Oesophagectomy anastomotic leak — FFICM MCQ

Correct answer: B — Oesophagogastric anastomotic leak

The correct answer is B, oesophagogastric anastomotic leak. In the timeframe typical for this complication (days 5 to 7 post-oesophagectomy), new atrial fibrillation, fever, rising CRP, rising lactate and an increasing oxygen requirement together represent the classic sepsis picture of a contained or free anastomotic dehiscence, and the pleural drain becoming turbid immediately after enteral feed is restarted is essentially pathognomonic, since feed or gastric contents are tracking into the pleural space through the leak. New-onset AF after oesophagectomy is a well recognised early clinical marker of intrathoracic sepsis and anastomotic leakage rather than a primary cardiac event. The combination of a left pleural effusion, systemic inflammatory response and feed-contaminated drain fluid in this postoperative window should prompt urgent CT with oral contrast and surgical or endoscopic review, as leaks carry high morbidity if diagnosis is delayed. Why the other options are wrong: D. Uncomplicated postoperative atelectasis: this does not produce turbid, feed-associated pleural drainage, rising CRP or lactate, and would not explain new AF; it is a benign radiological finding without a systemic septic response. E. Pulmonary embolism without sepsis: PE can cause hypoxia and AF but does not explain fever, rising CRP or turbid feed-contaminated pleural fluid, which requires a mechanical breach of the gut lumen. C. Acute myocardial infarction alone: AF can occur with ischaemia, but MI alone does not account for fever, pleural effusion, rising CRP or turbid enteral-feed-related drainage. A. Benign chylothorax: chylous drainage is classically milky, not turbid with feed contamination, and chylothorax typically presents without fever or a marked inflammatory or lactate rise unless secondarily infected. Key point: turbid pleural drain fluid coinciding with enteral feeding after oesophagectomy, especially alongside new AF and sepsis, must be treated as an anastomotic leak until proven otherwise.

Reference: Association of Upper Gastrointestinal Surgery of Great Britain and Ireland (AUGIS) / POQI consensus statement on perioperative care after oesophagectomy, British Journal of Surgery 2022; https://academic.oup.com/bjs/article/109/11/1096/6674692