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Jiang F, Yu MF, Ren BH, Yin GW, Zhang Q, Xu L. Nasogastric placement of sump tube through the leak for the treatment of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. J Surg Res 2010; 171:448-51. [PMID: 20828722 DOI: 10.1016/j.jss.2010.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2010] [Revised: 06/04/2010] [Accepted: 07/06/2010] [Indexed: 01/18/2023]
Abstract
OBJECTIVE We seek to retrospectively analyze the nasogastric placement of sump tube through the leak for the treatment of intra-thoracic esophagastric anastomotic leak after esophagectomy for esophageal carcinoma. MATERIALS AND METHODS Esophagectomy with intrathoracic esophagogastric anastomotic procedures were performed in 2954 patients who suffered from esophageal carcinoma in our hospital between May 2004 and July 2008. Anastomotic leak had developed in 38 patients, of whom four patients were treated by reoperations. Stent insertion, the traditional "three-tube method" and the nasogastric placement of sump tube through the leak were applied in two, seven, and 25 patients, respectively. RESULTS The presence of anastomotic leak was proven by radiographic contrast examinations in 38 patients (1.3%). Among them, four received reoperations and recovered. Two patients were treated with the placement of self-expanding metallic coated stents and both died 10 and 13 d after placement due to uncontrollable hematemesis. Seven and 25 patients were managed by the traditional "three-tube method" and the nasogastric placement of sump tube through the leak, respectively. The mean time interval of the leak treatment was 42 d in the traditional "three-tube method" group and 31.2 d in the nasogastric placement of sump tube through the leak group, and the relatively average hospital mortality rates were 14.3% and 12%, respectively. CONCLUSION The nasogastric placement of sump tube through the leak appears to be an effective, technically feasible, and minimally invasive option for the treatment of intrathoracic esophagogastric anastomotic leak.
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Affiliation(s)
- Feng Jiang
- Department of Thoracic Surgery, Cancer Hospital of Jiangsu Province, Cancer Institution of Jiangsu Province
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Bona D, Laface L, Bonavina L, Abate E, Schaffer M, Ugenti I, Siboni S, Carrinola R. Covered nitinol stents for the treatment of esophageal strictures and leaks. World J Gastroenterol 2010; 16:2260-4. [PMID: 20458763 PMCID: PMC2868219 DOI: 10.3748/wjg.v16.i18.2260] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [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
AIM: To compare 2 different types of covered esophageal nitinol stents (Ultraflex and Choostent) in terms of efficacy, complications, and long-term outcome.
METHODS: A retrospective review of a consecutive series of 65 patients who underwent endoscopic placement of an Ultraflex stent (n = 33) or a Choostent (n = 32) from June 2001 to October 2009 was conducted.
RESULTS: Stent placement was successful in all patients without hospital mortality. No significant differences in patient discomfort and complications were observed between the Ultraflex stent and Choostent groups. The median follow-up time was 6 mo (inter-quartile range 3-16 mo). Endoscopic reintervention was required in 9 patients (14%) because of stent migration or food obstruction. No significant difference in the rate of reintervention between the 2 groups was observed (P = 0.8). The mean dysphagia score 1 mo after stent placement was 1.9 ± 0.3 for the Ultraflex stent and 2.1 ± 0.4 for the Choostent (P = 0.6). At 1-mo follow-up endoscopy, the cover membrane of the stent appeared to be damaged more frequently in the Choostent group (P = 0.34). Removal of the Choostent was possible up to 8 wk without difficulty.
CONCLUSION: Ultraflex and Choostent proved to be equally reliable for palliation of dysphagia and leaks. Removal of the Choostent was easy and safe under mild sedation.
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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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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: 5.1] [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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Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ. Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 2010; 89:931-6; discussion 936-7. [PMID: 20172156 DOI: 10.1016/j.athoracsur.2009.10.061] [Citation(s) in RCA: 117] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Revised: 10/26/2009] [Accepted: 10/28/2009] [Indexed: 12/21/2022]
Abstract
BACKGROUND Esophageal or gastric leakage from anastomotic wound dehiscence, perforation, staple line dehiscence, or trauma can be a devastating event. Traditional therapy has often consisted of either surgical repair for rapidly diagnosed leaks or diversion for more complicated cases, commonly associated with a delayed diagnosis. This study summarizes our experience treating leaks or fistulas with novel, covered self-expanding metal stents (cSEMS). The primary objective of this study was to determine the efficacy and safety of covered self-expanding metal stents when used to treat complicated leaks and fistulas. METHODS Over 15 months, 25 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment. A prospective database was used to collect data. Stents were placed endoscopically, with contrast evaluation used for leak evaluation. Patients who did not improve clinically after stenting or whose leak could not be sealed underwent operative management. RESULTS During a mean follow-up of 15 months, 23 of the 25 patients with esophageal or gastric leaks during a 15-month period were managed with endoscopic stenting as primary treatment. Healing occurred in patients who were stented for anastomotic leakage after gastric bypass or sleeve gastrectomy (n = 10). One patient with three esophageal iatrogenic perforations healed with stenting. Eight patients successfully avoided esophageal diversion and healed with stenting and adjunctive therapy. Two of the 4 patients with tracheoesophageal fistulas sealed with the assistance of a new pexy technique to prevent stent migration; 1 additional patient had this same technique used to successfully heal an upper esophageal perforation. CONCLUSIONS Esophageal leaks and fistulas can be effectively managed with cSEMS as a primary modality. The potential benefits of esophageal stenting are healing without diversion or reconstruction and early return to an oral diet.
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Affiliation(s)
- Shanda H Blackmon
- Department of Surgery, The Methodist Hospital, Houston, Texas 77030, USA.
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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: 5.5] [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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57
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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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Abstract
The use of self-expanding metal esophageal stents has evolved dramatically over the last 20 years. Stents themselves have morphed from simple open-mesh wire devices to a variety of partially and fully covered metal and plastic protheses designed to resist in-growth and migration. Indications include grown considerably from simply palliating malignant dysphagia to the treatment of benign conditions such as refractory strictures, perforations, and fistulas, bridging tumors through neoadjuvant therapy and even serving as support for mucosal healing after ablative therapies. This article describes the current experience with esophageal stenting for malignant and benign conditions and examines new innovations in stent design and applications.
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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: 4.0] [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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60
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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: 67] [Impact Index Per Article: 4.5] [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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Turkyilmaz A, Eroglu A, Aydin Y, Tekinbas C, Muharrem Erol M, Karaoglanoglu N. The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. Dis Esophagus 2008; 22:119-26. [PMID: 18847447 DOI: 10.1111/j.1442-2050.2008.00866.x] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophagogastric anastomotic leaks are the most feared surgical complications following resection of esophageal cancers. We aimed to develop a therapeutic algorithm for this complication characterized by high morbidity and mortality using our 20 years of experience and the published literature. A total of 354 patients who had undergone an esophagectomy and esophagogastric anastomosis due to esophageal carcinoma were evaluated retrospectively. The incidence for anastomotic leak was 15.5% (n = 90) in the cervical region and 4.2% (n = 264) in the thoracic region (mean: 7.1%). Cervical anastomotic leaks were detected after a mean period of 7.2 days following the procedure. Fourteen patients with cervical leaks were treated conservatively. Four out of 14 patients (28.6%) died due to sepsis and multi-organ failure related to fistula. Thoracic anastomotic leaks were detected after a mean period of 4.7 days following the procedure. Emergency reoperation, resection and reconstruction procedures were performed in one patient. Self-expanding metallic coated stents were placed at the anastomosis region in two patients. A more conservative approach was employed in other patients with thoracic anastomotic leaks. Six of them (46.2%) died due to fistula. General mortality rate was 37.0%, and the duration of hospitalization was 40.0 days for patients with anastomotic leaks. Cervical anastomotic leaks are more common than thoracic anastomotic leaks, but most of them are successfully treated with conservative approaches. Thoracic anastomotic leaks that in the past were related to high mortality rates despite conservative or surgical procedures might be successfully treated nowadays with the use of self-expanding metallic coated stents.
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Affiliation(s)
- A Turkyilmaz
- Department of Thoracic Surgery, Faculty of Medicine, Atatürk University, Erzurum, Turkey.
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63
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Tuebergen D, Rijcken E, Mennigen R, Hopkins AM, Senninger N, Bruewer M. Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations. J Gastrointest Surg 2008; 12:1168-76. [PMID: 18317849 DOI: 10.1007/s11605-008-0500-4] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Accepted: 02/05/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center. METHODS Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured. RESULTS Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%). CONCLUSIONS Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment.
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Affiliation(s)
- Dirk Tuebergen
- Department of General Surgery, Unit of Surgical Endoscopy, University of Muenster, Muenster, Germany
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64
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Bona D, Sarli D, Saino G, Quarenghi M, Bonavina L. Successful conservative management of benign gastro-bronchial fistula after intrathoracic esophagogastrostomy. Ann Thorac Surg 2007; 84:1036-8. [PMID: 17720434 DOI: 10.1016/j.athoracsur.2007.04.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 04/09/2007] [Accepted: 04/13/2007] [Indexed: 02/07/2023]
Abstract
Benign gastro-bronchial fistula is a rare and devastating complication of esophagectomy with gastric replacement. The most likely cause is a leak from the esophagogastric anastomosis with subsequent mediastinal abscess and rupture into the posterior wall of the tracheobronchial tree. The clinical presentation includes cough upon swallowing, fever, and recurrent pneumonia. Early surgical treatment is the standard of care. A unique case of chronic gastro-bronchial fistula is reported in this article. The patient, a 57-year-old woman, was referred from another hospital after 6 months of symptomatic therapy and total enteral nutrition. A self-expanding esophageal metal stent allowed exclusion of the fistula with symptom relief and return to oral alimentation.
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Affiliation(s)
- Davide Bona
- Department of Medical and Surgical Sciences, Division of General Surgery, I.R.C.C.S. Policlinico San Donato, University of Milan, Milan, Italy
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65
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Nowakowski P, Ziaja K, Ludyga T, Kuczmik W, Biolik G, Cwik P, Ziaja D. Self-expandable metallic stents in the treatment of post-esophagogastrostomy/post-esophagoenterostomy fistula. Dis Esophagus 2007; 20:358-60. [PMID: 17617887 DOI: 10.1111/j.1442-2050.2007.00688.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Esophageus or gaster resection in patients with malignant disease is still a treatment of choice. It is obvious that each surgical procedure in these patients carries some possibility of complications. Esophageo-gastric or esophageo-jejuno anastomosis has a 4-27% frequency of fistula occurrence. All these result in 65% mortality in cases of poorer prognosis. The aim of this paper is not to present all types of complications but to objectively analyse the usefulness of the covered stent placement in the treatment of anastomotic fistulas. We present six patients who were treated for postoperative fistula of esophageo-gastric anastomosis (1 case) or esophageo-jejuno anastomosis (5 cases). All patients were treated with stapler suture for digestive tract reconstruction after malignancy removal during the primary surgical procedure. Signs and symptoms of suture leak between 5-8 days post-surgery were observed. Conservative therapy was not effective. Thus a new method of treatment was employed - covered stent placement. The procedure was performed under X-ray control. In all treated patients there was change for the better and quick reduction of secretion from the fistulas was observed. All patients were discharged from the department after several days and all had survived at 30 days follow-up. Covered esophageal stent placement seems to be a safe and promising method of treatment for patients with anastomotic fistula which significantly reduces mortality and improves quality of live. Our experiences confirms that of other investigators.
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Affiliation(s)
- P Nowakowski
- Department of General and Vascular Surgery, Medical University of Silesia, SPSK Nr 7 GCM Ziolowa Str. 47, 40-635 Katowice, Poland.
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66
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Abstract
Endoscopic closure of gastrointestinal perforations, fistulas, and anastomotic dehiscence is technically feasible. Endoluminal closure of the instrumental perforations of the gastrointestinal tract can be accomplished immediately after the recognition of perforation, while avoiding the delay of arranging surgery and the trauma associated with thoracotomy or laparotomy. In addition, endoscopic closure should be considered in patients with anastomotic dehiscence and chronic fistulas as this may avoid the risk associated with reoperation. The outcome of closure depends on the technical expertise in the proper selection and use of various endoluminal closure options. Training of the endoscopists in the use of this novel technology will enhance the quality of care of our patients.
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Affiliation(s)
- G S Raju
- Center for Endoscopic Research, Training, and Innovation (CERTAIN), Department of Internal Medicine, 4.106 McCullough Building, 301 University Boulevard, University of Texas Medical Branch, Galveston, TX 77555-0764, USA.
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67
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Profili S, Feo CF, Cossu ML, Scanu AM, Scognamillo F, Meloni F, Scaglione M, Meloni GB. Effective management of intrathoracic anastomotic leak with covered self-expandable metal stents. Report on three cases. Emerg Radiol 2007; 15:57-60. [PMID: 17570002 DOI: 10.1007/s10140-007-0630-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2007] [Accepted: 05/18/2007] [Indexed: 10/23/2022]
Abstract
Intrathoracic anastomotic leakage is one of the major complications of esophageal surgery that can lead to high mortality rate. Depending on the clinical presentation, therapeutic options include surgical reintervention and conservative management with or without external drainage or stenting. In this paper, we report a series of three patients, two men and one woman, mean age of 55.6 years (range 34-68 years), having intrathoracic anastomotic leak after esophagogastrectomy treated by insertion of four covered self-expandable metal stents performed exclusively under fluoroscopic view. Complete resolution of the leakage was obtained in all patients. Despite the limited number of patients, conservative management of intrathoracic anastomotic leaks with covered self-expandable metal stents performed under fluoroscopic guidance has proved to be rapid, safe, and effective in all cases of this series.
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Affiliation(s)
- Stefano Profili
- Service of Radiology, Paolo Dattori Hospital, 07029 Tempio Pausania, Italy.
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68
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Han YM, Kim CY, Yang DH, Kwak HS, Jin GY. Fluoroscopically guided feeding tube insertion for relief of postoperative gastrointestinal anastomotic obstruction and leakage. Cardiovasc Intervent Radiol 2006; 29:395-400. [PMID: 16502160 DOI: 10.1007/s00270-005-0095-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the feasibility and effectiveness of feeding tube insertion and enteral feeding for the treatment of postoperative gastrointestinal anastomotic obstruction and leakage. MATERIALS AND METHODS From June 1999 to June 2002, thirty-four cases of postoperative gastrointestinal anastomotic obstruction and leakage after surgery for gastric carcinoma were treated by insertion of a feeding tube under fluoroscopic guidance. Twenty-one patients were male and 13 were female. The patients' ages ranged from 39 to 74 years (mean age: 61 years). All the patients experienced vomiting, and 15 patients had anastomotic site or duodenal stump leakage. We evaluated the feasibility of feeding tube insertion for enteral feeding to improve the obstruction and facilitate leakage site closure, and the patients' nutritional benefit was also evaluated by checking the serum albumin level between pre- and post-enteral feeding via the feeding tube. RESULTS Thirty-two patients (94%) were successfully managed by feeding tube insertion, but the remaining two were not managed, and this was due to severe angulations at the anastomotic site. The procedure times for feeding tube insertion ranged from 15 to 60 minutes (mean time: 45 minutes). Twenty-eight patients experienced symptomatic relief of gastrointestinal obstruction, and they were able to resume a normal regular diet after feeding tube removal. Three patients underwent stent insertion due to recurrent symptoms, and one patient underwent jejunostomy feeding due to the presence of a persistent leakage site. Eleven patients achieved leakage site closure after enteral feeding via a feeding tube. The serum albumin level was significant, increased from pre-enteral feeding (2.65 +/- 0.37 g/dL) to the post-enteral feeding (3.64 +/- 0.58 g/dL) via the feeding tube (p < 0.001). The duration of follow-up ranged from one to 53 months (mean: 23 months). CONCLUSION The insertion of a feeding tube for enteral feeding under fluoroscopic guidance is safe, and it provides effective relief from gastrointestinal anastomotic site obstruction and leakage after gastric surgery. Moreover, our findings indicate that feeding tube insertion for enteral feeding may be used as the primary procedure to treat postoperative anastomotic obstruction and leakage.
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Affiliation(s)
- Young-Min Han
- Department of Radiology, Chonbuk National University Medical School and Hospital, Keumam Dong, Chonju, Republic of Korea.
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69
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Merrifield BF, Lautz D, Thompson CC. Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach. Gastrointest Endosc 2006; 63:710-4. [PMID: 16564884 DOI: 10.1016/j.gie.2005.11.018] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2005] [Accepted: 11/07/2005] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastric leaks represent an important source of morbidity and mortality associated with Roux-en-Y gastric bypass. These leaks, once managed acutely, can become chronic and represent a difficult clinical challenge. Surgical options to address a chronic gastric leak are technically challenging and often unsuccessful. We present a novel peroral endoscopic treatment for patients with chronic gastric leaks after Roux-en-Y gastric bypass. DESIGN Case series. INTERVENTIONS Repair of chronic gastric leaks after Roux-en-Y gastric bypass by using a combination of argon plasma coagulation, hemoclips, fibrin glue, Polyflex stent placement, and distal gastrojejunal stenosis dilation. The goal was to achieve durable fistula closure and avoid surgery. MAIN OUTCOME MEASUREMENTS Durable fistula closure as assessed by an upper-GI series and clinical evaluation. RESULTS Gastric leak closure was achieved in all 3 patients, with complete resolution of symptoms. Polyflex stent migration into the Roux limb occurred in 1 patient, and this was retrieved endoscopically. There were no other significant complications. CONCLUSIONS Peroral endoscopic repair of gastric leaks is technically feasible. This procedure may offer a less invasive alternative to traditional surgical revision.
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Affiliation(s)
- Benjamin F Merrifield
- Division of Gastroenterology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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70
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Endoscopic Management of Anastomotic Esophageal Leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2006. [DOI: 10.1016/j.tgie.2006.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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71
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Langer FB, Wenzl E, Prager G, Salat A, Miholic J, Mang T, Zacherl J. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 2005; 79:398-403; discussion 404. [PMID: 15680802 DOI: 10.1016/j.athoracsur.2004.07.006] [Citation(s) in RCA: 146] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2004] [Indexed: 01/12/2023]
Abstract
BACKGROUND Esophageal anastomotic leaks can lead to prolonged hospitalization. In this article we present our experience with the placement of the Polyflex self-expanding plastic stent (Willy Ruesch GMBH, Kernen, Germany) for leak occlusion. METHODS Between April 2000 and November 2003, 24 patients were included into this prospective study and underwent Polyflex stent placement for postoperative esophageal anastomotic leaks. The primary operation was esophagectomy in 13 patients, gastrectomy in 7, cardia resection in 2, and other procedures in 2 patients. The median interval between operation and stent placement was 19 days (range, 4 to 65). The effectiveness of leak occlusion was evaluated by water-soluble contrast swallow and the clinical course. RESULTS In 2 patients stent misplacement produced an enlarged anastomotic dehiscence that necessitated reoperation. Radiologic evaluation was impossible in 4 patients because of their generally restricted condition. Among 18 evaluable patients, leak occlusion was successful with a single stent in 16 patients (89%) based on radiologic evaluation. Immediate oral feeding was well tolerated by these patients. After a median follow-up of 220 days (range, 7 to 1221), 9 cases of late stent dislocation were observed. Stent removal in patients after esophagectomy with gastric pull-up led to dysphagia from anastomotic strictures in 2 patients. Symptomatic strictures did not develop in the 5 evaluable postgastrectomy patients after stent removal. CONCLUSIONS The placement of self-expanding plastic stents is a highly effective treatment for esophageal anastomotic leaks. Because clinically-relevant anastomotic strictures can be expected, we do not recommend stent removal after esophagectomy with gastric pull-up reconstruction.
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Affiliation(s)
- Felix B Langer
- Department of Surgery, Division of General Surgery, Medical University of Vienna, Vienna, Austria
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72
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Saranovic D, Djuric-Stefanovic A, Ivanovic A, Masulovic D, Pesko P. Fluoroscopically guided insertion of self-expandable metal esophageal stents for palliative treatment of patients with malignant stenosis of esophagus and cardia: comparison of uncovered and covered stent types. Dis Esophagus 2005; 18:230-8. [PMID: 16128779 DOI: 10.1111/j.1442-2050.2005.00484.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of this retrospective study was to present and compare the results of using two different types of esophageal self-expanding stents (uncovered and covered) for palliative treatment of patients with inoperable malignant stenosis of the esophagus and cardia. Over a period of 8 years, 152 patients underwent fluoroscopically guided insertion of metal esophageal stents. We inserted uncovered esophageal nitinol Strecker stents in 54 patients (group I) and covered esophageal Ultraflex stents in the remaining 98 patients (group II). The stent insertion procedure was successively performed in all patients. Closure of esophageal fistula by covered stents was achieved in 8/8 patients. Mean dysphagia score was significantly decreased in both patient groups at 4 weeks follow-up: from 2.73 before stent insertion to 0.15 in group I, and from 2.67 to 0.05 in group II (on 0-4 scale). Eighty-eight per cent of patients with covered stents and 54% with uncovered type were free of symptoms during follow-up. Complications occurring during follow-up and their comparative frequency in the two groups of patients were as follows (group I: group II%): stent migration (0:10%); tumor or granulation tissue ingrowth (100:53%); overgrowth at the ends of stents (17:30%); restenosis causing recurrent dysphagia (37:8%); and appearance of esophageal fistulas (8:6%). In conclusion, fluoroscopically guided insertion of self-expandable esophageal stents is a safe and comfortable method of palliation for patients suffering with malignant dysphagia. In selection of a stent, covered types should be given priority for prevention of restenosis.
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Affiliation(s)
- Dj Saranovic
- Institute for Radiology, Clinical Center of Serbia, Beograd, Serbia and Montenegro
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73
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Raju GS, Thompson C, Zwischenberger JB. Emerging endoscopic options in the management of esophageal leaks (videos). Gastrointest Endosc 2005; 62:278-86. [PMID: 16046996 DOI: 10.1016/s0016-5107(05)01632-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Gottumukkala S Raju
- Division of Gasterology and Thoraic Surgery, Center for Endoscopic Research, Education, and Training (CERTAIN), University of Texas Medical Branch, Galveston, 77555, USA
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74
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Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, Lippert H, Pross M. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents. Gastrointest Endosc 2005; 61:891-6. [PMID: 15933696 DOI: 10.1016/s0016-5107(05)00325-1] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic esophageal anastomotic leaks often is associated with poor results and carries a high morbidity and mortality. The successful treatment of esophageal anastomotic insufficiencies and perforations when using covered, self-expanding metallic stents is described. METHODS The feasibility and the outcome of endoscopic treatment of intrathoracic anastomotic leakages when using silicone-covered self-expanding polyester stents were investigated. Twelve consecutive patients presented with clinically apparent intrathoracic esophageal anastomotic leak caused by resection of an epiphrenic diverticulum (n = 1), esophagectomy for esophageal cancer (n = 9), or gastrectomy for gastric cancer (n = 2), were endoscopically treated in our department. The extent of the dehiscences ranged from about 20% to 70% of the anastomotic circumference. After endoscopic lavage and debridement of the leakage at 2-day intervals (mean duration, 8.6 days), a large-diameter polyester stent (Polyflex; proximal/distal diameters 25/21 mm) was placed to seal the leakage. Simultaneously, the periesophageal mediastinum was drained by chest drains. OBSERVATIONS All 12 patients were successfully treated endoscopically without the need for reoperation. A complete closure of the leakage was obtained in 11 of 12 patients after stent removal (median time to stent retrieval, 4 weeks, range 2-8 weeks). In one patient, a persistent leak was sealed endoscopically after stent removal by using 3 clips. Distal stent migration was obtained in two patients. CONCLUSIONS The placement of silicone-covered self-expanding polyester stents seems to be a successful minimally invasive treatment option for clinically apparent intrathoracic esophageal anastomotic leaks.
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Affiliation(s)
- Daniel Schubert
- Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany
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75
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Abstract
Anastomotic leaks are still among the most common severe postoperative complications and account for the majority of postoperative deaths after esophagectomy and gastrectomy. Every disturbance of the normal postoperative course should trigger surgeons to consider an underlying anastomotic leak and initiate a specific diagnostic workup. This includes direct endoscopic inspection of the anastomosis to evaluate the vitality of the anastomosed organs and the size of the leak. Adequate external drainage of the leak and prevention of further contamination are the primary therapeutic goals. Selection of therapy is guided by the available modalities for sufficiently draining the leak and avoiding sepsis. The spectrum of therapeutic options ranges from simple opening of the neck incision in cervical esophageal anastomoses, interventional placement of drains, to endoscopic intervention with closure of the fistula or placement of stents, and reoperation with exclusion, diversion, or discontinuity resection.
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Affiliation(s)
- J R Siewert
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München
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76
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Hünerbein M, Stroszczynski C, Moesta KT, Schlag PM. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents. Ann Surg 2004; 240:801-7. [PMID: 15492561 PMCID: PMC1356485 DOI: 10.1097/01.sla.0000143122.76666.ae] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To evaluate the efficacy of a self-expanding plastic stent in the treatment of thoracic leaks after esophagectomy for cancer. SUMMARY BACKGROUND DATA Anastomotic leaks are a major cause of morbidity and mortality after esophageal resection. Treatment options range from aggressive surgery to conservative management, but there remains much controversy on the best treatment. METHODS Over a 6-year period (1998-2003), esophagogastric leaks were observed in 19 of 204 patients (9.3%) after esophagectomy. Between 1998 and 2000, anastomotic leaks were managed by reexploration (n = 7) or by conservative treatment (n = 3). Since 2001, insertion of self-expanding plastic stents was performed for all anastomotic leaks (n = 9). The short-term efficacy and long-term outcome of both treatments were analyzed. RESULTS Self-expanding plastic stents were successfully placed in all patients without procedure-related morbidity. Immediate leak occlusion was obtained in 8 of 9 patients. The mean healing time (time to stent removal) was 29 days. Compared with the conventional treatment group, patients who were treated with stents had earlier oral intake (11 days versus 23 days), a less extensive intensive care course (25 days versus 47 days), and shorter hospital stay (35 days versus 57 days). In-hospital mortality was 0% (0 of 9 patients) in the stent group and 20% (2 of 10 patients) in the other group. After a mean follow-up of 12 months, none of the patients developed a stricture after stenting, but a stricture occurred in 1 patient after conservative treatment. CONCLUSIONS Self-expanding plastic stents can reduce leak-related morbidity and mortality after esophagectomy and may be considered a cost-effective treatment alternative.
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Affiliation(s)
- Michael Hünerbein
- Department of Surgery and Surgical Oncology, Charité Campus Buch and Helios Hospital, Berlin, Germany
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77
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N/A. N/A. Shijie Huaren Xiaohua Zazhi 2004; 12:1402-1404. [DOI: 10.11569/wcjd.v12.i6.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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78
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Marks G, Fagundes DJ, Cevalos FA. Nova técnica de alimentação enteral em fístulas esôfago-jejunais. Rev Col Bras Cir 2004. [DOI: 10.1590/s0100-69912004000100012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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79
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Sampaio JA, Waechter FL, Pereira-Lima J, Fossati MAM, Felicetti JC, Thiesen VLP, Rostirolla RA, Marques DL, Hornos AP, Pereira-Lima L. Successful treatment of esophagojejunal disconnection after total gastrectomy by insertion of a covered self-expandable esophageal metallic stent. Gastrointest Endosc 2003; 58:453-6. [PMID: 14528230 DOI: 10.1067/s0016-5107(03)00030-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- José Artur Sampaio
- Departments of Surgery and Gastroenterology, Hospital Moinhos de Vento, Porto Alegre, Brazil
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Lee SH. The role of oesophageal stenting in the non-surgical management of oesophageal strictures. Br J Radiol 2001; 74:891-900. [PMID: 11675304 DOI: 10.1259/bjr.74.886.740891] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The role of oesophageal stenting continues to evolve, with several new stents currently on the market. These stents possess anti-reflux valves, internal plastic coatings and retrievable threads. In patients with malignant dysphagia, management should ideally take place within multi-disciplinary teams such that accurate tumour staging occurs prior to treatment. Multi-modality therapy can not only improve dysphagia and response rates but may also improve survival. Several non-surgical palliative techniques are available to recanalize malignant obstruction, including oesophageal stenting. Other therapeutic modalities include the use of endoluminal laser therapy, photodynamic therapy, argon beam and bipolar electrocoagulation, ethanol injection and intracavity brachytherapy. Their use often depends on local availability and expertise. Although the initial costs of metal stents are high, the overall costs compare favourably with other forms of palliative therapy that often require multiple procedures with repeated inpatient hospitalization. Treatment of refractory benign strictures with oesophageal stents remains uncommon and several recent reports using retrievable stents appear to improve outcome, although more work is required in this area.
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Affiliation(s)
- S H Lee
- Department of Radiology, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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