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El-Sourani N, Miftode S, Bockhorn M, Arlt A, Meinhardt C. Endoscopic Management of Anastomotic Leakage after Esophageal Surgery - Ten Year Analysis in a Tertiary University Center. Clin Endosc 2021; 55:58-66. [PMID: 34645084 PMCID: PMC8831416 DOI: 10.5946/ce.2021.099] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 06/21/2021] [Indexed: 11/22/2022] Open
Abstract
Background/Aims Anastomotic leakage after esophageal surgery remains a feared complication. During the last decade, management of this complication changed from surgical revision to a more conservative and endoscopic approach. However, the treatment remains controversial as the indications for conservative, endoscopic, and surgical approaches remain non-standardized.
Methods Between 2010 and 2020, all patients who underwent Ivor Lewis esophagectomy for underlying malignancy were included in this study. The data of 28 patients diagnosed with anastomotic leak were further analyzed. Results Among 141 patients who underwent resection, 28 (19.9%) developed an anastomotic leak, eight (28.6%) of whom died. Thirteen patients were treated with endoluminal vacuum therapy (EVT), seven patients with self-expanding metal stents (SEMS) four patients with primary surgery, one patient with a hemoclip, and three patients were treated conservatively. EVT achieved closure in 92.3% of the patients with a large defect and no EVT-related complications. SEMS therapy was successful in clinically stable patients with small defect sizes.
Conclusions EVT can be successfully applied in the treatment of anastomotic leakage in critically ill patients, while SEMS should be limited to clinically stable patients with a small defect size. Surgery is only warranted in patients with sepsis with graft necrosis.
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Affiliation(s)
- Nader El-Sourani
- Department for General - and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Sorin Miftode
- Department for General - and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Maximilian Bockhorn
- Department for General - and Visceral Surgery, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Alexander Arlt
- Department for Internal Medicine and Gastroenterology, University Hospital, Klinikum Oldenburg AöR, Germany
| | - Christian Meinhardt
- Department for Internal Medicine and Gastroenterology, University Hospital, Klinikum Oldenburg AöR, Germany
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Sonomura J, Shimizu T, Taniguchi K, Lee SW, Tanaka R, Imai Y, Honda K, Kawai M, Tashiro K, Uchiyama K. Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report. Medicine (Baltimore) 2021; 100:e24494. [PMID: 33530270 PMCID: PMC7850741 DOI: 10.1097/md.0000000000024494] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/07/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited. PATIENT CONCERNS A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close. DIAGNOSES Intractable esophago-bronchial fistula associated with esophageal surgery. INTERVENTIONS AND OUTCOMES On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case. LESSONS We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.
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Affiliation(s)
- Jun Sonomura
- Department of General and Gastroenterological Surgery
| | | | - Kohei Taniguchi
- Department of General and Gastroenterological Surgery
- Translational Research Program, Osaka Medical College, 2-7, Daigaku-machi, Takatsuki city, Osaka, Japan
| | | | - Ryo Tanaka
- Department of General and Gastroenterological Surgery
| | - Yoshiro Imai
- Department of General and Gastroenterological Surgery
| | - Kotaro Honda
- Department of General and Gastroenterological Surgery
| | - Masaru Kawai
- Department of General and Gastroenterological Surgery
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Kamarajah SK, Bundred J, Spence G, Kennedy A, Dasari BVM, Griffiths EA. Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review. World J Surg 2020; 44:1173-1189. [PMID: 31686158 DOI: 10.1007/s00268-019-05259-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios. METHODS A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24-48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately. RESULTS A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001). CONCLUSIONS Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
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Affiliation(s)
- Sivesh K Kamarajah
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Freeman Hospital, Newcastle University NHS Foundation Trust Hospitals, Newcastle upon Tyne, UK
- Institute of Cellular Medicine, University of Newcastle, Newcastle upon Tyne, UK
| | - James Bundred
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Gary Spence
- Division of Gastroenterology and Surgery, Ulster Hospital, Belfast, Northern Ireland, UK
| | - Andrew Kennedy
- Department of Upper Gastro-Intestinal Surgery, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, UK
| | - Bobby V M Dasari
- Department of Hepatobiliary, Pancreatic and Transplant Surgery, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ewen A Griffiths
- Department of Upper Gastrointestinal Surgery, University Hospitals Birmingham NHS Foundation Trust, Area 6, 7th Floor, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WBUK, UK.
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
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Choi SI, Park JC, Jung DH, Shin SK, Lee SK, Lee YC. Efficacy of Endoscopic Vacuum-Assisted Closure Treatment for Postoperative Anastomotic Leak in Gastric Cancer. Gut Liver 2020; 14:746-754. [PMID: 33024061 PMCID: PMC7667929 DOI: 10.5009/gnl20114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/26/2020] [Accepted: 07/03/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic vacuum-assisted closure (EVAC) has been attempted as new nonsurgical treatment for anastomotic leakage. We aimed to evaluate the clinical outcomes of EVAC and compare its efficacy with the self-expandable metallic stent (SEMS) for postgastrectomy leakage. METHODS Between January 2007 and February 2018, 39 patients underwent endoscopic treatment for anastomotic leakage after gastric cancer surgery. Of them, 28 patients were treated with SEMS, seven with EVAC after SEMS failure, and four with EVAC. We retrospectively compared the clinical characteristics and therapeutic outcomes between EVAC (n=11) and SEMS (n=28). RESULTS The median followup duration was 17 months (interquartile range, 9 to 26 months) in both groups. In comparison of clinical characteristics between two groups, only the median size of the leak was larger in the EVAC group than in the SEMS group (2.1 cm vs 1.0 cm; p<0.001). All EVAC cases healed successfully; however, two cases (7.1%) failed to heal in the SEMS group. Anastomotic stricture occurred one case (9.1%) in EVAC and four cases (14.3%) in SEMS within 1 year after endoscopic treatment. The median treatment duration of EVAC was shorter than that of SEMS (15 days vs 36 days; p<0.001). Median weight loss after therapy was similar in both groups (8.0 kg in EVAC vs 9.0 kg in SEMS; p=0.356). CONCLUSIONS EVAC can be effective endoscopic treatment for postgastrectomy anastomotic leakage. Substantial leakage could be an important clinical factor for considering EVAC as a treatment option. Large randomized controlled trials are needed to confirm the efficacy of EVAC.
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Affiliation(s)
- Soo In Choi
- Division of Gastroenterology, Department of Internal Medicine, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Da Hyun Jung
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Severance Hospital, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Sendino O, Loras C, Mata A, Momblán D, Andujar X, Cruz M, Cárdenas A, Marquez I, Uchima H, Cordova H, de Lacy AM, Espinós J. Safety and efficacy of endoscopic vacuum therapy for the treatment of perforations and anastomotic leaks of the upper gastrointestinal tract. GASTROENTEROLOGIA Y HEPATOLOGIA 2020; 43:431-438. [PMID: 32680732 DOI: 10.1016/j.gastrohep.2020.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/19/2020] [Accepted: 01/23/2020] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the efficacy and safety of endoscopic vacuum therapy (EVT) in the management of perforations and anastomotic leaks of the upper gastrointestinal tract. PATIENTS AND METHODS This is a retrospective observational study which included patients who underwent EVT due to any upper gastrointestinal defect between April 2017 and February 2019 in three Spanish Hospitals. To this end, we used the only medical device approved to date for endoscopic use (Eso-SPONGEr; B. Braun Melsungen AG, Melsungen, Germany). RESULTS 11 patients were referred for EVT of an anastomotic leak after esophagectomy (n=7), gastrectomy (n=2), esophageal perforation secondary to endoscopic Zenker's septomiotomy (n=1) and Boerhaave syndrome (n=1). The median size of the cavity was 8×3cm. The median delay between surgery and EVT was 7 days. The median of EVT duration was 28 days. The median number of sponges used was 7 and the mean period replacement was 3.7 days. In 10 cases (91%), the defect was successfully closed. In 9 cases (82%) clinical resolution of the septic condition was achieved. 5 patients presented some adverse event: 3 anastomotic strictures, 1 retropharyngeal pain and 1 case of new-onset pneumonia. The median hospital stay from the start of EVT was 45 days. 1 patient died owing to septic complications secondary to the anastomotic leak. CONCLUSION EVT was successful in over 90% of perforations and anastomotic leaks of the upper gastrointestinal tract. Moreover, this is a safe therapy with only mild adverse events associated.
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Affiliation(s)
- O Sendino
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España.
| | - C Loras
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - A Mata
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - D Momblán
- Servicio de Cirugía Gastrointestinal, ICMDiM, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - X Andujar
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - M Cruz
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - A Cárdenas
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - I Marquez
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España
| | - H Uchima
- Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
| | - H Cordova
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, IDIBAPS, CIBEREHD, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - A M de Lacy
- Servicio de Cirugía Gastrointestinal, ICMDiM, IDIBAPS, CIBEREHD, AIS Channel, Hospital Clínic, Universitat de Barcelona, Barcelona, España
| | - J Espinós
- Servicio Digestivo, Hospital Universitari Mútua de Terrassa, Terrassa, España; Unidad de Endoscopia, Departamento de Gastroenterología, Centro Médico Teknon, Barcelona, España
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Clinical Feasibility and Safety of Endoscopic Self-Expandable Metal Stent Placement for Upper Gastrointestinal Pathologies. Int Surg 2018. [DOI: 10.9738/intsurg-d-15-00169.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We aimed to review our experiences to evaluate the practicality, safety, and effectiveness of endoscopic stent placement for the palliation of malignant obstructions of the upper gastrointestinal system (GIS) and the treatment of postoperative complications such as failure of anastomoses and fistulae. Endoscopic stent placement is increasingly used in the upper GIS for the management of both high grade malignancies causing obstruction and benign pathologies such as anastomosis failures, gastrointestinal fistulae, and strictures. Hospital records, clinical data, and endoscopy reports of 61 patients who had undergone endoscopic stenting between the years 2012 and 2015 were analyzed retrospectively. For all patients, self-expandable metal covered stents were used. Data involving technical and clinical success rates, complication, morbidity, and mortality rates of the endoscopic stenting procedure was collected and simple statistical analyses were made. Endoscopic stenting was successful in 60 of 61 patients (98.3%). Overall technical success rate was found to be 98.3%; clinical success rate, 86.6%; complication rate, 4.9%. No stent related mortality was observed in our series. Endoscopic stents can be effectively and safely used in the treatment of various lesions of the upper GIS.
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History of the Use of Esophageal Stent in Management of Dysphagia and Its Improvement Over the Years. Dysphagia 2017; 32:39-49. [PMID: 28101666 DOI: 10.1007/s00455-017-9781-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 01/01/2017] [Indexed: 01/07/2023]
Abstract
The art and science of using stents to treat dysphagia and seal fistula, leaks and perforations has been evolving. Lessons learnt from the deficiencies of previous models led to several improvements making stent deployment easier, and with some designs, it was also possible to remove the stents if needed. With these improvements, besides malignant dysphagia, newer indications for using stents emerged. Unfortunately, despite several decades of evolution, as yet, there is no perfect stent that "fits all." This article is an overview of how this evolution process happened and where we are currently with using stents to manage patients with dysphagia and with other esophageal disorders.
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Fernández A, González-Carrera V, González-Portela C, Carmona A, de-la-Iglesia M, Vázquez S. Fully covered metal stents for the treatment of leaks after gastric and esophageal surgery. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 107:608-13. [PMID: 26437979 DOI: 10.17235/reed.2015.3765/2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The use of fully covered metal stents (FCMS) for the treatment of benign conditions is increasing. The aim of our study was to assess the efficacy of FCMS in the management of post-operative leaks after gastric or esophageal surgery. MATERIAL AND METHODS During a three year period (2011-2013), patients who underwent a surgery related with esophageal or gastric cancer and developed a postoperative anastomotic leak treated with FCMS were prospectively included. RESULTS Fourteen patients were included (11 men, 3 women), with median age of 65 years. Placement of at least one stent was achieved in 13 patients (93% of cases), with initial closure of the leak in 12 of these 13 cases (92.3%). A final success (after removal of the stent) could be demonstrated in 9 cases (69.2%, intention to treat analysis); stent failed only in one case (7.7%) and there were 3 patients (23.1%) not evaluated because death before stent retrieval (not related with the endoscopic procedure). One stent were used in 9 cases (69.2%), and two in 4 (30.8%). Migration was observed in two cases (15.3%). There were no major complications related with the use of stents. There were no complications related with retrieval. CONCLUSIONS The placement of FCMS to achieve the leak closure after esophageal or gastric surgery is an effective and probably safe alternative feasible with minor risks.
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9
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Kuehn F, Loske G, Schiffmann L, Gock M, Klar E. Endoscopic vacuum therapy for various defects of the upper gastrointestinal tract. Surg Endosc 2017; 31:3449-3458. [PMID: 28078463 DOI: 10.1007/s00464-016-5404-x] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative, iatrogenic or spontaneous upper gastrointestinal defects result in significant morbidity and mortality of the patients. In the last few years, endoscopic vacuum therapy (EVT) has been recognized as a new promising method for repairing upper gastrointestinal defects of different etiology. However, probably due to insufficient data and no commercially available system for EVT of the upper gastrointestinal tract, until the end of 2014, covering of esophageal defects with self-expanding metal stents (SEMS) were still the mainstay of endoscopic therapy. The aim of this article is to review the data available about EVT for various upper gastrointestinal defects. METHODS A selective literature search was conducted in Medline and PubMed (2007-2016), taking into account all the published case series and case reports reporting on the use of EVT in the management of upper gastrointestinal defects. RESULTS EVT works through intracorporal application of negative pressure at the defect zone with an electronic controlled vacuum device along a polyurethane sponge drainage. This results in closure of the esophageal defect and internal drainage of the septic focus, simultaneously. Compared to stenting, EVT enables regular viewing of wound conditions with control of the septic focus and adjustment of therapy. Moreover, endoscopical negative pressure is applicable in all esophageal regions (cricopharygeal, tubular, gastroesophageal junction) and in anastomotic anatomic variants. EVT can be used solely as a definite treatment or as a complimentary therapy combined with operative revision. In total, there are published data of more than 200 patients with upper gastrointestinal defects treated with EVT, showing succes rates from 70-100%. CONCLUSION The available data indicate that EVT is feasible, safe and effective with good short-term and long-term clinical outcomes in the damage control of upper GI-tract leaks. Still, a prospective multi-center study has to be conducted to proof the definite benefit of EVT for patients with esophageal defects.
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Affiliation(s)
- Florian Kuehn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Gunnar Loske
- Department for General, Abdominal, Thoracic and Vascular Surgery, Katholisches Marienkrankenhaus Hamburg gGmbH, 22087, Hamburg, Germany
| | - Leif Schiffmann
- Westmecklenburg Hospital - Helene von Buelow, 19230, Hagenow, Ludwigslust, Germany
| | - Michael Gock
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
| | - Ernst Klar
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057, Rostock, Germany
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Hwang JJ, Jeong YS, Park YS, Yoon H, Shin CM, Kim N, Lee DH. Comparison of Endoscopic Vacuum Therapy and Endoscopic Stent Implantation With Self-Expandable Metal Stent in Treating Postsurgical Gastroesophageal Leakage. Medicine (Baltimore) 2016; 95:e3416. [PMID: 27100431 PMCID: PMC4845835 DOI: 10.1097/md.0000000000003416] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The aim of the present study was to evaluate the more effective therapy for the postsurgical gastroesophageal leakage by a head-to-head comparison of endoscopic vacuum therapy (EVT) and endoscopic stent implantation with self-expandable metal stent (E-SEMS). In this hospital-based, retrospective, observative study, the patients were classified into 2 groups. Those treated with EVT were assigned to the EVT group (n = 7), and those treated with E-SMS were assigned to the E-SEMS group (n = 11). We evaluated the clinical characteristics and treatment outcomes between the 2 groups. All 7 patients (100%) were treated with EVT, but only 7 of 11 patients (63.6%) in the stenting group were treated successfully. The median time to clinical success was 19.5 (5-21) days in the EVT group and 27.0 (3-84) days in the E-SEMS group. The median hospital stay was 37.1 (13-128) days in the EVT group and 87.3 (17-366) days in the E-SEMS group. The complicaion rate was lower in the EVT group (0/7, 0.0%) than that in the E-SEMS group (6/11, 54.5%) with statistically significant difference (P = 0.042). EVT is more effective and has fewer adverse effects than E-SMS therapy as a treatment for postsurgical gastroesophageal leakage.
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Affiliation(s)
- Jae J Hwang
- From the Department of Internal medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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11
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Gonzalez JM, Servajean C, Aider B, Gasmi M, D'Journo XB, Leone M, Grimaud JC, Barthet M. Efficacy of the endoscopic management of postoperative fistulas of leakages after esophageal surgery for cancer: a retrospective series. Surg Endosc 2016; 30:4895-4903. [PMID: 26944730 DOI: 10.1007/s00464-016-4828-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Anastomotic leakages are severe and often lethal adverse events of surgery for esophageal cancer. The endoscopic treatment is growing up in such indications. The aim was to evaluate the efficacy and describe the strategy of the endoscopic management of anastomotic leakages/fistulas after esophageal oncologic surgery. METHODS Single-center retrospective study on 126 patients operated for esophageal carcinomas between 2010 and 2014. Thirty-five patients with postoperative fistulas/leakages (27 %) were endoscopically managed and included. The primary endpoint was the efficacy of the endoscopic treatment. The secondary endpoints were: delays between surgery, diagnosis, endoscopy and recovery; number of procedures; material used; and adverse events rate. Uni- and multivariate analyses were carried out to determine predictive factors of success. RESULTS There were mostly men, with a median age of 61.7 years ± 8.9 [43-85]. 48.6 % underwent Lewis-Santy surgery and 45.7 % Akiyama's. 71.4 % patients received neo-adjuvant chemo-radiation therapy. The primary and secondary efficacy was 48.6 and 68.6 %, respectively. The delay between surgery and endoscopy was 8.5 days [6.00-18.25]. Eighty-eight percentages of the patients were treated using double-type metallic stents, with removability and migration rates of 100 and 18 %, respectively. In the other cases, we used over-the-scope clips, naso-cystic drain or combined approach. The mean number of endoscopy was 2.6 ± 1.57 [1-10]. The mortality rate was 17 %, none being related to procedures. No predictive factor of efficacy could be identified. CONCLUSIONS The endoscopic management of leakages or fistulas after esophageal surgery reached an efficacy rate of 68.8 %, mostly using stents, without significant adverse events. The mortality rate could be decreased from 40-100 to 17 %.
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Affiliation(s)
- Jean-Michel Gonzalez
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France.
| | - C Servajean
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - B Aider
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - M Gasmi
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - X B D'Journo
- Department of Thoracic Surgery, APHM, North Hospital, University of Mediterranean, Marseille, France
| | - M Leone
- Intensive Care Unit, APHM, North Hospital, University of Mediterranean, Marseille, France
| | - J C Grimaud
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
| | - M Barthet
- Department of Gastroenterology, APHM, North Hospital, University of Mediterranean, Chemin des Bourrelys, 13915, Marseille, France
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Endoscopic Vacuum-assisted Closure With Sponge for Esophagotracheal Fistula After Esophagectomy. Surg Laparosc Endosc Percutan Tech 2015; 25:e76-7. [DOI: 10.1097/sle.0000000000000143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Raimondo D, Sinagra E, Facella T, Rossi F, Messina M, Spada M, Martorana G, Marchesa PE, Squatrito R, Tomasello G, Lo Monte AI, Pompei G, La Rocca E. Self-expandable metal stent placement for closure of a leak after total gastrectomy for gastric cancer: report on three cases and review of the literature. Case Rep Gastrointest Med 2014; 2014:409283. [PMID: 25371833 PMCID: PMC4209762 DOI: 10.1155/2014/409283] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 09/16/2014] [Indexed: 12/17/2022] Open
Abstract
In the setting of the curative oncological surgery, the gastric surgery is exposed to complicated upper gastrointestinal leaks, and consequently the management of this problem has become more critically focused than was previously possible. We report here three cases of placement of a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, NC, USA) in patients who underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric adenocarcinoma. The promising results of our report, despite the small number of patients, suggest that early stenting (through a partially silicone-coated SEMS) is a feasible alternative to surgical treatment in this subset of patients. In fact, in the treatment of leakage after total gastrectomy, plastic stents and totally covered metallic stents may not adhere sufficiently to the esophagojejunal walls and, as a result, migrate beyond the anastomosis. However, prospective studies with a larger number of patients might assess the real effectiveness and safety of this procedure.
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Affiliation(s)
- Dario Raimondo
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
- Ph.D. Course in Surgical Biotechnology and Regenerative Medicine, University of Palermo, Piazza delle Cliniche 2, 90100 Palermo, Italy
- Euro-Mediterranean Institute of Science and Technology (IEMEST), Via Emerico Amari 123, 90100 Palermo, Italy
| | - Tiziana Facella
- Surgery Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Francesca Rossi
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Marco Messina
- Oncology Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Massimiliano Spada
- Oncology Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Guido Martorana
- Surgery Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Pier Enrico Marchesa
- Surgery Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Rosario Squatrito
- Internal Medicine Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Giovanni Tomasello
- Euro-Mediterranean Institute of Science and Technology (IEMEST), Via Emerico Amari 123, 90100 Palermo, Italy
- Department of Surgical and Oncological Disciplines, University of Palermo, Piazza delle Cliniche 2, 90100 Palermo, Italy
| | - Attilio Ignazio Lo Monte
- Department of Surgical and Oncological Disciplines, University of Palermo, Piazza delle Cliniche 2, 90100 Palermo, Italy
| | - Giancarlo Pompei
- Pathology Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
| | - Ennio La Rocca
- Internal Medicine Unit, Fondazione Istituto San Raffaele-G. Giglio, Contrada Pietra Pollastra Pisciotto, 90015 Cefalù, Italy
- Unità Operativa di Medicina Interna e Trapiantologia, Ospedale San Raffaele, Via Olgettina 60, Milano, Italy
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Schaheen L, Blackmon SH, Nason KS. Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review. Am J Surg 2014; 208:536-43. [PMID: 25151186 DOI: 10.1016/j.amjsurg.2014.05.011] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 05/10/2014] [Accepted: 05/20/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Recently, endoscopic interventions (eg, esophageal stenting) have been successfully used for the management of intrathoracic leak. The purpose of this systematic review was to assess the safety and efficacy of techniques used in the management of intrathoracic anastomotic leak. DATA SOURCES We performed a systematic review of MEDLINE, EMBASE, and PubMed to identify eligible studies analyzing management of intrathoracic esophageal leak following esophagectomy. CONCLUSIONS Intraoperative anastomotic drain placement was associated with earlier identification and resolution of anastomotic leak (mean 23.4 vs 80.7 days). In addition, reinforcement of the anastomosis with omentoplasty may reduce the incidence of anastomotic leak by nearly 50%. Endoscopic stent placement was associated with leak resolution in 72%; fatal complications were reported, however, and safety remains to be proven. Negative pressure therapy, a potentially useful tool, requires further study. If stenting and wound vacuum are used, undrained mediastinal contamination and persistent leak require surgical intervention.
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Affiliation(s)
- Lara Schaheen
- Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Shanda H Blackmon
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, MN, USA
| | - Katie S Nason
- Division of Thoracic and Foregut Surgery, University of Pittsburgh, Pittsburgh, PA, USA.
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Mennigen R, Senninger N, Laukoetter MG. Novel treatment options for perforations of the upper gastrointestinal tract: Endoscopic vacuum therapy and over-the-scope clips. World J Gastroenterol 2014; 20:7767-7776. [PMID: 24976714 PMCID: PMC4069305 DOI: 10.3748/wjg.v20.i24.7767] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/23/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.
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16
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Endoscopic endoluminal vacuum therapy in esophageal perforation. Ann Thorac Surg 2014; 97:1029-35. [PMID: 24444874 DOI: 10.1016/j.athoracsur.2013.11.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Revised: 11/04/2013] [Accepted: 11/11/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Esophageal perforation is a serious disease with a high morbidity and mortality rate. Endoscopic vacuum therapy (EVT) is a new endoscopic treatment option, which is used to treat anastomotic leakages after rectal and esophageal resections. We report on 10 patients treated with EVT for esophageal perforation. METHODS Clinical and therapy-related data such as age, sex, duration of intensive care stay, length of hospital stay, reasons for perforation, EVT-associated complications, mortality, need for alternative treatment options, and course of infectious variables were analyzed. RESULTS Ten patients were treated with 54 vacuum sponges that were placed in upper gastrointestinal defects. Causes for perforation were iatrogenic, spontaneous, or foreign body-associated. Mean number of sponge insertions was 5.4 (range, 2 to 12) with a mean period of 19 ± 14.26 days. Successful therapy was achieved in 9 of 10 patients. After successful primary treatment, 1 patient died during therapy as a result of general failure of the cardiovascular system. In 1 patient, surgical resection was necessary after repeated Mallory-Weiss lesions and minor perforations during the course of immunosuppressive therapy. In a third patient an endoscopic stent was inserted in the clean wound cavity after primary EVT. CONCLUSIONS In this small trial EVT has been shown to be a safe and feasible therapy option for perforations of the upper gastrointestinal tract. If necessary, EVT can be combined with operative revision for better control of the local septic focus or used as a bridging procedure for wound conditioning before aggressive surgical treatment.
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Hoeppner J, Kulemann B, Seifert G, Marjanovic G, Fischer A, Hopt UT, Richter-Schrag HJ. Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses. Surg Endosc 2014; 28:1703-11. [PMID: 24380994 DOI: 10.1007/s00464-013-3379-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 12/10/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage. METHODS From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality. RESULTS In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1-78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤ 10 versus >10 mm (68 vs. 64 %; p = 0.479). CONCLUSION CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase.
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Affiliation(s)
- Jens Hoeppner
- Department of General Surgery, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany,
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18
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Manta R, Magno L, Conigliaro R, Caruso A, Bertani H, Manno M, Zullo A, Frazzoni M, Bassotti G, Galloro G. Endoscopic repair of post-surgical gastrointestinal complications. Dig Liver Dis 2013; 45:879-885. [PMID: 23623147 DOI: 10.1016/j.dld.2013.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/28/2013] [Accepted: 03/09/2013] [Indexed: 12/11/2022]
Abstract
Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.
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Affiliation(s)
- Raffaele Manta
- Gastroenterology and Endoscopy Unit, New S. Agostino Hospital, Modena, Italy.
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Shim CN, Kim HI, Hyung WJ, Noh SH, Song MK, Kang DR, Park JC, Lee H, Shin SK, Lee YC, Lee SK. Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy? Surg Endosc 2013; 28:833-40. [PMID: 24114516 DOI: 10.1007/s00464-013-3228-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 09/12/2013] [Indexed: 01/07/2023]
Abstract
BACKGROUND Anastomotic leaks are a life-threatening complication of gastrectomies with high mortality after surgical reintervention. Endoscopic therapy using fibrin glue injection, endoclip, and other devices is an alternative to surgical intervention for anastomotic leaks. Recently, self-expanding metal stents (SEMS) were introduced to treat anastomotic leaks. The purpose of this study was to assess the clinical characteristics and therapeutic outcomes of SEMS and nonstent endoscopic therapy (NSET) for treatment of anastomotic leaks after total gastrectomy with the aim of assisting endoscopists in choosing a treatment method. METHODS Between July 2002 and March 2013, 13 patients treated with SEMS and 14 patients treated with NSET for anastomotic leaks after total gastrectomy were enrolled onto the study. Enrolled patients received 16 SEMS placement sessions and 21 NSET sessions. RESULTS No significant differences in baseline characteristics or clinical characteristics related to leakage were detected in patients with SEMS compared to NSET. The successful sealing rate at the first attempt by SEMS was significantly better than that of NSET (80.0 vs. 28.6 %, P = 0.036), whereas the successful sealing rate after multiple endoscopic treatments was not statistically different (80.0 vs. 64.3 %, P = 0.653). The main reason for reintervention with SEMS was complications and with NSET was nonseal (P = 0.004). Clinical outcomes including length of hospital stay, endoscopic treatment-related mortality, and all-cause mortality were not significantly different between the 2 groups. CONCLUSIONS In terms of efficacy by single effort, SEMS was superior to other methods for treating anastomotic leaks after total gastrectomy. However, complications with SEMS should be considered when choosing an endoscopic treatment method.
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Affiliation(s)
- Choong Nam Shim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul, 120-752, South Korea,
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20
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Schniewind B, Schafmayer C, Voehrs G, Egberts J, von Schoenfels W, Rose T, Kurdow R, Arlt A, Ellrichmann M, Jürgensen C, Schreiber S, Becker T, Hampe J. Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study. Surg Endosc 2013; 27:3883-90. [PMID: 23708716 DOI: 10.1007/s00464-013-2998-0] [Citation(s) in RCA: 130] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available. METHODS In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed. RESULTS Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival. CONCLUSIONS Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.
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Affiliation(s)
- Bodo Schniewind
- Department of General and Thoracic Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Strasse 3 (Haus 18), 24105, Kiel, Germany,
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21
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[Endoscopic vacuum-assisted closure]. Internist (Berl) 2013; 54:309-14. [PMID: 23430199 DOI: 10.1007/s00108-012-3182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Anastomotic leakage in the upper and lower intestinal tract is associated with high morbidity and mortality. Within the last 10 years endoscopic treatment options have been accepted as sufficient treatment option of these surgical complications. Endoscopic vacuum assisted closure (E-VAC) is a new innovative endoscopic therapeutic option in this field. E-VAC transfers the positive effects of vacuum assisted closure (VAC) on infected cutaneous wounds to infected cavities that can only be reached endoscopically. A sponge connected to a drainage tube is endoscopically placed in the leakage and a continuous vacuum is applied. Sponge and vacuum allow removal of infected fluids and promote granulation of the leakage. This results in clean wound grounds and finally allows wound closure. Meanwhile the method was also successfully used in the treatment of necrotic pancreatitis.
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Villarreal-Galvan JJ, Gonzalez-Gonzalez JA, Maldonado Garza HJ. Total loss of the covering of a metallic stent during esophageal leak treatment. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2013; 78:49-51. [PMID: 23375493 DOI: 10.1016/j.rgmx.2012.07.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 07/05/2012] [Accepted: 07/16/2012] [Indexed: 10/27/2022]
Abstract
A 41-year-old man underwent a Heller myotomy due to achalasia. An unexpected puncture in the esophageal wall was identified during the procedure. A partially covered 15cm stent (PSEMS) (UltraFlex) was placed at the mucosal defect. It was removed 26 days later and the endoscopic image showed esophageal tissue embedded in the covered portion of the stent. PSEMS covering loss is a rare complication that can have serious consequences.
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Affiliation(s)
- J J Villarreal-Galvan
- Gastroenterology and Endoscopy Division, Hospital Universitario Jose E. Gonzalez, Monterrey, Mexico
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Choi HJ, Lee BI, Kim JJ, Kim JH, Song JY, Ji JS, Kim BW, Choi H, Choi KY. The temporary placement of covered self-expandable metal stents to seal various gastrointestinal leaks after surgery. Gut Liver 2013; 7:112-115. [PMID: 23423176 PMCID: PMC3572311 DOI: 10.5009/gnl.2013.7.1.112] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 04/09/2011] [Indexed: 01/19/2023] Open
Abstract
Gastrointestinal leakage is one of the most serious post surgical complications and is a major source of mortality and morbidity. The insertion of a covered self-expandable metal stent could be a treatment option in selected cases. However, it is unclear how long the stent should be retained to achieve complete sealing, and membrane-covered stents have the problem of a high migration rate. We observed four cases of postsurgical leakage following the primary closure of a duodenal perforation, esophagojejunostomy, and esophagogastrostomy, each of which was successfully managed by the temporary placement of covered stents. In all cases, the optimal time of stent removal could be estimated by the markedly decreased amount of drainage, the lack of leakage observed on radiocontrast images, and the endoscopic findings. In this case series, all of the stents could be removed within 7 weeks. For those cases with a high risk of migration, stents with temporary fixations to earlobes and/or partially uncovered proximal flanges were used. These results suggest that the application of a covered stent could be a treatment option for various gastrointestinal leaks after surgery, particularly when the defect cannot be sealed by conservative care and the leakage has good external drainage.
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Affiliation(s)
- Hye Jung Choi
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Bo-In Lee
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Jin-Jo Kim
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Ji Hoon Kim
- Department of Surgery, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Joo Yong Song
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Jeong Seon Ji
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Byoung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Hwang Choi
- Department of Internal Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea College of Medicine, Incheon, Korea
| | - Kyu Yong Choi
- Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
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Werner J, Sauer P. Nahtinsuffizienz intestinaler Anastomosen: Endoskopische und laparoskopische Therapieoptionen. Visc Med 2013. [DOI: 10.1159/000348266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen die schwerwiegendste septische Komplikation nach viszeralchirurgischen Eingriffen dar. Neben der chirurgischen Therapie sind zunehmend endoskopische Behandlungsoptionen möglich. <b><i>Methode: </i></b>Literaturübersicht. <b><i>Ergebnisse: </i></b>Therapieoptionen von Anastomoseninsuffizienzen sind abhängig von der klinischen Symptomatik, der Art der Anastomose, der Defektgröße, den lokalen Gewebeverhältnissen sowie dem Zeitpunkt der Diagnose. Bei einer Nekrose oder Minderdurchblutung der Viszeralorgane müssen diese operativ reseziert werden. Prinzipiell sind alle operativen Revisionseingriffe auch laparoskopisch durchführbar. Bei erhaltener Gewebeperfusion können die Leckagen lokal übernäht oder endoskopisch verschlossen werden. Die Ergebnisse für die Stenttherapie nach Ösophagus- und Magenresektionen sind für moderne Stents sehr Erfolg versprechend. Im Gegensatz dazu sind die Ergebnisse der endoskopischen Stenttherapie bei Insuffizienz nach kolorektalen Eingriffen enttäuschend; dafür steht hier mit der Schwammtherapie eine vielversprechende endoskopische Alternative zur Verfügung. <b><i>Schlussfolgerung: </i></b>Die aktuellen Daten zeigen, dass neue laparoskopische und endoskopische Optionen zur Therapie von Anastomoseninsuffizienzen bestehen, die jedoch noch in prospektiven und randomisierten Studien evaluiert werden müssen.
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25
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Kuehn F, Schiffmann L, Rau BM, Klar E. Surgical endoscopic vacuum therapy for anastomotic leakage and perforation of the upper gastrointestinal tract. J Gastrointest Surg 2012; 16:2145-50. [PMID: 22948839 DOI: 10.1007/s11605-012-2014-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 08/14/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Emergency operations for perforations and anastomotic leakage of the upper gastrointestinal tract are associated with a high overall morbidity and mortality rate. An endoscopic vacuum therapy (EVT) has been established successfully for anastomotic leakage after rectal resection but only limited data exist for EVT of the upper GI tract. METHODS We report on a series of nine patients treated with EVT for defects of the upper intestinal tract between March 2011 and May 2012. In four patients, initial endoscopic sponge placement was performed in combination with open surgical revision. Median follow-up was 189 (range, 51-366) days. RESULTS In total, 52 vacuum sponges were placed in upper GI defects of nine patients. Indication for EVT were anastomotic leakage after esophageal resection or gastrectomy (n = 5) and iatrogenic or spontaneous esophageal perforations (n = 4). The mean number of sponge insertions was six (range, 1-13) with a mean changing interval of 3.5 days (range, 2-5). A successful vacuum therapy for upper intestinal defects was achieved in eight of nine patients (89 %). CONCLUSION EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. If necessary the endoscopic procedure can be combined with operative revision for better control of the local septic focus.
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Affiliation(s)
- F Kuehn
- Department of General, Thoracic, Vascular and Transplantation Surgery, University of Rostock, Schillingallee 35, 18057 Rostock, Germany.
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Mardin WA, Palmes D, Bruewer M. Current concepts in the management of leakages after esophagectomy. Thorac Cancer 2012; 3:117-124. [DOI: 10.1111/j.1759-7714.2012.00117.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
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Dai Y, Chopra SS, Steinbach M, Kneif S, Hünerbein M. Esophageal stents for leaks and perforations. Semin Thorac Cardiovasc Surg 2012; 23:159-62. [PMID: 22041049 DOI: 10.1053/j.semtcvs.2011.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2011] [Indexed: 12/16/2022]
Abstract
Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak.
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Affiliation(s)
- Yiyang Dai
- Department of Surgery and Surgical Oncology, Helios Hospital, Berlin, Germany
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van Boeckel PGA, Dua KS, Weusten BLAM, Schmits RJH, Surapaneni N, Timmer R, Vleggaar FP, Siersema PD. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012; 12:19. [PMID: 22375711 PMCID: PMC3313862 DOI: 10.1186/1471-230x-12-19] [Citation(s) in RCA: 119] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 02/29/2012] [Indexed: 12/14/2022] Open
Abstract
Background Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. Methods Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected Results A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n = 32), iatrogenic rupture (n = 13), Boerhaave's syndrome (n = 4) or other cause (n = 3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (all Ultraflex; n = 6), food obstruction (n = 3), severe pain (n = 2), esophageal rupture (n = 2), hemorrhage (n = 2)). One (2%) patient died of a stent-related cause. Conclusions Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Room F02,618, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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van Boeckel PGA, Dua KS, Weusten BLAM, Schmits RJH, Surapaneni N, Timmer R, Vleggaar FP, Siersema PD. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012. [PMID: 22375711 DOI: 10.1186/1471-230x-12-19.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. METHODS Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected RESULTS A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause. CONCLUSIONS Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
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Affiliation(s)
- Petra G A van Boeckel
- Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Room F02,618, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands.
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Abstract
<b><i>Hintergrund: </i></b>Nahtinsuffizienzen stellen eine gefürchtete Komplikation nach Operationen an der Speiseröhre dar, die mit hoher Morbidität und Mortalität vergesellschaftet sind. <b><i>Methoden: </i></b>Die Einlage komplett beschichteter Stents stellt die am häufigsten eingesetzte Methode zur Behandlung ösophagealer Leckagen dar. Eine neue endoskopische Therapiemodalität besteht mit der endoskopischen Vakuumschwammtherapie. Hierbei macht man sich die positiven Effekte des vakuumassistierten Verschlusses (Vacuum-Assisted Closure, V.A.C.), der eine etablierte Therapiemodalität zur Behandlung ausgedehnter infizierter Hautdefekte darstellt, zunutze. Durch neue Entwicklungen haben auch Clips (insbesondere der «Over-the-Scope-Clip», OTSC) wieder eine Bedeutung beim Verschluss von ösophagealen Nahtinsuffizienzen erhalten. <b><i>Ergebnisse: </i></b>Mit diesen endoskopischen Techniken lassen sich Nahtinsuffizienzen des Ösophagus in über 80% der Fälle erfolgreich verschließen. <b><i>Schlussfolgerung</i></b>: Endoskopische Techniken stellen eine geeignete Methode zum Verschluss ösophagealer Leckagen dar und konnten daher in den letzten 10 Jahren die chirurgische Revision weitestgehend verdrängen
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The use of self-expanding plastic stents in the management of oesophageal leaks and spontaneous oesophageal perforations. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2011; 2011:418103. [PMID: 21785560 PMCID: PMC3137963 DOI: 10.1155/2011/418103] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 05/18/2011] [Indexed: 12/19/2022]
Abstract
Leakage after oesophageal anastomosis or perforation remains a challenge for the surgeon. Traditional management has been operative repair or intensive conservative management. Both treatments are associated with prolonged hospitalisation and high morbidity and mortality rates. Self-expanding metallic stents have played an important role in the palliation of malignant oesophageal strictures and the treatment of tracheoesophageal fistulae. However, self-expanding metal stents in benign oesophageal disease are associated with complications such as bleeding, food bolus impaction, stent migration, and difficulty in retrieval. The Polyflex stent is the only commercially available self-expanding plastic stent which has been used in the management of malignant oesophageal strictures with good results. This review will consider the literature concerning the use of self-expanding plastic stents in the treatment of oesophageal anastomotic leakage and spontaneous perforations of the oesophagus.
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Abstract
Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.
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Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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van Boeckel PGA, Sijbring A, Vleggaar FP, Siersema PD. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther 2011; 33:1292-301. [PMID: 21517921 DOI: 10.1111/j.1365-2036.2011.04663.x] [Citation(s) in RCA: 188] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred. AIM To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs. METHODS A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival. RESULTS Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68]. CONCLUSIONS Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).
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Affiliation(s)
- P G A van Boeckel
- Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, The Netherlands
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Feith M, Gillen S, Schuster T, Theisen J, Friess H, Gertler R. Healing occurs in most patients that receive endoscopic stents for anastomotic leakage; dislocation remains a problem. Clin Gastroenterol Hepatol 2011; 9:202-10. [PMID: 21172455 DOI: 10.1016/j.cgh.2010.12.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 11/16/2010] [Accepted: 12/04/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND & AIMS There is controversy about the best way to treat esophageal anastomotic leakage. We evaluated the effects of treatment with self-expanding metal stents in patients with esophageal anastomotic leakage after esophagectomy or gastrectomy for cancer. METHODS We investigated outcomes and procedure-related complications of 115 patients who received endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy at a university hospital from 2004 to 2009. We also performed a systematic literature review on stent therapy and compared outcomes with that of other treatment regimens for esophageal anastomotic leakage. RESULTS Among the 115 patients who received stents, the in-hospital mortality rate was 9% and complete anastomotic healing was achieved in 70% (95% confidence interval [CI], 64%-76%). Stent dislocation occurred in 53% of the patients (95% CI, 43%-62%), in all patients with esophagocolonostomy, in 61% with esophagojejunostomy, and in 49% with esophagogastrostomy. Three percent of patients (95% CI, 1%-5%) needed laparotomy to remove dislocated stents. Elective endoscopic stent removal was performed in 80% of the patients after a median of 54 days (range 17-427 d); 12% of these patients developed symptomatic anastomotic strictures after stent removal. CONCLUSIONS Anastomoses completely heal in 70% of patients that receive endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy. Stent therapy should be used in the management of patients with adequately perfused esophageal anastomotic leakage. However, stent dislocation remains a common problem after surgery.
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Affiliation(s)
- Marcus Feith
- Department of Surgery, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany.
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Hirdes MMC, Siersema PD, Houben MHMG, Weusten BLAM, Vleggaar FP. Stent-in-stent technique for removal of embedded esophageal self-expanding metal stents. Am J Gastroenterol 2011; 106:286-93. [PMID: 20940709 DOI: 10.1038/ajg.2010.394] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Partially covered self-expanding metal stents (SEMSs) are regularly used for malignant and occasionally for benign esophageal disorders. Safe removal of these stents can be challenging due to embedding of the uncovered stent ends. Our aim is to report the results of removal of embedded, partially covered SEMSs by induction of pressure necrosis using the stent-in-stent technique. METHODS Consecutive patients referred to three endoscopy units in 2007-2009, treated by the stent-in-stent technique, were reviewed. The partially covered SEMSs were inserted for malignant (n=3) or benign (n=16) conditions and were left in situ for a median of 42 days (14-189). When SEMSs were found to be embedded, a fully covered self-expanding plastic stent (SEPS) or fully covered SEMS was placed inside the partially uncovered SEMS. Subsequent removal of both stents was planned after a period of 10-14 days. RESULTS In total, 23 stent-in-stent procedures were performed in 19 patients (10 males). Placement of a fully covered stent (SEPS: n=9 and SEMS: n=14) was technically successful in all patients. In 21 of 23 (91%) procedures, both stents were successfully removed in one procedure after a median of 12 days (5-18). In two patients, a repeat stent-in-stent procedure was needed for persistent embedding of the partially uncovered SEMSs. One (5%) procedure was complicated by severe bleeding, which could be treated endoscopically. In seven (36%) patients, the initial disorder had resolved after stent removal and no further endoscopic interventions were needed. Two (10%) patients were treated with chemoradiation or surgery for esophageal cancer after stent removal. In 10 (53%) patients, a repeat endoscopic intervention was required during follow-up because of progressive dysphagia or a persisting leak or fistula. CONCLUSIONS The stent-in-stent technique is safe and effective for the removal of partially covered SEMSs that are embedded in the esophageal wall.
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Affiliation(s)
- M M C Hirdes
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands.
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Weidenhagen R, Hartl WH, Gruetzner KU, Eichhorn ME, Spelsberg F, Jauch KW. Anastomotic leakage after esophageal resection: new treatment options by endoluminal vacuum therapy. Ann Thorac Surg 2010; 90:1674-81. [PMID: 20971288 DOI: 10.1016/j.athoracsur.2010.07.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Revised: 06/29/2010] [Accepted: 07/06/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic leakage after esophagectomy is an important determinant of early and late morbidity and mortality. Control of the septic focus is essential when treating patients with anastomotic leakages. Surgical and endoscopic treatment options are limited. METHODS Between 2005 and 2009, we treated 6 patients who experienced an intrathoracic anastomotic leakage after esophageal resection. After all established therapeutic measures had failed, we explored the feasibility of an endoscopically assisted mediastinal vacuum therapy. RESULTS We were able to heal intrathoracic esophageal leakages in all 6 patients without any local complications and without the need for reoperation. One patient died because of a progressive pneumonia. CONCLUSIONS Endoscopic vacuum-assisted closure of anastomotic leakages may help to overcome the limitations that are associated with intermittent endoscopic treatment and conventional drainage therapy. Our preliminary results suggest that this new concept may be suitable for those patients.
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Affiliation(s)
- Rolf Weidenhagen
- Department of Surgery, University Hospital Campus Grosshadern, Ludwig-Maximilian-University of Munich, Munich, Germany.
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Fritscher-Ravens A, Hampe J, Grange P, Holland C, Olagbeye F, Milla P, von Herbay A, Jacobsen B, Seehusen F, Hadeler KG, Mannur K. Clip closure versus endoscopic suturing versus thoracoscopic repair of an iatrogenic esophageal perforation: a randomized, comparative, long-term survival study in a porcine model (with videos). Gastrointest Endosc 2010; 72:1020-6. [PMID: 21034902 DOI: 10.1016/j.gie.2010.07.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2010] [Accepted: 07/21/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Esophageal full-thickness wall repair is an important but unsolved issue in endoscopy. It is unknown how well endoscopic clip closure (ECC) and endoscopic closure with suturing (ECS) perform compared with the criterion standard of thoracoscopic closure (TC). OBJECTIVE Comparison of technical success, feasibility, long-term patency, complications, and histological quality of the different closure techniques (ECC, ECS, TC) for esophageal perforations. DESIGN Comparative animal study. SETTING Approved animal facility. SUBJECTS Eighteen pigs. INTERVENTIONS Eighteen pigs were randomized, 6 each into 3 groups (ECC, ECS, TC). After endoscopic wall incision and mediastinoscopy, closure was performed by using 1 of the 3 techniques. After 8 to 12 weeks, pre-euthanasia endoscopic, necropsy, histological, and morphometric analyses were performed. MAIN OUTCOME MEASUREMENT Long-term survival and histological quality of the repair. RESULTS The closure of the esophageal incisions was successful in all pigs. On days 2 and 6, 1 animal died of mediastinitis, 1 in the ECS group because of reflux of gastric contents into the mediastinum before the repair and 1 in the TC group because of leakage of the sutured closure (P = 1.0). No strictures were seen on prenecropsy endoscopy. At necropsy, 1 mediastinal abscess was found in an ECS animal (P = 1.0). Minor complications included periesophageal adhesions and reactive lymph nodes in 3 of 6 (ECC group) and 5 of 6 (TC and ECS groups). Histology showed muscle layer defects up to 12 mm in width and 21 mm in length, with a trend toward smaller defect size of width and length in the ECS group of animals. LIMITATIONS Animal study of limited size. CONCLUSIONS Overall, ECS and ECC performed similarly to TC. ECS showed the smallest histological defects in the long-term repair.
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Affiliation(s)
- Annette Fritscher-Ravens
- Interdisciplinary Endoscopy, Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany.
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Stent for nonmalignant leaks, perforations, and ruptures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2011.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Lv Y, Yuan S, Yun J, Yao Q, Chen J, Yi J, Ling R, Wang L. Management of intrathoracic leakage after radical total gastrectomy. J Thorac Dis 2010; 2:180-4. [PMID: 22263041 DOI: 10.3978/j.issn.2072-1439.2010.02.03.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 08/01/2010] [Indexed: 11/14/2022]
Abstract
BACKGROUND Intrathoracic anastomotic leakage resulted from radical total gastrectomy with an end-to-side esophagojejunostomy are exclusively abdominal. CASE PRESENTATION We report the case of a 64-year-old male who underwent radical total gastrectomy and intraabdominal end-to-side esophagojejunostomy for gastric cardiac carcinoma. Anastomotic leakage to the thoracic cavity occurred which was confirmed by contrast radiography 18 days after the operation. The symptoms included coughing and fever, with elevated white blood cells over 10×10(9)/L. Coughing and fever disappeared after successful sealing of the fistulous orifice with an endoscopically placed covered metallic stent with the applications of antibiotics and drainage of the pleural effusion. The patient was recovered and discharged from the hospital approximately two months after the occurrence of the leakage without any symptoms except intermittent esophageal reflux which could be resolved by treatment with cisapride, or by intaking less liquid food. The patient then received 4 cycles of adjuvant chemotherapy with regimen of FOLFOX4 (fluorouracil, leucovorin and oxaliplatin). Unfortunately, he died of a disease- or treatment- unrelated accidence 5 months after the discharge. CONCLUSION The thorough drainage combined with antibiotic treatment is able to eliminate empyema without the need for a specific thoracoscopy or thoracic surgery for patients with intrathoracic leakage.
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Affiliation(s)
- Yonggang Lv
- Department of Vascular and Endocrine Surgery, First Affiliated Hospital, Fourth Military Medical University, Xi'an, PR China
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Lee KM, Shin SJ, Hwang JC, Yoo BM, Cheong JY, Lim SG, Kim JK, Cho YK, Han SU, Lee SR, Kim JH. Proximal-releasing stent insertion under transnasal endoscopic guidance in patients with postoperative esophageal leakage. Gastrointest Endosc 2010; 72:180-5. [PMID: 20546733 DOI: 10.1016/j.gie.2010.02.052] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 02/18/2010] [Indexed: 12/10/2022]
Abstract
BACKGROUND Covered metallic or plastic stent placement has become an important treatment for postoperative esophageal leakage; however, fluoroscopic guidance is also required. Here we present a novel stent insertion technique with a newly designed proximal-releasing, self-expanding metallic stent (PR-SEMS) and transnasal endoscope that can enable stent insertion without fluoroscopy as a new method to prevent stent migration. OBJECTIVE To describe our experience with 7 patients who underwent PR-SEMS insertion with the direct-vision technique and our use of the transnasal endoscope without fluoroscopy. DESIGN Prospective outcome study. SETTING A tertiary-care referral university hospital. PATIENTS This study involved all patients at our center who experienced postoperative esophageal leakage after esophagectomy, primary closure, or total gastrectomy. INTERVENTION PR-SEMS insertion with the direct vision technique and use of transnasal endoscopy without fluoroscopy. MAIN OUTCOME MEASUREMENTS Success rate of stent insertion, healing rate of postoperative esophageal leaks, and stent migration rate. RESULTS All stents were placed at the expected location without complications. One patient had massive hematemesis and underwent surgery. The bleeding focus was the splenic artery, which was damaged during gastrectomy. A significant marginal ulcer occurred in one patient, and the stent was immediately retrieved with an endoscope. After stent removal, 4 postoperative leakages were completely healed, and 2 lesions were not occluded. The 2 remaining minimal lesions became completely occluded with conservative management after stent removal. Stent migration did not occur. LIMITATIONS A small number of patients. Further prospective, randomized, controlled trials are needed. CONCLUSION PR-SEMS insertion under transnasal endoscopic guidance is a feasible, safe, and effective treatment for postoperative esophageal leakage, and it can be performed as a bedside procedure. Our anchoring method is effective for the prevention of migration from nonobstructed lesions.
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Affiliation(s)
- Kee Myung Lee
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Abstract
OBJECTIVES The standard approach to benign esophageal perforations consists of conservative treatment or surgery. In this study, we investigated the efficacy of short-term stent placement for nonmalignant esophageal perforations. METHODS This is a prospective single-center study of patients with benign esophageal perforations in whom a removable self-expandable stent was placed. Data were collected from a prospective database, endoscopy records, and operation reports. To obtain follow-up data, we contacted the patients, their relatives, or their general practitioner. RESULTS A total of 33 patients underwent stent insertion owing to an iatrogenic perforation (n=19), Boerhaave's syndrome (n=10), or other causes (n=4); this resulted in an immediate and complete sealing of the lesion in 32 patients (97%). Stents migrated in 11 patients (33%). Four patients required an esophageal resection for failed stent therapy (n=3) and failed stent removal (n=1). The 90-day mortality rate was 15%. A total of 33 endoscopic stent extractions were attempted. Overall, 23 stents were extracted within 6 weeks (group I) and 10 stents between 6 and 84 weeks (group II). Extractions were uncomplicated in all patients in group I (100%) vs. in 5 patients in group II (50%) (P=0.001). Six extraction-related complications occurred in group II, including two self-limiting bleedings, three stent fractures, and one impacted stent. CONCLUSIONS In patients with a benign esophageal perforation, temporary stent therapy is effective and provides a good alternative to surgery. Complications due to stent removal can be prevented by removal of the prosthesis within 6 weeks after insertion, without compromising the efficacy of treatment.
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Kanatas AN, Aldouri A, Hayden JD. Anastomotic leak after oesophagectomy and stent implantation: a systematic review. Oncol Rev 2010. [DOI: 10.1007/s12156-010-0045-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
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Iacopini F, Lorenzo ND, Altorio F, Schurr MO, Scozzarro A. Over-the-scope clip closure of two chronic fistulas after gastric band penetration. World J Gastroenterol 2010; 16:1665-9. [PMID: 20355247 PMCID: PMC2848377 DOI: 10.3748/wjg.v16.i13.1665] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal perforations are conservatively managed at endoscopy by through-the-scope endoclips and covered self expandable stents, according to the size and tissue features of the perforation. This is believed to be the first report of successful closure of two gastro-cutaneous fistulas with over-the-scope clips (OTSCs). After laparoscopic gastric banding, a 45-year old woman presented with band erosion and penetration. Despite surgical band removal and gastric wall suturing, external drainage of enteric material persisted for 2 wk, and esophagogastroduodenoscopy demonstrated two adjacent 10-mm and 15-mm fistulous orifices at the esophagogastric junction. After cauterization of the margins, the 10-mm fistulous tract was grasped by the OTSC anchor, invaginated into the applicator cap, and closed by a traumatic OTSC. The other 15-mm fistula was too large to be firmly grasped, and a fully-covered metal stent was temporarily placed. No leak occurred during the following 6 wk. At stent removal: the OTSC was completely embedded in hyperplastic overgrowth; the 15-mm fistula significantly reduced in diameter, and it was closed by another traumatic OTSC. After the procedure, no external fistula recurred and both OTSCs were lost spontaneously after 4 wk. The use of the anchor and the OTSC seem highly effective for successful closure of small chronic perforations.
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Repici A, Presbitero P, Carlino A, Strangio G, Rando G, Pagano N, Romeo F, Rosati R. First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video). Gastrointest Endosc 2010; 71:867-9. [PMID: 20185124 DOI: 10.1016/j.gie.2009.08.036] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2009] [Accepted: 08/30/2009] [Indexed: 02/08/2023]
Affiliation(s)
- Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
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46
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Endoscopic vacuum sponge therapy for esophageal defects. Surg Endosc 2010; 24:2531-5. [PMID: 20333402 DOI: 10.1007/s00464-010-0998-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 03/02/2010] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anastomotic insufficiency in esophageal anastomosis and esophageal defects of other etiology are very severe complications. For anastomotic insufficiency in the rectum, endoscopic vacuum therapy has already been used successfully. The authors used vacuum therapy for anastomotic defects and other lesions of the esophagus. METHODS Between November 2006 and September 2009, 10 patients (5 men and 5 women, ages 46-82 years) were treated with endoscopic vacuum sponge therapy for anastomotic insufficiency secondary to esophagectomy or gastrectomy (n = 5), iatrogenic esophageal perforation (n = 2), esophageal wall necrosis (n = 1), Boerhaave's syndrome (n = 1), and perforation of esophageal cancer (n = 1). RESULTS After one to seven changes of the sponge at intervals of 2-7 days and a mean therapy duration of 12 days, the defects were healed in all the surviving patients. During treatment, the patients were fed via an intestinal tube or percutaneous endoscopic gastrostomy (PEG), or enterally past the sponge. One patient died of intercurrent severe colitis. In three cases, a revision laparotomy was necessary at the beginning of treatment. No postinterventional stricture or functional relevant scar formation was observed during a follow-up period of 10-380 days after termination of the vacuum therapy. CONCLUSION Esophageal anastomotic insufficiency and esophageal wall defects of other causes can be treated successfully with endoscopic vacuum sponge therapy.
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Wedemeyer J, Brangewitz M, Kubicka S, Jackobs S, Winkler M, Neipp M, Klempnauer J, Manns MP, Schneider AS. Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system. Gastrointest Endosc 2010; 71:382-6. [PMID: 19879566 DOI: 10.1016/j.gie.2009.07.011] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Accepted: 07/06/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic treatment options for postsurgical intrathoracic leaks include injection of fibrin glue, clip application, and stent placement. Endoscopic vacuum-assisted closure (E-VAC) may be an effective treatment option. OBJECTIVE To demonstrate that E-VAC is an effective endoscopic treatment option for closure of major intrathoracic postsurgical leaks. DESIGN AND SETTING A prospective, single-center study at an academic medical center. PATIENTS Eight consecutive patients with major intrathoracic postsurgical leaks. INTERVENTIONS Endoscopic placement of transnasal draining tubes, armed with a size-adjusted sponge at their distal end, in the necrotic anastomotic cavities, followed by continuous suction. Sponge and drainage were changed twice weekly. Patients were followed-up for 193 +/- 137 days. MAIN OUTCOME MEASUREMENT Successful leak closure. RESULTS Successful closure of leaks was achieved in 7 of 8 patients (88%) after a mean of 23 +/- 8 days. A median of 7 endoscopic interventions was necessary. No major treatment-associated short-term or long-term (follow-up, 193 +/- 137 days) complications were noted. LIMITATIONS Small sample size, single-center study, and lack of randomization. CONCLUSION E-VAC is an effective endoscopic treatment modality for major postsurgical intrathoracic leaks. (This study is registered at Clinicaltrials.gov, identifier NCT00876551.).
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Affiliation(s)
- Jochen Wedemeyer
- Department of Gastroenterology, Medical School of Hannover, Hannover, Germany
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Murphy T, Jobe BA. Endoluminal management of anastomotic dehiscence after esophagectomy: an increasing quiver of options reflects the difficulty in realizing a definitive therapy. Gastrointest Endosc 2010; 71:387-9. [PMID: 20152315 DOI: 10.1016/j.gie.2009.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Accepted: 09/27/2009] [Indexed: 12/10/2022]
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Treatment of upper gastrointestinal leaks with a removable, covered, self-expanding metallic stent. Surg Laparosc Endosc Percutan Tech 2009; 19:e1-4. [PMID: 19238047 DOI: 10.1097/sle.0b013e318196c706] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anastomotic and staple line leaks are serious complications after upper gastrointestinal and bariatric procedures. In patients who are actively septic "diversion and drainage" with aspiration of esophageal and gastric secretions, operative placement of perianastomotic drains, bowel rest, and parenteral nutrition form the conventional management strategy of leaks. Treatment of leaks by direct suture repair, revision, patching, and application of fibrin glue to leaks have failed to gain widespread acceptance owing to a high failure rate in the septic patient. This report describes a case series where anastomotic leaks in patients with established sepsis after upper gastrointestinal resections and bariatric procedures as well as Boerhaave syndrome were managed with a combination of surgical drainage and stent placement. A new technique where the stent is sutured into place transluminally to prevent migration is described. METHOD Seven patients with staple line and anastomotic dehiscences and a single case of Boerhaave syndrome were treated at St George Hospital, Sydney, over the period January 2003 to December 2006 by using a removable, polyester covered self-expanding metal stent (ELLA Boubella, Ella-CS, Hradec, Czech Republic). All patients had active severe sepsis and significant contamination in the abdomen or thorax at the time of stenting. In 4 cases, the stent was sutured in place with dissolvable synthetic sutures with suture bites incorporating the full thickness of the gut wall and the stent itself to prevent stent migration. RESULTS All patients showed resolution of their intra-abdominal sepsis and were able to resume an oral diet after stenting. All stents were retrieved endoscopically after clinical resolution of the leak. Stent migration after leak resolution was observed in 3 patients. In patients with large defects or minimal anatomic barriers to stent migration, suture fixation stabilized the stent. There were no episodes of persistent leak or development of stricture in this series. CONCLUSIONS In this small series, the use of a removable covered stent in the setting of anastomotic leak or spontaneous perforation, alone or as an adjunct to conventional surgical management, is feasible in sealing the leak, resolving sepsis, and expediting return to enteral nutrition. Stenting is feasible in cases with substantial tissue loss or contamination. Suturing the stent transluminally stabilizes the stent where risk of migration is high.
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Dai YY, Gretschel S, Dudeck O, Rau B, Schlag PM, Hünerbein M. Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents. Br J Surg 2009; 96:887-91. [PMID: 19591167 DOI: 10.1002/bjs.6648] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Oesophageal anastomotic leakage is associated with considerable morbidity and mortality. The aim of the present study was to assess the feasibility of using temporary self-expanding plastic stents to treat postoperative oesophageal leaks. METHODS Patients with anastomotic leakage after abdominothoracic oesophagectomy treated by endoscopic insertion of self-expanding plastic stents between 2001 and 2007 were studied. Clinical outcomes were analysed, including healing of the leak, morbidity and mortality. RESULTS Stents were inserted successfully in all 22 patients without procedure-related complications. Ten patients also required computed tomography-guided drainage because surgical drains had been removed. Non-ventilated patients received oral nutrition a mean of 4 days after stent placement. Combined treatment with stenting and drainage resulted in resolution of the leak in 21 of 22 patients. The mean healing time (time to stent removal) was 23 days. Stent migration occurred in five of 22 patients, but endoscopic reintervention with placement of a new stent was successful in all patients. Repeat thoracotomy with intraoperative stent placement was necessary in one patient with an oesophagocolonic anastomosis. One patient died in hospital. CONCLUSION In combination with effective drainage, self-expanding plastic stents are an option for the treatment of oesophageal anastomotic leaks, and may reduce leak-related morbidity and mortality.
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Affiliation(s)
- Y Y Dai
- Department of Surgery and Surgical Oncology, Universitätsmedizin Berlin and Helios Hospital, Berlin, Buch and Charité Campus Buch, Germany
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