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Dyas AR, Thomas MB, Bronsert MR, Madsen HJ, Colborn KL, Henderson WG, David EA, Velopulos CG, Meguid RA. Emergency thoracic surgery patients have worse risk-adjusted outcomes than non-emergency patients. Surgery 2023; 174:956-963. [PMID: 37507304 DOI: 10.1016/j.surg.2023.06.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 06/13/2023] [Accepted: 06/18/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations. METHODS We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors. RESULTS Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery. CONCLUSION Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.
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Affiliation(s)
- Adam R Dyas
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado Hospital, Aurora, CO.
| | - Madeline B Thomas
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Michael R Bronsert
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Helen J Madsen
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Kathryn L Colborn
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO; Department of Medicine, University of Colorado Hospital, Aurora, CO
| | - William G Henderson
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
| | - Elizabeth A David
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Catherine G Velopulos
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Department of Surgery, University of Colorado Hospital, Aurora, CO
| | - Robert A Meguid
- Surgical Outcomes and Applied Research Program, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO; Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, CO
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Rosianu CG, Hoara P, Achim F, Birla R, Bolocan A, Mohssen A, Copca N, Constantinoiu S. The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review. Life (Basel) 2023; 13:life13040966. [PMID: 37109495 PMCID: PMC10144597 DOI: 10.3390/life13040966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives. MATERIALS AND METHODS We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. RESULTS The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. CONCLUSIONS Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.
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Affiliation(s)
- Cristian Gelu Rosianu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Petre Hoara
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Florin Achim
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Rodica Birla
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Alexandra Bolocan
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ahmed Mohssen
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Narcis Copca
- Second Department of Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
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3
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Tapias LF, Wright CD, Lanuti M, Muniappan A, Deschler D, Mathisen DJ. Hyperbaric oxygen therapy in the prevention and management of tracheal and oesophageal anastomotic complications. Eur J Cardiothorac Surg 2021; 57:1203-1209. [PMID: 31930317 DOI: 10.1093/ejcts/ezz364] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Failure of anastomotic healing is a morbid complication after airway or oesophageal surgery. Hyperbaric oxygen therapy (HBOT) has been used extensively in the management of complex wound-healing problems. We demonstrate the use of HBOT to rescue at-risk anastomoses or manage anastomotic failures in thoracic surgery. METHODS Retrospective review of 25 patients who received HBOT as part of the management of tracheal or oesophageal anastomotic problems during 2007-2018. HBOT was delivered at 2 atm with 100% oxygen in 90-min sessions. RESULTS Twenty-three patients underwent airway resection and reconstruction while 2 patients underwent oesophagectomy. There were 16 (70%) laryngotracheal and 7 (30%) tracheal resections. Necrosis at the airway anastomosis was found in 13 (57%) patients, partial dehiscence in 2 (9%) patients and both in 6 (26%) patients. HBOT was prophylactic in 2 (9%) patients. Patients received a median of 9.5 HBOT sessions (interquartile range 5-19 sessions) over a median course of 8 days. The airway anastomosis healed in 20 of 23 (87%) patients. Overall, a satisfactory long-term airway outcome was achieved in 19 (83%) patients; 4 patients failed and required reoperation (2 tracheostomies and 1 T-tube). HBOT was used in 2 patients after oesophagectomy to manage focal necrosis or ischaemia at the anastomosis, with success in 1 patient. Complications from HBOT were infrequent and mild (e.g. ear discomfort). CONCLUSIONS HBOT should be considered as an adjunct in the management of anastomotic problems after airway surgery. It may also play a role after oesophagectomy. Possible mechanisms of action are rapid granulation, early re-epithelialization and angiogenesis.
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Affiliation(s)
- Luis F Tapias
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cameron D Wright
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Lanuti
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ashok Muniappan
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel Deschler
- Department of Otolaryngology, Norman Knight Hyperbaric Medicine Center, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Douglas J Mathisen
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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Abstract
Newer surgical techniques have reduced complications and mortality following esophagectomy, but they nevertheless remain high. Data regarding complications are frequently inconsistent and, therefore, difficult to compare between groups. As a result, considerable energy is spent trying to identify best practices to minimize complications. This article reviews the rates of complications and attempts to give guidance regarding their management and outcomes.
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Affiliation(s)
- Thomas Fabian
- Section of Thoracic Surgery, Albany Medical College, Third Floor, 50 New Scotland Avenue, Albany, NY 12159, USA.
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5
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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: 2.8] [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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6
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Schweigert M, Solymosi N, Dubecz A, GonzáLez MP, Stein HJ, Ofner D. One Decade of Experience with Endoscopic Stenting for Intrathoracic Anastomotic Leakage after Esophagectomy: Brilliant Breakthrough or Flash in the Pan? Am Surg 2020. [DOI: 10.1177/000313481408000820] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Management of intrathoracic anastomotic leakage after esophagectomy by means of endoscopic stent insertion has gained wide acceptance as an alternative to surgical reintervention. Between January 2004 and March 2013 all patients who underwent esophagectomy at a German high-volume center for esophageal surgery were included in this retrospective study. The study comprises 356 patients. Anastomotic leakage occurred in 49 cases. There were no significant differences in age, American Society of Anesthesiologists (ASA) score, or frequency of neoadjuvant therapy between cases with and without leak. However, leak patients sustained significantly more often postoperative pneumonia, pleural empyema, sepsis, and acute renal failure. Moreover, leak victims had higher odds for fatal outcome (16 of 49 vs 33 of 307; odds ratio, 5.94; 95% confidence interval, 2.65 to 13.15; P < 0.0001). The leakage was amendable by endoscopic stenting in 29 cases, whereas rethoracotomy was mandatory in 20 patients. Between stent and rethoracotomy cases, we observed no significant differences in age, ASA score, neoadjuvant therapy, occurrence of pneumonia, pleural empyema, or tracheostomy rate. Rethoracotomy patients sustained more often sepsis (16 of 20 vs 14 of 29; P = 0.04) and acute renal failure (nine of 20 vs four of 29; P = 0.02) as expression of more severe septic disease. Nevertheless, there was no significant difference in mortality (seven of 29 vs nine of 20; P = 0.21). Furthermore, we observed three cases of stent-related aortic erosion with peracute death from exsanguination. Despite being the preferred treatment option, endoscopic stenting was only feasible in approximately 60 per cent of all intrathoracic leaks. The results are marred by the occurrence of deadly vascular erosion. Therefore, individualized strategies should be preferred to a general recommendation for endoscopic stenting.
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Affiliation(s)
- Michael Schweigert
- Department of Surgery, Klinikum Neumarkt, Neumarkt, Germany; the
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | | | - Attila Dubecz
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | | | - Hubert J. Stein
- Department of General and Thoracic Surgery, Klinikum Nuremberg, Nuremberg, Germany
| | - Dietmar Ofner
- Department of Surgery, Paracelsus Medical University, Salzburg, Austria
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7
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Plum PS, Herbold T, Berlth F, Christ H, Alakus H, Bludau M, Chang DH, Bruns CJ, Hölscher AH, Chon SH. Outcome of Self-Expanding Metal Stents in the Treatment of Anastomotic Leaks After Ivor Lewis Esophagectomy. World J Surg 2019; 43:862-869. [PMID: 30377723 DOI: 10.1007/s00268-018-4832-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Esophageal anastomotic leakages after Ivor Lewis esophagectomy are severe and life-threatening complications. We analyzed the outcome of using self-expanding metal stents (SEMS) in the treatment of postoperative leakage after esophagogastrostomy. METHODS Seventy patients with esophageal anastomotic leakage after Ivor Lewis esophagectomy for esophageal cancer who had received SEMS treatment between January 2006 and December 2015 at our clinic were identified in this retrospective study. The patients were analyzed according to demographic characteristics, risk factors, leakage characteristics, stent characteristics, stent-related complications, sealing success rate and mortality. RESULTS Over a 10-year period, 70 patients received SEMS as treatment for postoperative anastomotic leakage after esophagectomy. Technical success of esophageal stenting in anastomotic leakage was achieved in 50 out of 70 cases (71.4%). Sealing success rate was 70% (n = 49) with a median treatment of 28 days (range 7-87). In 20 patients (28.6%), stent-related complications, such as stenosis, dislocation, leakage persistence, perforation or esophagotracheal fistula occurred after the SEMS treatment. Sixty-one patients (87.1%) survived SEMS treatment of esophagogastric anastomotic leakage. Mean follow-up for all patients was 38 months (IQR 10-76), and no significant difference was found in a comparison of the long-term survival rate between patients with successful and unsuccessful SEMS treatment. CONCLUSIONS The management of esophageal anastomotic leaks after Ivor Lewis esophagectomy with SEMS is effective, safe and technically feasible. Aggressive non-surgical management should be considered when developing a treatment plan for stenting.
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Affiliation(s)
- Patrick Sven Plum
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Till Herbold
- Department of General, Visceral and Transplantation Surgery, RWTH Aachen, Aachen, Germany
| | - Felix Berlth
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Hildegard Christ
- Institute of Medical Statistics and Bioinformatics, University of Cologne, Cologne, Germany
| | - Hakan Alakus
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Marc Bludau
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - De-Hua Chang
- Institute of Radiology, University Hospital of Cologne, Cologne, Germany
| | - Christiane Josephine Bruns
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | | | - Seung-Hun Chon
- Department of General, Visceral and Cancer Surgery, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
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8
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Abstract
A variety of esophageal diseases are treated with esophagectomy, from benign to esophageal cancer. Careful attention must be given to management of the difficult conduit, including patients who have had prior gastric surgery and other procedures, patients with conditions such as diabetic gastroparesis, which can affect the stomach as a future usable conduit, and patients who have an absent or unusable stomach. In these situations, consideration should be raised for the use of alternative conduits, including jejunal and colonic interposition conduits. The esophageal surgeon should also be adept at management of intraoperative difficulties with the conduit.
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Affiliation(s)
- Rajat Kumar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama Birmingham Medical Center, Birmingham, AL, USA
| | - Benjamin Wei
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama Birmingham Medical Center, Birmingham, AL, USA.
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9
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Dua KS, Sasikala M. Repairing the human esophagus with tissue engineering. Gastrointest Endosc 2018; 88:579-588. [PMID: 30220298 DOI: 10.1016/j.gie.2018.06.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Affiliation(s)
- Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Mitnala Sasikala
- Institute of Basic Sciences and Translational Research, Asian Healthcare Foundation, Asian Institute of Gastroenterology, Hyderabad, India
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10
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Freeman RK, Arevalo G, Ascioti AJ, Dake M, Mahidhara RS. An Assessment of the Frequency of Palliative Procedures in Thoracic Surgery. JOURNAL OF SURGICAL EDUCATION 2017; 74:878-882. [PMID: 28347662 DOI: 10.1016/j.jsurg.2017.02.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 02/01/2017] [Accepted: 02/21/2017] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Palliative care is a medical specialty focused on improving the quality of life of patients and their families with life threatening illness by preventing or relieving suffering. An assessment of a thoracic surgery service was performed to identify the scope and frequency of care that was considered palliative and any implications the findings might have on the current thoracic surgery residency curriculum. METHODS A retrospective review of a prospectively collected database of general thoracic surgery procedures performed over a 5-year period at a single institution was performed. Procedures considered palliative were reviewed for demographics, diagnoses, palliative prognosis score, treatment, morbidity, operative mortality, and survival. Excluded were referrals from thoracic surgery to other specialties for palliative procedures. RESULTS During the study period, 3842 procedures were performed of which 884 (23%) were palliative. Indications included pleural or pericardial effusion or both, dysphagia, hemoptysis, tracheobronchial obstruction, bronchopleural fistula, and tracheoesophageal fistula. The majority was related to a malignancy. Only 127 patients (14%) had a palliative care assessment before thoracic surgery consultation. Mean survival following thoracic surgery intervention was 110 days for patients with malignancy. CONCLUSIONS This investigation found that thoracic surgeons commonly care for patients when the intention or indication or both is palliation. Most of these patients have an associated malignancy, a poor performance status and a projected significantly decreased survival compared with the general population. Thoracic surgeons should be familiar with the concepts of palliative care and consideration should be given to expanding exposure to the principles of palliative care in the cardiothoracic residency training curriculum.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana.
| | - Gabriel Arevalo
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
| | - Anthony J Ascioti
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
| | - Megan Dake
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
| | - Raja S Mahidhara
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
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11
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Abstract
Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents. Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse complications. This review summarizes the modern history of esophageal stent use in the treatment of esophageal perforation as well as the evidenced based recommendations for the use of esophageal stent placement in the treatment of acute esophageal perforation.
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Affiliation(s)
- Gabie K B Ong
- Department of Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA
| | - Richard K Freeman
- Division of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana, USA
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12
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Endoskopische Vakuumtherapie bei Ösophagusläsionen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0069-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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13
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van den Berg MW, Kerbert AC, van Soest EJ, Schwartz MP, Bakker CM, Gilissen LPL, van Hooft JE. Safety and efficacy of a fully covered large-diameter self-expanding metal stent for the treatment of upper gastrointestinal perforations, anastomotic leaks, and fistula. Dis Esophagus 2016; 29:572-9. [PMID: 25893629 DOI: 10.1111/dote.12363] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Upper gastrointestinal perforations, fistula, and anastomotic leaks are severe conditions with high mortality. Temporary endoscopic placement of fully covered self-expanding metal stent (fSEMS) has emerged as treatment option. Stent migration is a major drawback of currently used stents. Migration is often attributed to a relatively too small stent diameter as esophageal stents were initially intended for the treatment of strictures. This study aimed to investigate the safety and efficacy of a large-diameter fSEMS for treatment of these conditions. Data were retrospectively collected from patients who received this stent in the Netherlands between March 2011 and August 2013. Clinical success was defined as sufficient leak closure after stent removal as confirmed by endoscopy or X-ray with oral contrast without surgical intervention or placement of another type of stent. Adverse events were graded according a standardized grading system. Stent placement was performed in 34 patients for the following indications: perforation (n = 6), anastomotic leak (n = 26), and fistula (n = 2). Technical success rate was 97% (33/34). Clinical success rate was 44% (15/34) after one stent and 50% (17/34) after an additional stent. There were no severe adverse events and stent-related mortality. The overall adverse event rate was 50% (all graded 'moderate'). There were 14 (41%) stent migrations (complete n = 8, partial n = 6). Other adverse events were bleeding (n = 2) and aspiration pneumonia (n = 1). Reinterventions for failure of the large-diameter fSEMS were placement of another type of fSEMS (n = 4), surgical repair (n = 3), or esophagectomy (n = 1). Eleven patients (32%) died in-hospital because of persisting intrathoracic sepsis (n = 10) or preexistent bowel ischemia (n = 1). This study suggests that temporary placement of a large-diameter fSEMS for the treatment of upper gastrointestinal perforations, fistula, and anastomotic leaks is safe in terms of severe adverse events and stent-related mortality. The larger diameter does not seem to prevent stent migration.
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Affiliation(s)
- M W van den Berg
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - A C Kerbert
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - E J van Soest
- Department of Gastroenterology and Hepatology, Kennemer Gasthuis Hospital, Haarlem, the Netherlands
| | - M P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort, the Netherlands
| | - C M Bakker
- Department of Gastroenterology and Hepatology, Atrium Medical Center, Heerlen, the Netherlands
| | - L P L Gilissen
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - J E van Hooft
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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14
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Recent improvements in the management of esophageal anastomotic leak after surgery for cancer. Eur J Surg Oncol 2016; 43:258-269. [PMID: 27396305 DOI: 10.1016/j.ejso.2016.06.394] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/05/2016] [Accepted: 06/18/2016] [Indexed: 12/11/2022] Open
Abstract
Anastomotic leakage following total gastrectomy or esophagectomy is a significant complication that considerably increases postoperative mortality. The location of the anastomosis together with the anatomy of the esophagus explains the severity of this complication. Surgical knowledge should include general and specific predictive factors of leakage to avoid any technical-related cause of leakage. Clinical presentations may vary from minimally symptomatic to life-threatening situations. Investigations should be undertaken as soon as the diagnosis is suspected because delay greatly worsens the prognosis. CT scans with oral contrast and low insufflation early endoscopy are the preferred diagnostic tools and can also aid in therapeutic procedures. Communication and multidisciplinary teamwork are the cornerstones of treatment. When the leak occurs early with acute and important sepsis, the recommendation is surgical treatment. On the contrary, if the leak is late, non-symptomatic or minimally symptomatic, conservative management with intensive surveillance could be proposed. When the situation is in between these two extremes, endoscopic treatment is often proposed. Based on a review of the literature and experience from high volume centers, in this educational review, we present the incidence, predictive factors, clinical presentations, diagnostic tools, management, and therapeutic algorithms for anastomotic leaks following elective esophagectomy and total gastrectomy for cancer.
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Dent B, Griffin SM, Jones R, Wahed S, Immanuel A, Hayes N. Management and outcomes of anastomotic leaks after oesophagectomy. Br J Surg 2016; 103:1033-8. [PMID: 27146631 DOI: 10.1002/bjs.10175] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/02/2015] [Accepted: 02/22/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality. METHODS All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database. RESULTS A total of 390 oesophagectomies were performed (median age 65 (range 32-81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52-80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15-159) days; none of these patients died. CONCLUSION Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.
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Affiliation(s)
- B Dent
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S M Griffin
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - R Jones
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - S Wahed
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - A Immanuel
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - N Hayes
- Northern Oesophago-Gastric Cancer Unit, Royal Victoria Infirmary, Newcastle upon Tyne, UK
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Kim SY, Kang CH, Park IK, Kim YT. Esophageal Stent Insertion for Postesophagectomy Anastomosis Site Leakage. Clin Exp Otorhinolaryngol 2016; 9:382-384. [PMID: 27095519 PMCID: PMC5115142 DOI: 10.21053/ceo.2015.00724] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 06/16/2015] [Accepted: 07/08/2015] [Indexed: 11/22/2022] Open
Abstract
In Ivor Lewis operation, anastomosis site leakage is a critical complication. Interventional approach utilizing covered metal stent has been introduced for the management of this complication. This patient was diagnosed as esophageal cancer and underwent robot-assisted Ivor Lewis operation. Due to symptoms suggesting anastomosis site leakage, video-assisted thoracoscopic surgery exploration was performed without identification of gross leakage site. On esophagogastroduodenoscopy, anastomosis site leakage was detected and esophageal stent was placed. Four weeks later, the stent was removed, and the patient could intake all his diet orally without discomfort. Esophageal stent insertion can be an option to manage postesophagectomy leakage problem.
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Affiliation(s)
- Sang Yoon Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
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Baruah A, Kee Song LMW, Buttar NS. Endoscopic management of fistulas, perforations, and leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2016.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
BACKGROUND The high morbidity and mortality of esophageal defects show that the clinical challenge in the treatment of this disease still remains. An innovative method which has been developed in recent years for esophageal leakage is endoscopic vacuum therapy. OBJECTIVES A retrospective analysis of all patients treated for esophageal perforation with endoscopic vacuum therapy in our department was carried out. METHODS From November 2006 to October 2013 a total of 35 patients were treated with this method and of these 21 had anastomotic leakage, 7 had iatrogenic perforation due to flexible or rigid endoscopy and 7 patients had esophageal defects of various other origins. Drainage systems with an open pore polyurethane tip were placed using a standard endoscope. The vacuum drainage may be positioned either in the esophageal lumen onto the defect or through the defect into the extraluminal wound cavity. The intraluminal or intracavitary vacuum drainage is connected to an electronically controlled vacuum device and a continuous negative pressure of 125 mmHg is maintained for several days. The esophageal lumen or wound cavity collapses around the drainage resulting in intraluminal evacuation and closure of the defect. Under endoscopic monitoring the vacuum system is changed regularly until stable secondary healing of the intracorporeal wound or closure of the transmural defect is achieved. RESULTS In 32 out of 35 patients (91.4 %) healing of defects was achieved after median treatment duration of 11 days (range 4-78 days). The postoperative anastomotic leakage healed in 20 out of 21 patients (95.2 %) after a median of 11 days (range 4-46 days) of therapy. The defects in the 7 patients who were treated for iatrogenic perforation all healed (100 %) after a median treatment time of 5 days (range 4-7 days). There was one case of a recurrent fistula 75 days after treatment. The 90-day mortality in this series of 35 patients was 5.7 %. DISCUSSION The results of this retrospective study emphasize the increasing importance of endoscopic vacuum therapy in the current literature as an endoscopic treatment method in the management of esophageal perforation and anastomotic leakage.
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Abstract
Anastomotic leaks remain a significant clinical challenge following esophagectomy with foregut reconstruction. Despite an increasing understanding of the multiple contributing factors, advancements in perioperative optimization of modifiable risks, and improvements in surgical, endoscopic, and percutaneous management techniques, leaks remain a source of major morbidity associated with esophageal resection. The surgeon should be well versed in the principles underlying the cause of leaks, and strategies to minimize their occurrence. Appropriately diagnosed and managed, most anastomotic leaks following esophagectomy can be brought to a successful resolution.
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Freeman RK, Ascioti AJ, Dake M, Mahidhara RS. An Assessment of the Optimal Time for Removal of Esophageal Stents Used in the Treatment of an Esophageal Anastomotic Leak or Perforation. Ann Thorac Surg 2015; 100:422-8. [DOI: 10.1016/j.athoracsur.2015.03.085] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 03/22/2015] [Accepted: 03/25/2015] [Indexed: 01/18/2023]
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van Halsema EE, van Hooft JE. Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature. World J Gastrointest Endosc 2015. [PMID: 25685270 DOI: 10.4253/wjge.v7.i2.135.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
AIM To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature. METHODS The PubMed, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics. RESULTS Fully covered self-expandable metal stents (FC SEMS) (n = 85), biodegradable (BD) stents (n = 77) and self-expandable plastic stents (SEPS) (n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major (17.7%) and minor (13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks (64.5%), iatrogenic perforations (19.6%), Boerhaave's syndrome (7.8%) and fistulae (3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major (7.8%) and minor (5.5%) complications. CONCLUSION The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforations and fistulae is promising.
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Affiliation(s)
- Emo E van Halsema
- Emo E van Halsema, Jeanin E van Hooft, Department of Gastroenterology and Hepatology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Emo E van Halsema, Jeanin E van Hooft, Department of Gastroenterology and Hepatology, Academic Medical Center, 1105 AZ Amsterdam, The Netherlands
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Girard E, Messager M, Sauvanet A, Benoist S, Piessen G, Mabrut JY, Mariette C. Anastomotic leakage after gastrointestinal surgery: diagnosis and management. J Visc Surg 2014; 151:441-50. [PMID: 25455960 DOI: 10.1016/j.jviscsurg.2014.10.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Anastomotic leakage represents a major complication of gastrointestinal surgery, leading to increased postoperative morbidity; it the foremost cause of mortality after intestinal resection. Identification of risk factors is essential for the prevention of AL. AL can present with various clinical pictures, ranging from the absence of symptoms to life-threatening septic shock. Contrast-enhanced CT scan is the most complete investigation to define AL and its consequences. Early and optimal multidisciplinary management is based on three options: medical management, radiologic or endoscopic intervention, or surgical re-intervention. Prompt treatment should help decrease postoperative morbidity and mortality, with the choice depending on the septic status of the patient. If the patient is asymptomatic, treatment can be medical only, coupled with close surveillance. Interventional management is indicated when the fistula is symptomatic but not life-threatening. On the other hand, when the vital prognosis is engaged, surgery is indicated, emergently, associated with intensive care. Even more than their prevention, early and appropriate management counts most to decrease their consequences.
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Affiliation(s)
- E Girard
- Service de chirurgie générale, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - M Messager
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, centre hospitalier régional et universitaire, place de Verdun, 59037 Lille cedex, France
| | - A Sauvanet
- Service de chirurgie hépatique et pancréatique, hôpital Beaujon, 100, boulevard du Général-Leclerc, 92110 Clichy, France
| | - S Benoist
- Service de chirurgie oncologique et digestive, hôpital Kremlin-Bicêtre, 78, rue du Général-Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - G Piessen
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, centre hospitalier régional et universitaire, place de Verdun, 59037 Lille cedex, France
| | - J-Y Mabrut
- Service de chirurgie générale, hôpital de la Croix-Rousse, 103, Grande-rue-de-la-Croix-Rousse, 69004 Lyon, France
| | - C Mariette
- Service de chirurgie digestive et générale, hôpital Claude-Huriez, centre hospitalier régional et universitaire, place de Verdun, 59037 Lille cedex, France.
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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: 61] [Impact Index Per Article: 6.1] [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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El Hajj II, Imperiale TF, Rex DK, Ballard D, Kesler KA, Birdas TJ, Fatima H, Kessler WR, DeWitt JM. Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes. Gastrointest Endosc 2014; 79:589-98. [PMID: 24125513 DOI: 10.1016/j.gie.2013.08.039] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known. OBJECTIVES To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure. DESIGN Retrospective. SETTING Academic tertiary referral center. PATIENTS All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012. INTERVENTION Esophageal stent placement and removal. MAIN OUTCOME MEASUREMENTS Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure). RESULTS Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002). LIMITATIONS Retrospective, single-center study. CONCLUSIONS Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.
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Affiliation(s)
- Ihab I El Hajj
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Thomas F Imperiale
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Douglas K Rex
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Darren Ballard
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Kenneth A Kesler
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Thomas J Birdas
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Hala Fatima
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - William R Kessler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - John M DeWitt
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
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Freeman RK, Ascioti AJ, Dake M, Mahidhara RS. An analysis of esophageal stent placement for persistent leak after the operative repair of intrathoracic esophageal perforations. Ann Thorac Surg 2014; 97:1715-9; discussion 1719-20. [PMID: 24629300 DOI: 10.1016/j.athoracsur.2014.01.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 12/31/2013] [Accepted: 01/06/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastinal necrosis. However, the leak rate after primary surgical repair is reported to range between 15% and 20% and increases to 45% and 70% in patients whose repair is delayed beyond 24 hours. This analysis reviews patients who experienced a leak after the operative repair of an esophageal perforation treated with esophageal stent placement. METHODS Patients undergoing esophageal stent placement for the treatment of a leak after the operative repair of an intrathoracic esophageal perforation were identified from a single institution's database, which included patients initially treated at other facilities. Patient outcomes were recorded and analyzed. RESULTS During a 7-year period, 32 esophageal stents were placed in 29 patients who experienced an esophageal leak after operative repair. Associated surgical procedures were simultaneously performed in 7 (24%) patients. Leak occlusion occurred in 27 patients (93%). Two patients required a reoperative repair. Twenty-five patients (86%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration in 5 patients (19%) required repositioning (n=2) or replacement (n=3). Stents were removed at a mean of 22±16 days after placement. Mean hospital length of stay was 8±11 days. CONCLUSIONS Endoluminal esophageal stent placement is a safe and effective treatment for the majority of leaks after the operative repair of an intrathoracic esophageal perforation. Stent placement resulted in rapid leak occlusion and provided the opportunity for early oral nutrition while eliminating the need for reoperative repair or esophageal exclusion in the majority of patients.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana.
| | - Anthony J Ascioti
- Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana
| | - Megan Dake
- Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana
| | - Raja S Mahidhara
- Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana
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Rajan PS, Bansal S, Balaji NS, Rajapandian S, Parthasarathi R, Senthilnathan P, Praveenraj P, Palanivelu C. Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome. Surg Endosc 2014; 28:2368-73. [PMID: 24609701 DOI: 10.1007/s00464-014-3471-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 01/18/2014] [Indexed: 01/11/2023]
Abstract
BACKGROUND Leaks following oesophageal surgery are considered to be amongst the most dreaded complications and contributory to postoperative mortality. Controversies still exist regarding the best option for the management of oesophageal leaks due to lack of standardized treatment protocols. This study was designed to analyse the feasibility outcome and complications associated with placement of removable, fully covered, self-expanding metallic stents for oesophageal leaks with concomitant minimally invasive drainage when appropriate. METHODS The study group included 32 patients from a prospectively maintained database of oesophageal leaks, with the majority being anastomotic leaks after minimally invasive oesophagectomy (n = 28), followed by laparoscopic cardiomyotomy (n = 3) and extended total gastrectomy (n = 1). The procedures took place between March 2007 and April 2013. RESULTS Most patients had an intrathoracic leak (n = 22), with a mean time to detection of the leak following surgery of 7.50 days (SD = 2.23). Subsequent to endoscopic stenting, enteral feeding via a nasojejunal tube was started on the second day and oral feeding was delayed until the 14th day (n = 31). Six patients underwent thoracoscopic (n = 5) or laparoscopic drainage (n = 1) along with stenting for significant mediastinal and intra-abdominal contamination. The stent migration rate of our study was 8.54%. The overall success in terms of preventing mortality was 96%. CONCLUSION Endoscopic stenting should be considered a primary option for managing oesophageal leaks. Delayed oral intake may reduce the incidence of stent migration. Larger stents (bariatric or colorectal stents) serve as a useful option in case of migrated stents. Combined minimally invasive procedures can be safely adapted in appropriate clinical circumstances and may contribute to better outcomes.
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Affiliation(s)
- P S Rajan
- Department of Upper GI Surgery and Therapeutic Endoscopy, GEM Hospital, 45/A Pankaja Mill Road, Ramanathapuram, Coimbatore, 641045, India,
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Al-issa MA, Petersen TI, Taha AY, Shehatha JS. The role of esophageal stent placement in the management of postesophagectomy anastomotic leak. SAUDI JOURNAL OF GASTROENTEROLOGY : OFFICIAL JOURNAL OF THE SAUDI GASTROENTEROLOGY ASSOCIATION 2014. [PMID: 24496156 DOI: 10.4103/1319-3767.126315.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND/AIM Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The study intended to assess the outcome of endoluminal self-expanding stent in the treatment of this problem. SETTINGS AND DESIGN Department of Thoracic and Cardiovascular Surgery, Arhus University Hospital, Skejby, Arhus, Denmark. A retrospective study. PATIENTS AND METHODS From January 2007 to December 2010, 209 patients underwent esophagectomy for malignant disease of the esophagus or the cardia. Twenty patients developed anastomotic leak. Treatment consisted of conservative measures, surgery, and stent placement. Details of treatment, clinical outcome, complications, and mortality were evaluated. STATISTICAL ANALYSIS None. RESULTS One hundred and forty-seven patients (70.3%) had carcinoma of the cardia, whereas 62 patients (29.7%) had esophageal carcinoma. Twenty patients (9.5%) developed anastomotic leak; small (<1 cm) in two patients (10%); managed conservatively and bigger than 1 cm in 15 patients (75%); treated with an esophageal stent (Hanaro stent, DIAGMED Healthcare, Thirsk, YO7 3TD, United Kingdom). In three patients (15%), perforation of the staple line of the intrathoracic gastric conduit was found and managed by reoperation. Functional sealing of anastomoses after stent placement could be achieved in 10 patients (67%). Stent-related morbidity developed in five patients (33%): Migration of the stent, n=3 and tracheoesophageal fistula, n=2. Stents were smoothly removed 3 weeks after discharge. The mean hospital stay was 25 days. There was only one stent-related death (6.6%). CONCLUSION Endoluminal stent implantation is an effective and safe option in the management of postesophagectomy leaks.
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Affiliation(s)
| | | | - Abdulsalam Y Taha
- Department of Cardiothoracic and Vascular Surgery, School of Medicine, University of Sulaimania, Sulaimania, Region of Kurdistan, Iraq
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Al-issa MA, Petersen TI, Taha AY, Shehatha JS. The role of esophageal stent placement in the management of postesophagectomy anastomotic leak. Saudi J Gastroenterol 2014; 20:39-42. [PMID: 24496156 PMCID: PMC3952418 DOI: 10.4103/1319-3767.126315] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND/AIM Anastomotic leak after esophagectomy is one of the most challenging complications resulting in a high morbidity and mortality and prolonged hospitalization. The study intended to assess the outcome of endoluminal self-expanding stent in the treatment of this problem. SETTINGS AND DESIGN Department of Thoracic and Cardiovascular Surgery, Arhus University Hospital, Skejby, Arhus, Denmark. A retrospective study. PATIENTS AND METHODS From January 2007 to December 2010, 209 patients underwent esophagectomy for malignant disease of the esophagus or the cardia. Twenty patients developed anastomotic leak. Treatment consisted of conservative measures, surgery, and stent placement. Details of treatment, clinical outcome, complications, and mortality were evaluated. STATISTICAL ANALYSIS None. RESULTS One hundred and forty-seven patients (70.3%) had carcinoma of the cardia, whereas 62 patients (29.7%) had esophageal carcinoma. Twenty patients (9.5%) developed anastomotic leak; small (<1 cm) in two patients (10%); managed conservatively and bigger than 1 cm in 15 patients (75%); treated with an esophageal stent (Hanaro stent, DIAGMED Healthcare, Thirsk, YO7 3TD, United Kingdom). In three patients (15%), perforation of the staple line of the intrathoracic gastric conduit was found and managed by reoperation. Functional sealing of anastomoses after stent placement could be achieved in 10 patients (67%). Stent-related morbidity developed in five patients (33%): Migration of the stent, n=3 and tracheoesophageal fistula, n=2. Stents were smoothly removed 3 weeks after discharge. The mean hospital stay was 25 days. There was only one stent-related death (6.6%). CONCLUSION Endoluminal stent implantation is an effective and safe option in the management of postesophagectomy leaks.
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Affiliation(s)
- Mohammad A. Al-issa
- Department of Thoracic and Cardiovascular Surgery, PAR Hospital, Erbil, Region of Kurdistan, Iraq
| | | | - Abdulsalam Y. Taha
- Department of Cardiothoracic and Vascular Surgery, School of Medicine, University of Sulaimania, Sulaimania, Region of Kurdistan, Iraq,Address for correspondence: Prof. Abdulsalam Y. Taha, Department of Cardiothoracic and Vascular Surgery, School of Medicine, University of Sulaimania, Sulaimania, PO Box: 414, Region of Kurdistan, Iraq. E-mail:
| | - Jaffar S. Shehatha
- Department of Thoracic and Cardiovascular Surgery, PAR Hospital, Erbil, Region of Kurdistan, Iraq
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Hourneaux de Moura EG, Toma K, Goh KL, Romero R, Dua KS, Felix VN, Levine MS, Kochhar R, Appasani S, Gusmon CC. Stents for benign and malignant esophageal strictures. Ann N Y Acad Sci 2013; 1300:119-143. [PMID: 24117639 DOI: 10.1111/nyas.12242] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This paper presents commentaries on endotherapy for esophageal perforation/leaks; treatment of esophageal perforation; whether esophageal stents should be used for treating benign esophageal strictures; what determines the optimal stenting period in benign esophageal strictures/leaks; how to choose an esophageal stent; how a new fistula secondary to an esophageal stent should be treated; which strategy should be adopted when a fistula of a cervical anastomosis occurs; intralesional steroids for refractory esophageal strictures; balloon and bougie dilators for esophageal strictures and predictors of response to dilation; whether refractory strictures from different etiologies respond differently to endotherapy; surgical therapy of benign esophageal strictures; and whether stenoses following severe esophageal burns should be treated by esophageal resection or esophageal bypass.
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Affiliation(s)
| | - Kengo Toma
- Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Khean-Lee Goh
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Ronald Romero
- Division of Gastroenterology and GI Endoscopy, University of Malaya, Kuala Lumpur, Malaysia
| | - Kulwinder S Dua
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Marc S Levine
- Department of Gastrointestinal Radiation, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania.,Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rakesh Kochhar
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sreekanth Appasani
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Carla Cristina Gusmon
- Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universdade de São Paulo, São Paulo, Brazil
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Kassis ES, Kosinski AS, Ross P, Koppes KE, Donahue JM, Daniel VC. Predictors of anastomotic leak after esophagectomy: an analysis of the society of thoracic surgeons general thoracic database. Ann Thorac Surg 2013; 96:1919-26. [PMID: 24075499 DOI: 10.1016/j.athoracsur.2013.07.119] [Citation(s) in RCA: 341] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 07/17/2013] [Accepted: 07/18/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Anastomotic leak is an important cause of morbidity and mortality after esophagectomy. Few studies have targeted risk factors for the development of leak after esophagectomy. The purpose of this study is to use The Society of Thoracic Surgeons Database to identify variables associated with leak after esophagectomy. METHODS The Society of Thoracic Surgeons Database was queried for patients treated with esophagectomy for esophageal cancer between 2001 and 2011. Univariate and multivariate analysis of variables associated with an increased risk anastomotic leak was performed. RESULTS There were 7,595 esophagectomies, with 804 (10.6%) leaks. Thirty-day mortality and length of stay were higher for patients with anastomotic leak. Mortality in patients requiring surgical management was 11.6% (38 of 327) compared with 4.4% (20 of 458) in medically managed leaks (p < 0.001). The leak rate was higher in patients with cervical anastomosis compared with those with intrathoracic anastomoses, 12.3% versus 9.3%, respectively (p = 0.006). There was no difference in leak-associated mortality between the two approaches. Factors associated with leak on univariate analysis include obesity, heart failure, coronary disease, vascular disease, hypertension, steroids, diabetes, renal insufficiency, tobacco use, procedure duration greater than 5 hours, and type of procedure (p < 0.05). Multivariable regression analysis associated heart failure, hypertension, renal insufficiency, and type of procedure as risk factors for the development of leak (p < 0.05). CONCLUSIONS Anastomotic leak after esophagectomy is an important cause of postoperative mortality and increased length of stay. We have identified important risk factors for the development of esophageal anastomotic leak after esophagectomy. Further studies aimed at risk reduction are warranted.
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Affiliation(s)
- Edmund S Kassis
- Division of Thoracic Surgery, The Ohio State University Medical Center, Columbus, Ohio.
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Leenders BJM, Stronkhorst A, Smulders FJ, Nieuwenhuijzen GA, Gilissen LPL. Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital. Surg Endosc 2013; 27:2751-9. [PMID: 23436082 DOI: 10.1007/s00464-013-2802-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/03/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND Anastomotic leakages are severe complications of upper gastrointestinal surgery with serious morbidity and mortality. Until recently, only abscess drainage was possible. Since 2007, removable and repositionable covered metal self-expandable stents (RReCoMSeS) have been used in our hospital to cover leaks. METHODS Patients with postsurgical gastrointestinal leaks treated with RReCoMSeS between January 2007 and March 2010 were retrospectively evaluated and described. RESULTS Twenty-six patients were treated with RReCoMSeS (totally covered Choo/Hanaro and partially covered Endoflex stents). Included patients had anastomotic leaks after esophagectomy (15) and bariatric surgery (11). Overall successful sealing of the leak occurred in 81 % (including multiple procedures). In total 33 RReCoMSeS were used (mean 1.3 stents and 1.7 procedures per patient). Twenty-one of 33 RReCoMSeS succeeded in sealing the leak (64 %). Migration occurred in 24 % RReCoMSeS, and 9 % disintegrated. One stent (3 %) caused a perforation. CONCLUSIONS RReCoMSeS are a safe alternative for treating postsurgical leaks in the upper gastrointestinal tract. In 81 % of patients and with 64 % of the inserted stents, leaks were sealed successfully, with few complications. Fewer stents per patient were needed thanks to their repositionability. Stent migration is a major problem.
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Affiliation(s)
- Bart J M Leenders
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands.
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Lyons CD, Kim MP, Blackmon SH. A novel fixation procedure to eliminate covered self-expanding metal stent migration. Ann Thorac Surg 2013; 94:1748-50. [PMID: 23098966 DOI: 10.1016/j.athoracsur.2012.06.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Revised: 06/05/2012] [Accepted: 06/07/2012] [Indexed: 11/26/2022]
Abstract
Leakage from esophageal and gastric perforation carries a high morbidity rate and requires surgical or endoscopic intervention. When stenting is utilized, migration of the stent is a common complication. A novel technique to prevent migration of the stent is described. Fourteen patients presenting with leakage from the foregut underwent stent fixation with this technique. A bridle is created by delivering umbilical tape through each nostril securing the stent for 4 days. None of the 14 patients' X-rays showed migration of the stent. This new technique is both safe and effective when treating leaks and perforations from the foregut. Until nonmigrating stents can be developed, such techniques will be an important resource for treatment.
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Affiliation(s)
- Calvin D Lyons
- Department of Surgery, the Methodist Hospital, Houston, TX 77030, USA
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Abstract
Surgical resection remains a standard treatment option for localized esophageal cancer. Surgical approaches to esophagectomy include transhiatal and transthoracic techniques as well as minimally invasive techniques that have been developed to reduce the morbidities associated with laparotomy and thoracotomy incisions. The perioperative mortality for esophagectomy remains high with cardiopulmonary and anastomotic complications as the most frequent and serious morbidities. This article reviews the management of patients presenting for esophagectomy, with a focus on evidence-based anesthetic and perioperative approaches for improving outcomes.
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Affiliation(s)
- J Michael Jaeger
- TCV Surgical ICU, University of Virginia Health System, Charlottesville, VA 22908-0710, USA
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35
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Xia BT, Rosato EL, Chojnacki KA, Crawford AG, Weksler B, Berger AC. Major Perioperative Morbidity Does Not Affect Long-Term Survival in Patients Undergoing Esophagectomy for Cancer of the Esophagus or Gastroesophageal Junction. World J Surg 2012; 37:408-15. [DOI: 10.1007/s00268-012-1823-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Freeman RK, Ascioti AJ, Mahidhara RJ. Palliative therapy for patients with unresectable esophageal carcinoma. Surg Clin North Am 2012; 92:1337-51. [PMID: 23026285 DOI: 10.1016/j.suc.2012.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Most patients diagnosed with carcinoma of the esophagus do not undergo therapy with curative intent. The focus of treatment for these patients is to maximize their progression-free survival and palliate the most common sequelae of their disease: dysphagia, malnutrition, pain, and intraluminal tumor bleeding. This article discusses the available treatment options for palliation of patients with unresectable esophageal cancer.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, IN 46260, USA.
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Freeman RK, Ascioti AJ, Giannini T, Mahidhara RJ. Analysis of unsuccessful esophageal stent placements for esophageal perforation, fistula, or anastomotic leak. Ann Thorac Surg 2012; 94:959-64; discussion 964-5. [PMID: 22795060 DOI: 10.1016/j.athoracsur.2012.05.047] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 05/07/2012] [Accepted: 05/11/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Esophageal stent placement for the treatment of a perforation, anastomotic leak, or fistula has been adopted by some thoracic surgeons. Results have been reported for this technique, but little discussion has focused on treatment failures. This analysis reviews patients in whom esophageal stent placement was not successful in an attempt to identify factors that may increase the likelihood of failure of this technique. METHODS Patients undergoing esophageal stent placement for the treatment of an esophageal perforation, anastomotic leak, or fistula in which the stent failed to adequately seal the esophageal leak were identified from a single institution's database. The anatomic location, chronicity, and cause of the esophageal leak were recorded using a newly developed classification system. Comparison was made to patients in whom stent placement was successful. RESULTS Over a 7-year period, 187 patients had an esophageal stent placed for esophageal leaks. Fifteen (8%) of these patients required traditional operative repair when the esophageal stent failed to resolve the esophageal leak after an average of 3 days. A comparison of the 2 patient groups found that stent failure was significantly more frequent in patients who had an esophageal leak of the proximal cervical esophagus, 1 that traversed the gastroesophageal junction, an esophageal injury longer than 6 cm, or an anastomotic leak associated with a more distal conduit leak (p<0.05). Malignancy or previous radiation therapy was not associated with treatment failure. CONCLUSIONS This investigation identified 4 factors that significantly reduce the effectiveness of esophageal stent placement for the treatment of esophageal perforation, fistula, or anastomotic leak. These potential contraindications should be considered when developing a treatment plan for individual patients and may prompt traditional operative repair as initial therapy.
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Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana 46260, USA.
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Vereczkei A. [Esophageal surgery]. Magy Seb 2012; 65:98-107. [PMID: 22717964 DOI: 10.1556/maseb.65.2012.3.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Freeman RK, Ascioti AJ. Esophageal stent placement for the treatment of perforation, fistula, or anastomotic leak. Semin Thorac Cardiovasc Surg 2012; 23:154-8. [PMID: 22041048 DOI: 10.1053/j.semtcvs.2011.08.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2011] [Indexed: 01/17/2023]
Affiliation(s)
- Richard K Freeman
- Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital and Health System, Indianapolis, Indiana 46260, USA.
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Ananthakrishnan N, Lakshmi CP, Kate V. Esophageal stents in benign and malignant diseases. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2011. [DOI: 10.1016/s2222-1808(11)60074-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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