Treatment of a ruptured anastomotic esophageal stricture following bougienage with a Dacron-covered nitinol stent

Fluoroscopically guided feeding tube insertion for relief of postoperative gastrointestinal anastomotic obstruction and leakage

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.

Temporary partially-covered metal stent insertion in benign esophageal stricture

AIM: To study the therapeutic efficacy of temporary partially-covered metal stent insertion on benign esophageal stricture.

METHODS: Temporary partially-covered metal stent was inserted in 83 patients with benign esophageal stricture. All the patients had various dysphagia scores.

RESULTS: Insertion of 85 temporary partially-covered metal stents was performed successfully in 83 patients with benign esophageal stricture and dysphagia was effectively remitted in all the 83 cases. The dysphagia score was 3.20 ± 0.63 (mean ± SD) and 0.68 ± 0.31 before and after stent insertion, and 0.86 ± 0.48 after stent removal. The mean diameter of the strictured esophageal lumen was 3.37 ± 1.23 mm and 25.77 ± 3.89 mm before and after stent insertion, and 16.15 ± 2.96 mm after stent removal. Follow-up time was from 1 week to 96 months (mean 54.26 ± 12.75 months). The complications were chest pain (n = 37) after stent insertion, and bleeding (n = 12) and reflux (n = 13) after stent removal.

CONCLUSION: Temporary partially-covered metal stent insertion is one of the best methods for treatment of benign esophageal stricture.

Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents

OBJECTIVE

Gastroesophageal anastomotic leak after cancer resection has a mortality rate of up to 60% and significant morbidity, whatever the mode of treatment. We assessed the efficacy of esophageal stenting as a therapeutic option to reduce the mortality and morbidity associated with symptomatic intrathoracic anastomotic leakage.

SUBJECTS AND METHODS

During a 52-month period, 14 patients had placement of stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophagojejunal anastomosis. Thirteen of 14 patients had tumors that were histologically staged as T3 N1 M0 or worse. Significant anastomotic leaks were revealed by a contrast-enhanced study at 3-28 days after surgery. Stents were inserted in patients in whom the leakage was debilitating or initial conservative treatment had failed. Stenting outcome in terms of clinical and radiologic healing, hospital stay, survival, and complications was assessed.

RESULTS

No procedural morbidity or 30-day mortality occurred. Immediate postprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing time of 6 days. Of the 13 patients, healing occurred within 10 days in 10 patients (76.9%). Eight of these 10 early closures received a knitted nitinol stent (p = 0.02). One patient (7%) died as a consequence of leakage at 135 days. Median survival for all 14 patients was 11 months (Kaplan-Meier method). Complications included five episodes of food blockages in three patients, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic stricture or occlusive epithelial hyperplasia.

CONCLUSION

Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesophageal cancer. Knitted nitinol stents may be best suited to this purpose.

Patient tolerance of cervical esophageal metallic stents

PURPOSE

To demonstrate that proximal esophageal stenoses and tracheoesophageal fistulas can be adequately palliated with use of metallic stents without significant foreign-body sensation.

MATERIALS AND METHODS

Between June 1994 and March 1999, 22 patients with lesions within 3 cm of the cricopharyngeus were treated by placement of metallic stents. The series was reviewed retrospectively. Twenty patients had surgically unresectable malignant lesions, two patients had benign disease. Ten patients had associated tracheoesophageal fistulas. In all, the upper limit of the stent was between C5 vertebral body inferior endplate and the T2 vertebral body superior endplate. The case-notes were reviewed until patient death (range, 6-198 days), or to date in the two surviving patients with benign disease.

RESULTS

Immediate technical success was 93% (27 of 29). Dysphagia scores improved from a median of 3 to 2 after stent placement. Eighteen of 22 (82%) patients reported no foreign-body sensation. There have been no cases of proximal migration, periprocedural perforation, or deaths. The two patients with benign disease experienced significant complications.

CONCLUSION

Lesions in proximity to the cricopharyngeus can be successfully palliated without significant foreign-body sensation in the majority of patients with use of metallic stents. The authors urge caution in placing stents in patients with benign disease.

An update in the palliative management of malignant dysphagia

BACKGROUND

Oesophageal cancer is generally associated with late presentation and poor prognosis. Therefore palliative surgery has been largely superseded by less invasive non-surgical techniques. Once palliation is indicated, the aims of the management should be: the maintenance of oral intake, minimizing hospital stay, relief of pain, elimination of reflux and regurgitation and the prevention of aspiration.

METHODS

This study was a review of all published English language data on the palliation of malignant dysphagia between 1994-1999. The Medline and Bids databases were searched and other references were derived from the material perused.

RESULTS AND CONCLUSIONS

Palliative treatment for oesophageal cancer should be individualized and relate to tumour stage, size and location, the patient's medical condition and his/her personal wishes. The palliative treatment largely includes self-expanding metal stents (SEMS), laser (including photodynamic therapy (PDT)) or a combination of the two to relieve symptoms, this may be employed with or without other treatments such as radiotherapy/chemotherapy (RT/CT) with the aim of reducing tumour bulk and possibly prolonging survival. A multi-disciplinary approach is vital in patients with advanced oesophageal cancer.