Severity of oEsophageal Anastomotic Leak in patients after oesophagectomy: the SEAL score
Authors: Ubels Sander , Verstegen Moniek , Klarenbeek Bastiaan , Bouwense Stefan , van Berge Henegouwen Mark , Daams Freek , van Det Marc J , Griffiths Ewen A , Haveman Jan W , Heisterkamp Joos , Koshy Renol , Nieuwenhuijzen Grard , Polat Fatih , Siersema Peter D , Singh Pritam , Wijnhoven Bas , Hannink Gerjon , van Workum Frans , Rosman Camiel ,   the TENTACLE—Esophagus Collaborative Group, Matthée E , Slootmans C A M , Ultee G , Schouten J , Gisbertz S S , Eshuis W J , Kalff M C , Feenstra M L , van der Peet D L , Stam W T , van Etten B , Poelmann F , Vuurberg N , van den Berg J W , Martijnse I S , Matthijsen R M , Luyer M , Curvers W , Nieuwenhuijzen T , Taselaar A K E , Kouwenhoven E A , Lubbers M , Sosef M , Lecot F , Geraedts T C M , van Esser S , Dekker J W T , van den Wildenberg F , Kelder W , Lubbers M , Baas P C , de Haas J W A , Hartgrink H H , Bahadoer R R , van Sandick J W , Hartemink K J , Veenhof X , Stockmann H , Gorgec B , Weeder P , Wiezer M J , Genders C M S , Belt E , Blomberg B , van Duijvendijk P , Claassen L , Reetz D , Steenvoorde P , Mastboom W , Klein Ganseij H J , van Dalsen A D , Joldersma A , Zwakman M , Groenendijk R P R , Montazeri M , Mercer St , Knight B , van Boxel G , McGregor R J , Skipworth R J E , Frattini C , Bradley A , Nilsson M , Hayami M , Huang B , Bundred J , Evans R , Grimminger P P , van der Sluis P C , Eren U , Saunders J , Theophilidou E , Khanzada Z , Elliott J A , Ponten J , King S , Reynolds J V , Sgromo B , Akbari K , Shalaby S , Gutschow C A , Schmidt H , Vetter D , Moorthy K , Ibrahim M A H , Christodoulidis G , Räsänen J V , Kauppi J , Söderström H , Manatakis D K , Korkolis D P , Balalis D , Rompu A , Alkhaffaf B , Alasmar M , Arebi M , Piessen G , Nuytens F , Degisors S , Ahmed A , Boddy A , Gandhi S , Fashina O , Van Daele E , Pattyn P , Robb W B , Arumugasamy M , Al Azzawi M , Whooley J , Colak E , Aybar E , Sari A C , Uyanik M S , Ciftci A B , Sayyed R , Ayub B , Murtaza G , Saeed A , Ramesh P , Charalabopoulos A , Liakakos T , Schizas D , Baili E , Kapelouzou A , Valmasoni M , Pierobon E S , Capovilla G , Merigliano S , Silviu C , Rodica B , Florin A , Cristian Gelu R , Petre H , Guevara Castro R , Salcedo A F , Negoi I , Negoita V M , Ciubotaru C , Stoica B , Hostiuc S , Colucci N , Mönig S P , Wassmer C H , Meyer J , Takeda F R , Aissar Sallum R A , Ribeiro U , Cecconello I , Toledo E , Trugeda M S , Fernández M J , Gil C , Castanedo S , Isik A , Kurnaz E , Videira J F , Peyroteo M , Canotilho R , Weindelmayer J , Giacopuzzi S , De Pasqual C A , Bruna M , Mingol F , Vaque J , Pérez C , Phillips A W , Chmelo J , Brown J , Han L E , Gossage J A , Davies A R , Baker C R , Kelly M , Saad M , Bernardi D , Bonavina L , Asti E , Riva C , Scaramuzzo R , Elhadi M , Abdelkarem Ahmed H , Elhadi A , Elnagar F A , Msherghi A A A , Wills V , Campbell C , Perez Cerdeira M , Whiting S , Merrett N , Das A , Apostolou C , Lorenzo A , Sousa F , Adelino Barbosa J , Devezas V , Barbosa E , Fernandes C , Smith G , Li E Y , Bhimani N , Chan P , Kotecha K , Hii M W , Ward S M , Johnson M , Read M , Chong L , Hollands M J , Allaway M , Richardson A , Johnston E , Chen A Z L , Kanhere H , Prasad S , McQuillan P , Surman T , Trochsler M I , Schofield W A , Ahmed S K , Reid J L , Harris M C , Gananadha S , Farrant J , Rodrigues N , Fergusson J , Hindmarsh A , Afzal Z , Safranek P , Sujendran V , Rooney S , Loureiro C , Leturio Fernández S , Díez del Val I , Jaunoo S , Kennedy L , Hussain A , Theodorou D , Triantafyllou T , Theodoropoulos C , Palyvou T , Elhadi M , Abdullah Ben Taher F , Ekheel M , Msherghi A A A 
Published: June 2022

Abstract

Background
Anastomotic leak (AL) is a common but severe complication after oesophagectomy. It is unknown how to determine the severity of AL objectively at diagnosis. Determining leak severity may guide treatment decisions and improve future research. This study aimed to identify leak-related prognostic factors for mortality, and to develop a Severity of oEsophageal Anastomotic Leak (SEAL) score.

Methods
This international, retrospective cohort study in 71 centres worldwide included patients with AL after oesophagectomy between 2011 and 2019. The primary endpoint was 90-day mortality. Leak-related prognostic factors were identified after adjusting for confounders and were included in multivariable logistic regression to develop the SEAL score. Four classes of leak severity (mild, moderate, severe, and critical) were defined based on the risk of 90-day mortality, and the score was validated internally.

Results
Some 1509 patients with AL were included and the 90-day mortality rate was 11.7 per cent. Twelve leak-related prognostic factors were included in the SEAL score. The score showed good calibration and discrimination (c-index 0.77, 95 per cent c.i. 0.73 to 0.81). Higher classes of leak severity graded by the SEAL score were associated with a significant increase in duration of ICU stay, healing time, Comprehensive Complication Index score, and Esophagectomy Complications Consensus Group classification.

Conclusion
The SEAL score grades leak severity into four classes by combining 12 leak-related predictors and can be used to the assess severity of AL after oesophagectomy.