data collected included AL location, clinical outcomes, treatments and 90-day mortality. ALs were categorised as early or late, and their association with surgical and clinical data was assessed. Finally, a comparison with patients who underwent total gastrectomy for GC without AL (controls) was also performed. Results Out of 151 total gastrectomies, 13 patients had an AL. The median time to diagnosis was 3 days; 7 patients were categorised in the early leak group. Overall, 84.6% reported AL on the right side of the anastomosis. Surgical intervention was required for most cases, either alone (53.8%) or in combination with endoscopic treatment (38.5%). Half of the patients required emergency intensive care unit (ICU) admission, and the mean postoperative stay was 48.5 days. The 90-day mortality was 15.4%. Patients with AL experienced significant delays in resuming adjuvant chemotherapy. When compared with the 133 controls, patients with AL were documented with more comorbidity (American Society of Anesthesiologists 3–4 53.9% vs 18.8%, p 0.003), and lower preoperative haemoglobin values (112 g/L vs 122 g/L, p 0.002), with longer hospitalisation and increased emergency ICU admissions. Conclusions ALs are more common on the right side of the oesophagojejunostomy. Leaks continue to represent a critical challenge following total gastrectomy, with significant implications for patient morbidity and mortality.