Endoscopic management of esophageal leaks

Abstract

Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents.Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse J Thorac Dis 2017;9(Suppl 2):S135-S145 jtd.amegroups.com significantly less esophageal dilatation, a lower rate of migration and improved palliation for malignant esophageal strictures and malignant tracheo-esophageal fistulae (10,11). However, placement of these prostheses continued to be reserved only for the patient requiring palliative therapy for a malignancy because of the potential esophageal damage associated with extraction including reports of irreparable, sometimes life threatening, fistulae.To combat these complications, second generation metallic stent designs were developed incorporating a covering of silicone, polyurethane or other polymers (12). While offering the advantage of diminishing amount of tumor ingrowth and fixation to the esophageal wall, it came with the cost of higher migration rates. Later, the ends of these covered stents were modified to be partially covered with a margin of 1.5 cm on both proximal and distal ends to optimize purchase of the esophageal wall (13).Further evolution in esophageal stent biomaterials resulted in the development of an occlusive plastic prosthesis coated with silicone. This new design allowed ease of insertion, a minimal requirement for esophageal dilation and the ability to form an occlusive seal within the lumen of the esophagus (14). The distinctive advantage of these non-metallic endoprostheses was the ability for removal or replacement even after an extended period of time without damage to the esophagus. However, similar to the covered metallic stents, a higher incidence of migration was appreciated (15).These synergistic developments led to a crucial turning point in management of esophageal perforations. The ease in manipulation of high-quality covered, occlusive stents in the esophagus, led some investigators to implant these stents in select patients as a temporary measure to treat intrathoracic anastomotic leaks following esophagogastrostomy and acute perforations. Segalin et al. and Roy-Choudhury et al. were am...

Safety of Esophageal Stent Placement Without Fluoroscopy

“…There are publications showing that esophageal stents have been successfully used in upper gastrointestinal system leaks (8,(15)(16)(17). In our study, one patient underwent a semi-coated, selfexpanding metallic stent due to leakage after sleeve gastrectomy.…”

“…Fluoroscopic-guided stent placement is a technique that is easy to perform and has high success rates (8). However, the use of fluoroscopy carries a higher risk of radiation exposure for the patient, surgeon, and surgical team.…”

Feasibility, Effectiveness, and Safety of Endoscopic Vacuum Therapy for Intrathoracic Anastomotic Leakage Following Transthoracic Esophageal Resection: A Prospective Study

“…This involves treating the patient with antibiotics, maintaining nil per os, giving parenteral nutrition temporarily, or applying endoscopic metal clips or over-the-scope clips (OTSC) for defect closure (23)(24)(25)(26). For cases with larger leakages, the placement of self-expanding covered metal or plastic stents (SEMS or SEPS) has served as the rst-line therapy (26)(27)(28)(29). The reported success rates of stent therapy range between 65-91% (26,30,31).…”

“…For cases with larger leakages, the placement of self-expanding covered metal or plastic stents (SEMS or SEPS) has served as the rst-line therapy (26)(27)(28)(29). The reported success rates of stent therapy range between 65-91% (26,30,31). However, common adverse events have been observed.…”

Interdisziplinäres Management bei Anastomoseninsuffizienz nach Ösophagusresektion zur Vermeidung der Ösophagektomie

“…Zur Versorgung der Anastomoseninsuffizienz hat sich die Behandlung über selbstexpandierende, beschichtete ösophageale Stents seit den 1990er-Jahren durchgesetzt [8]. Die Erfolgsraten dieser Behandlungsoption liegen bei etwa 70-85 %.…”