The role of esophageal stent placement in the management of postesophagectomy anastomotic leak

Abstract

Background/Aim:Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The study intended to assess the outcome of endoluminal self-expanding stent in the treatment of this problem.Settings and Design:Department of Thoracic and Cardiovascular Surgery, Arhus University Hospital, Skejby, Arhus, Denmark. A retrospective study.Patients and Methods:From January 2007 to December 2010, 209 patients underwent esophagectomy for malignant disease of the esophagus or the cardia. Twenty patients developed anastomotic leak. Treatment consisted of conservative measures, surgery, and stent placement. Details of treatment, clinical outcome, complications, and mortality were evaluated.Statistical analysis:None.Results:One hundred and forty-seven patients (70.3%) had carcinoma of the cardia, whereas 62 patients (29.7%) had esophageal carcinoma. Twenty patients (9.5%) developed anastomotic leak; small (<1 cm) in two patients (10%); managed conservatively and bigger than 1 cm in 15 patients (75%); treated with an esophageal stent (Hanaro stent, DIAGMED Healthcare, Thirsk, YO7 3TD, United Kingdom). In three patients (15%), perforation of the staple line of the intrathoracic gastric conduit was found and managed by reoperation. Functional sealing of anastomoses after stent placement could be achieved in 10 patients (67%). Stent-related morbidity developed in five patients (33%): Migration of the stent, n=3 and tracheoesophageal fistula, n=2. Stents were smoothly removed 3 weeks after discharge. The mean hospital stay was 25 days. There was only one stent-related death (6.6%).Conclusion:Endoluminal stent implantation is an effective and safe option in the management of postesophagectomy leaks.

Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS)

“…There is a paucity of literature regarding the direct comparison between endoscopic and surgical management for gastrointestinal leaks in general, although one recent study reported higher mortality rates in patients treated with stents when compared to those treated with surgery for esophageal perforation [26]. Other recent studies have shown stents to be effective at controlling leaks due to a variety of etiologies in the foregut [8,14,16,17,24,27,28]. Our study provides additional evidence that the use of SEMS is effective in the management of anastomotic leaks after foregut surgery; however, major complications such as aorto-esophageal fistula formation and death can be encountered.…”

“…While we did not discover specific predictive factors, some patients may benefit from conservative treatment instead of SEMS. Al-issa et al [29] achieved successful resolution of small anastomotic leaks (\1 cm) in their cohort with drainage, antibiotic therapy, and restriction of oral intake. While the number of patients treated this way was small, this is evidence that small leaks can be managed effectively with more conservative management.…”

“…The benefits of SEMS include providing a barrier between intraluminal contents and the healing anastomosis to prevent leakage and subsequent infection while simultaneously allowing for oral nutrition. However, the management of leaks with endoscopic stents is not without problems, the most common being stent migration [9,14,17,24,25]. Other complications include tissue ingrowth, mucosal erosion, and endoscopic complications associated with placement and removal such as perforation.…”

“…With recent advancements in endoscopy, the use of fully covered self-expanding metal stents (SEMS) has been gaining popularity as a minimally invasive treatment of gastrointestinal leaks for both malignant [14][15][16][17] and benign [9,18,19] pathologies. Although SEMS were only FDA approved for malignant stricture, many endoscopists have been pushing the envelope in the past decade and using SEMS to treat anastomotic leaks after foregut surgery.…”

Predictive Factors for the Migration of Endoscopic Self-Expanding Metal Stents Placed in the Foregut

“…8,9 The management of GI diseases with endoscopic stents has been troubled by complications including tissue ingrowth, mucosal erosion, and endoscopic complications associated with both placement and removal such as perforation; however, the most common has been stent migration. [9][10][11][12][13] Stent migration rates range from 3.7% to 50% depending on the stent's diameter, the covering, location of insertion, and material used to make the stent. [14][15][16][17] Migration has been associated with significant morbidity and complications, including failure to resolve the leak or stricture and the need for subsequent procedures, such as surgical removal of the stent and repeat endoscopy for stent replacement.…”