Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents

Management of esophageal anastomotic leaks, a systematic review and network meta-analysis

There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.

Endoscopic Self-Expanding Metallic Stent Placement in the Management of Post Laparoscopic Sleeve Gastrectomy Complications

Introduction Endoscopic treatments have become popular by providing the best solution for healing complications while allowing oral nutrition. In this study, we aim to evaluate outcomes of the endoscopic-covered stents for staple line complications following bariatric surgery.

Methods A prospective evaluation was performed for all patients treated for staple line complications after bariatric surgery. Bariatric patients with acute leaks, chronic gastrocutaneous fistulas, and anastomotic strictures refractory to endoscopic dilation after sleeve gastrectomy were included in this survey.

Results From January 2019 to June 2020, 41 patients (12 with acute leaks, 16 with chronic fistulas, and 13 with strictures) were treated with endoscopic silicone-covered stents (polyester or nitinol). The mean follow-up was 3.5 months. Immediate symptomatic improvement occurred in 95.2% (91.7% of acute leaks, 81.2% of fistulas, and 92.3% of strictures). In addition, 87.8% of patients initiated oral feeding immediately after stenting. There was no mortality case in this population.

Conclusion Although stent migration rarely occurs in subjects, the endoscopic silicone-covered stents strategy is one of the best treatments for anastomotic complications after bariatric surgery, providing rapid healing while simultaneously allowing for oral nutrition.

Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery

BACKGROUND

Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery.

MATERIALS AND METHODS

Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success.

RESULTS

In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05).

CONCLUSION

SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.

Human Adipose Derived Stem Cells Enhance Healing in a Rat Model of Esophageal Injury with Stent

BACKGROUND

Mesenchymal stem cells have been proven to promote cellular recruitment and remodeling during healing. Considering challenges encountered in the healing process of esophageal injury, we sought to evaluate the effect of human adipose derived stem cells (hASC) on esophageal injury with stent and to assess the feasibility of submucosal hASC injection as a mechanism of delivery.

METHODS

An intrabdominal esophagotomy was created in rodents with placement of an expandable fully covered metal esophageal stent. A submucosal injection of 2 × 10⁶ hASC was delivered in experimental animals. Animals were sacrificed on postoperative day 3 (POD3) or 7 (POD7). Macroscopic, immunohistochemical and immunofluorescence analyses were conducted to assess for markers of healing and viability of transplanted cells.

RESULTS

hASC were identified within submucosal and muscular layers with proliferation demonstrated in respective areas on anti-Ki67 stained sections. Lower adhesion and abscess scores were observed in hASC specimens without significant statistical difference. Prevalence of submucosal collagen was increased in samples treated with hASC compared to control, with abundant collagen deposition demonstrated within the POD7 group. Granulation tissue at the site of esophageal injury was more prominent in tissue sections treated with hASC compared to control, with significantly higher density at POD3 (control 1.94 versus hASC 2.83, P < 0.01).

CONCLUSIONS

Presence of hASC at the site of an esophageal injury may enhance wound healing predominantly through increased granulation and decreased inflammation in conjunction with esophageal stent placement. Targeted submucosal injection at the time of esophageal stent placement is an effective delivery method of hASC therapy.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Esophageal cancer surgery: review of complications and their management

Esophagectomy, even with the progress in surgical technique and perioperative management, is a highly specialized surgery, associated with a high rate of complications. Early recognition and adequate treatment should be a standard of care for the most common postoperative complications: anastomotic leakage, pneumonia, atrial fibrillation, chylothorax, and recurrent laryngeal nerve palsy. Recent progress in endoscopy with vacuum and stent placement, or in radiology with embolization, has changed the management of these complications. The success of nonoperative treatments should be frequently reassessed and reoperation must be proposed in case of failure. We have summarized the clinical signs, diagnostic process, and management of the frequent complications after esophagectomy for esophageal cancer.

Surgical management and prognostic factors in esophageal perforation caused by foreign body

OBJECTIVES

Esophageal perforation is associated with multiple serious complications and high mortality. Herein, we identify some predictors for postoperative outcomes, compare the outcomes of various surgical approaches, and summarize our experience with esophageal perforation over the past 13 years.

METHODS

We retrospectively analyzed 38 patients diagnosed with esophageal perforation caused by foreign body between November 2004 and May 2018. Univariate analysis and multivariate logistic regression analysis were performed to identify potential risk factors related to prognosis. Effects of different surgery were compared based on postoperative outcomes.

RESULTS

Of the 38 patients, the number of females was equal to males with a mean age of 55.6 ± 14.9 (range 23-93) years; 22 had thoracic perforations and 16 had cervical perforations. The overall mortality rate was 5.3%. Univariate analysis revealed that sex (p = 0.049), type of foreign body (p = 0.042), abscess (p = 0.049), and site of perforation (p = 0.031) were associated with prognosis. The interval between perforation and surgery did not significantly influence prognosis (p = 0.929). No significant difference was found in postoperative outcomes among various surgeries.

CONCLUSIONS

The interval between perforation and treatment was not as important as previously reported. Surgical management should be performed early when feasible, even if the interval between perforation and surgery is 24 h or longer.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

Clinical outcomes following self-expanding metal stent placement for esophageal salvage

OBJECTIVES

To assess the efficacy of self-expanding metal stents (SEMS) for esophageal salvage in patients who would otherwise require esophageal/conduit resection.

METHODS

We performed a retrospective chart review of patients who had SEMS placed from January 2010 to December 2015. Patient demographics, esophageal stent characteristics, and outcomes were assessed in our patient cohort.

RESULTS

Our study included a total of 83 patients. A total of 148 SEMS were placed, with 121 partially covered SEMS (pcSEMS) and 27 fully covered SEMS (cSEMS). A stent was placed more than once in 42.2% of the patients. Median duration of stent placement was 23 days. Indications for SEMS placement included esophageal leak after esophageal resection (45.8%), spontaneous esophageal perforation (22.9%), iatrogenic esophageal perforation (20.5%), and esophageal obstruction (9.6%). Complications from SEMS placement included 6 stent migrations and 1 esophageal perforation. Of the 6 stents that migrated, 2 were pcSEMS and 4 were cSEMS. In a patient who underwent stent placement for a stricture refractory to dilation, a perforation at the distal end was discovered 2 days after stent removal. The perforation healed after the second SEMS placement. Ultimately, 15 patients (18.1%) had to undergo a subsequent esophagectomy or takedown of their conduit with an overall 81.9% salvage of native esophagus or conduits.

CONCLUSIONS

Our study demonstrates the successful use of SEMS in patients with anastomotic leaks, perforations, and recalcitrant strictures.

Postsurgical Perforation of the Esophagus Can Be Treated Using a Fully Covered Stent in Children

OBJECTIVES

Surgery and conservative treatment of esophageal or gastric perforations are both often associated with poor results and carry a high morbidity and mortality rate. The aim of the present study was to evaluate the effectiveness and safety of using fully covered self-expending metallic stents (SEMS) in children with upper digestive leaks.

METHODS

This retrospective study reviewed all children with esophageal or gastric perforation who were treated with placement of an SEMS from January 2011 to January 2015. Closure of the perforation was the primary outcome measured. Secondary outcomes were the duration of antibiotic therapy and parenteral nutrition, adverse events, and length of hospitalization.

RESULTS

A total of 19 SEMS were placed in 10 patients (median age: 5.5 years; 5 girls) treated for postanastomotic leaks of esophageal atresia (n = 3), esophagogastroplasty (n = 4), resection of esophageal duplication (n = 1) or perforation during Toupet surgical dismantling (n = 1), and gastric rupture after Nissen surgery (n = 1). The perforation closed in 9 out of 10 patients in a mean of 36 days after stenting (range: 13-158 days). All patients received antibiotic therapy for an average of 17.5 days (3-109 days) and parenteral nutrition for 49 days (17-266 days). During a median follow-up of 8.9 months, 4 out of 9 sealed perforations developed stenosis, which was efficiently treated by endoscopic dilations in 2 patients and surgical redo in 2 patients with dilation-resistant stenosis.

CONCLUSIONS

Covered stents appear to be beneficial in closing esophageal perforations in children and can avoid the high morbidity of a surgical repair. Stenosis, however, occurred frequently after larger leakages.

Endoscopic Management of Esophageal Perforations: Who, When, and How?

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Esophageal surgery in minimally invasive era

The widespread popularity of new surgical technologies such as laparoscopy, thoracoscopy and robotics has led many surgeons to treat esophageal diseases with these methods. The expected benefits of minimally invasive surgery (MIS) mainly include reductions of postoperative complications, length of hospital stay, and pain and better cosmetic results. All of these benefits could potentially be of great interest when dealing with the esophagus due to the potentially severe complications that can occur after conventional surgery. Moreover, robotic platforms are expected to reduce many of the difficulties encountered during advanced laparoscopic and thoracoscopic procedures such as anastomotic reconstructions, accurate lymphadenectomies, and vascular sutures. Almost all esophageal diseases are approachable in a minimally invasive way, including diverticula, gastro-esophageal reflux disease, achalasia, perforations and cancer. Nevertheless, while the limits of MIS for benign esophageal diseases are mainly technical issues and costs, oncologic outcomes remain the cornerstone of any procedure to cure malignancies, for which the long-term results are critical. Furthermore, many of the minimally invasive esophageal operations should be compared to pharmacologic interventions and advanced pure endoscopic procedures; such a comparison requires a difficult literature analysis and leads to some confounding results of clinical trials. This review aims to examine the evidence for the use of MIS in both malignancies and more common benign disease of the esophagus, with a particular emphasis on future developments and ongoing areas of research.

Treatment of anastomotic leaks with metallic stent after esophagectomies

The diagnosis and the treatment of anastomotic leak after esophagectomy are the keys to reduce the morbidity and mortality after this surgery. The stent plays an important role in the treatment of the leakage and in the prevention of reoperation. We have analyzed the database of the section of the esophagogastric surgery of Donostia University Hospital from June 2003 to May 2012. It is a retrospective study of 113 patients with esophagectomy resulting from tumor, and 24 (21.13%) of these patients developed anastomotic leak. Of these 24 patients, 13 (54.16%) have been treated with a metallic stent and 11 (45.84%) without a stent. The average age of the patients was 55.69 and 62.45 years, respectively. All patients treated with and without a stent have been males. Eight (61.5%) stents were placed in the neck and five (38.5%) in the chest. However, among the 11 fistulas treated without a stent, 9 patients had cervical anastomosis (81.81%) and 2 patients (18.18%) had anastomosis in the chest. Twelve patients (92.30%) with a stent preserve digestive continuity, and 10 patients (90.90%) were treated without a stent. One patient died in the stent group and one in the nonstent group. The treatment with metallic stent of the anastomotic leak after esophagectomy is an option that can prevent reoperation in these patients, but it does not decrease the average of the hospital stay. The stent may be more useful in thoracic anastomotic leaks.

Endoscopic Management of Esophageal Anastomotic Leaks After Surgery for Malignant Disease

BACKGROUND

Esophageal anastomotic leaks after cancer surgery remain a major cause of morbidity and mortality. Endoscopic interventions, including covered metal stents (cSEMS), clips, and direct percutaneous endoscopic jejunostomy (dPEJ) tubes are increasingly used despite limited published data regarding their utility in this setting. This study aimed to determine the efficacy and safety of a multimodality endoscopic approach to anastomotic leak management after operation for esophageal or gastric cancer.

METHODS

We performed a retrospective review of prospectively maintained databases of gastric and esophageal operations at our hospital between January 2003 and December 2012. Included patients had an operation for esophageal or gastric cancer, demonstrated evidence of an anastomotic leak at the esophageal anastomosis, and underwent attempted endoscopic therapy. Healing was defined as clinical and radiographic leak resolution.

RESULTS

Forty-nine patients with leaks underwent endoscopic management. Of the 49 patients, 31 (63%) received cSEMS, 40 (82%) had dPEJ tubes inserted, and 3 (6%) received clips. Twenty-three (47%) patients underwent a combined approach. Overall, 88% of patients achieved healing in a median of 83 days. Twenty-two of 23 patients (96%) who underwent a multimodality endoscopic approach healed. Only 1 patient had a major complication associated with stent erosion into the pulmonary artery, which was successfully treated with operative repair.

CONCLUSIONS

Esophageal anastomotic leaks after esophageal and gastric cancer operations can be managed successfully and safely with endoscopic therapy. Combining cSEMS for leak control and dPEJ tube placement for nutritional support was highly effective in achieving healing, without the need for surgical repair.

[Perforations near the cardia in benign diseases]

Esophageal perforations nearby the cardia are a clinical disorder of various causes. Perforations occur most often following diagnostic or interventional endoscopy but spontaneous perforations (Boerhaave syndrome) are less frequent. Due to the heterogeneous etiology there is a broad range of therapeutic options. In most cases the esophageal perforation site can be covered by an endoscopic stent. Recent endoscopic procedures are the intraluminal application of an endoscopic vacuum-assisted closure system (endo-VAC) or clipping of the esophageal defect. Surgical procedures include direct suturing with external coverage of the defect or transhiatal blunt dissection of the esophagus without primary reconstruction. All endoscopic and surgical procedures often require an additional drainage of the mediastinum and if necessary of the thoracic and abdominal cavities. The clinical presentation ranges from a simple perforation without concomitant esophageal pathology to a defect of considerable length with pleural perforation and associated septic multiple organ failure. The severity of the septic course is the crucial parameter for the choice of the procedure. An early multiple organ failure indicates an insufficient drainage of the septic focus and is indicative for surgical resection. The overall mortality is given as 12 % in the current literature and primarily depends on the localization and the etiology of the perforation. The highest mortality rates are observed with Boerhaave syndrome. The most important prognostic variable is the time interval between perforation and initiation of therapy whereby the mortality rises up to 20 % if the interval exceeds 24 h. Due to the complex therapy and the poor prognosis esophageal perforations should be treated in specialized centers.

Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature

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.

Usefulness of over-the-scope clipping system for closing digestive fistulas

BACKGROUND AND AIM

Therapeutic endoscopy has recently evolved into the treatment of complex gastrointestinal (GI) postoperative leakage, especially with over-the-scope clips (OTSC). We describe our 2-year experience of 30 patients treated for digestive fistulas using the OTSC device.

METHODS

This was a retrospective study conducted on patients referred for GI fistulas in two French hospitals. Technical aspects, clinical outcomes and closure rates were recorded.

RESULTS

Thirty patients were treated for GI leaks: 19 (63%) had a gastric fistula after laparoscopic sleeve gastrectomy (LSG); the others had rectovaginal, urethrorectal, rectovesical, gastrogastric, gastrocutaneous, esophagojejunal fistulas and colorectal anastomotic leak. Average follow up was 10.4 months. Eighteen (60%) had undergone previous endoscopic or surgical treatment. Orifice size was 3-20 mm (average 7.2 mm). Successful OTSC placement was achieved in 30 out of 34 attempts. There were four intraoperative undesired events (13.3%) but these were successfully managed. Overall success rate was 71.4% and 16 patients (53%) recovered with primary efficacy. Six patients (20%) required a subsequent endoscopic treatment. Eight patients (26.7%) required surgery for failure. In nine cases, we used one or more additional endoscopic procedures concomitantly with the OTSC combining self-expandable metal stents, standard clips and glue injection. Healing rate after LSG fistula was 88.9%, which was significantly higher than the overall rate (P = 0.01).

CONCLUSION

OTSC placement seems to be safe and effective for the treatment of GI fistulas. Better results were seen in leaks after LSG.

Closing perforations and postperforation management in endoscopy: esophagus and stomach

Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.

Optimal approach to the management of intrathoracic esophageal leak following esophagectomy: a systematic review

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.

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes

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.

Role of endoscopic stents and selective minimal access drainage in oesophageal leaks: feasibility and outcome

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.

Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses

BACKGROUND

Anastomotic leakage of esophagogastric and esophagojejunal anastomoses is a severe complication after esophagectomy and gastrectomy associated with a high mortality. We conducted this non-randomized observational study to evaluate the outcomes and clinical effectiveness of covered self-expanding stents (CSESs) in treating esophageal anastomotic leakage.

METHODS

From 2002 to 2013, consecutive patients with anastomotic leakage after esophagogastrostomy or esophagojejunostomy who received CSESs were analyzed concerning leakage characteristics, leakage sealing rate, success and failure rates of CSES treatment, stent-related complications, and mortality.

RESULTS

In 35 patients, anastomotic leakage originating from 5 cervical esophagogastrostomies, 6 thoracic esophagogastrostomies, 12 mediastinal esophagojejunostomies and 12 abdominal esophagojejunostomies were treated with 48 CSESs (16 fully CSES, 32 partially CSES). Of 35 patients, 24 received one stent, 9 received two consecutive stents, and 2 received three consecutive stents. Stent-related complications occurred in 71 % of patients (25/35). The most frequent complications were leakage persistence (44 %) and stent dislocation (19 %). Sealing of the anastomotic leakage was achieved in 24 (69 %) patients after a median (range) stenting time of 19 (1-78) days. Sealing rates differed significantly with 20 % (cervical esophagogastrostomies), 50 % (thoracic esophagogastrostomies), 92 % (mediastinal esophagojejunostomies) and 67 % (abdominal esophagojejunostomies) of patients (p = 0.023). Moreover, clinical success rates differed among these groups (60 vs. 67 vs. 92 vs. 58 %; p = 0.247). Clinical failure of stent treatment was more likely to be recognized in early postoperative leakage (median postoperative day 3 vs. 8; p = 0.098) compared with successful treatment, whereas no difference for clinical success rates was found comparing leakage ≤ 10 versus >10 mm (68 vs. 64 %; p = 0.479).

CONCLUSION

CSESs are an effective treatment for anastomotic leakage in patients with esophagogastrostomies and esophagojejunostomies. Best results can be achieved in patients with anastomotic leakages following mediastinal esophagojejunostomy, and in leakages occurring after the very early postoperative phase.

Necrotizing pancreatitis complicated by oesophageal haemorrhage

Bleeding is a rare complication of pancreatic pseudocyst. We describe an exceptional case of necrotizing pseudocyst with mediastinal extension providing cataclysmic oesophageal haemorrhage. The patient was successfully treated by adequate endoscopic, radiological and surgical management.

Esophageal perforation

Esophageal perforation is uncommon but carries a high morbidity and mortality, particularly if the injury is not detected early before the onset of systemic signs of sepsis. The fact that it is an uncommon problem and it produces symptoms that can mimic other serious thoracic conditions, such as myocardial infarction, contributes to the delay in diagnosis. Patients at risk for iatrogenic perforations (esophageal malignancy) frequently have comorbidities that increase their perioperative morbidity and mortality. The optimal treatment of esophageal perforation varies with respect to the time of presentation, the extent of the perforation, and the underlying esophageal pathologic conditions.

Endoscopic closure of acute esophageal perforations

Esophageal leak is a life-threatening problem that can result from spontaneous rupture of the esophagus, cancer, anastomotic dehiscence after surgery, or as a complication of endoscopy. During the last decade, developments in the minimally invasive endoluminal approach to the management of esophageal leaks include utilization of endoscopy not only for diagnosis but also for closure of leaks with clips or sutures, bypass of the leaks with stents, and/or endoluminal drainage of mediastinal infection. The aim of this review is to summarize recent advances and the principles of endoscopic management of acute esophageal perforations.

Clinical outcomes of endoscopic and surgical management for postoperative upper gastrointestinal leakage

BACKGROUND

The purpose of this study was to evaluate the safety and efficacy of endoscopic therapy, an alternative and less invasive modality for the management of leakage after gastrectomy.

METHODS

An electronic database of 35 patients with anastomotic leaks after surgery for stomach cancer that were treated with either an endoscopic procedure or surgery between January 2004 and March 2012 was reviewed. The success rates and safety of both modalities were evaluated.

RESULTS

Endoscopic treatment was performed in 20 patients and surgical treatment in 15 patients. The median time interval between the primary surgery and diagnosis of leakage was 8.0 days (interquartile range, 5.0-14.0 days). Of the 20 patients with endoscopic treatment, technical success was achieved in 19 patients (95 %) with resulting clinical success achieved in all of these 19 patients (100 %). One patient with failed endoscopic management went on to receive surgery. There were no cases of leakage-related deaths after endoscopic treatment. Of the 15 patients with surgical treatment, 5 died due to sepsis, bleeding, or hospital-acquired pneumonia. For diagnosis of leakage, 17 patients from the endoscopy group underwent computed tomography (CT) scanning, which revealed leakages in 3 patients (17.6 %) and occult leakages were subsequently defined at fluoroscopy in all 20 patients. Seven of twelve patients (58.3 %) from the surgical group had leakages diagnosed by CT scan.

CONCLUSIONS

Endoscopic treatment can be considered a valuable option for the management of postoperative anastomotic leakage with a high degree of technical feasibility and safety, particularly for leakages that are not excessively large.

Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital

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.

Total loss of the covering of a metallic stent during esophageal leak treatment

A 41-year-old man underwent a Heller myotomy due to achalasia. An unexpected puncture in the esophageal wall was identified during the procedure. A partially covered 15cm stent (PSEMS) (UltraFlex) was placed at the mucosal defect. It was removed 26 days later and the endoscopic image showed esophageal tissue embedded in the covered portion of the stent. PSEMS covering loss is a rare complication that can have serious consequences.

Esophageal perforation caused by a fish bone treated with surgically indwelling drainage and fibrin glue injection for fistula formation

We herein report a case of thoracic esophageal perforation caused by a fish bone. The patient was a 68-year-old female who presented with a persistent sore throat after eating sea bream four days previously. She was diagnosed with an esophageal perforation and posterior mediastinal abscess formation by chest computed tomography and inflammatory findings in her blood test. Surgically indwelling drainage was able to effectively control the leakage of contaminants and infection. Endoscopic injection of fibrin glue into the long-standing thoracic-esophageal fistula promoted closure of the esophageal wall defect and enabled her to restart oral intake. This case report suggests that effective drainage and the use of fibrin glue sealant may be one of the treatment options for esophageal perforation.

Esophageal stents for leaks and perforations

Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak.

Advances in the management of esophageal perforation

Therapy for acute esophageal perforation in the last decade has benefited from newer technology in endoscopy and imaging. Success with nonoperative therapies such as endoluminal stenting and clipping has improved outcomes and shortened length of stay in selected patients. Iatrogenic injury currently comprises most acute esophageal perforation, and nonoperative therapy may be appropriate in a significant percentage of patients. The decision regarding operative vs non-operative therapy is best done by a dedicated surgical team with experience in all the surgical and endoscopic treatment options. Boerhaave syndrome occurs less often and may be treated with endoscopic therapy, although it more likely requires operative intervention. This article reviews current advances in the diagnosis and management of acute esophageal perforation.

Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage

BACKGROUND

Intrathoracic contamination from esophageal perforation, staple line dehiscence, or trauma can be a preterminal event. In our institution, covered self-expanding metal stents have been used aggressively in the management of esophageal leak, but their use remains controversial. The primary objective of this study was to evaluate the efficacy of esophageal salvage using stents to assist in the management of intrathoracic esophageal leakage.

METHODS

Over 38 months, 63 patients with esophageal or gastric leaks were evaluated for stenting as primary treatment and identified using a prospective database.

RESULTS

Fifty-six patients were managed with endoscopic stenting as primary therapy and 30 of those patients required a thoracic intervention after stenting. Seven of these patients required esophageal diversion after stent failure. Thirty-day mortality was 10% in the patients with intrathoracic contamination.

CONCLUSIONS

We suggest that the use of covered self-expanding metal stents in patients with intrathoracic leak after esophageal perforation is safe and offers esophageal salvage in 77% regardless of time of presentation.

Expandable stents for benign esophageal disease

Partially covered self-expandable esophageal stents have been associated with unacceptable complications when used for benign esophageal disorders. With the introduction of removable or potentially removable fully covered stents and biodegradable stents, interest in using expandable stents for benign indications has been revived. Although expandable stents can offer a minimally invasive alternative to surgery, they can be associated with serious complications; hence, this approach should be considered in carefully selected patients, preferably on a protocol basis.