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

CIRSE Standards of Practice on Placement of Upper Gastrointestinal Stents

BACKGROUND

Image-guided insertion of stents in the upper gastrointestinal trunk is an effective, minimally invasive treatment option to provide immediate relief of symptoms caused by upper gastrointestinal tract obstruction related to advanced-stage malignant causes or benign causes that lead to lumen narrowing.

PURPOSE

This document, as with all CIRSE Standards of Practice documents, is not intended to impose a standard of clinical patient care but will recommend a reasonable approach to best practices for performing stenting of the upper gastrointestinal tract, namely the oesophageal and gastroduodenal segments. Our purpose is to provide up-to-date recommendations for placement of upper gastrointestinal tract stents based on the previously published guidelines on this topic in 2005 and 2007.

METHODS

The writing group was established by the CIRSE Standards of Practice Committee and consisted of a group of internationally recognised experts in performing upper gastrointestinal stenting. The writing group reviewed the existing literature using PubMed to search for relevant publications in the English language up to September 2021. The final recommendations were formulated through consensus.

CONCLUSION

Insertion of stents in the oesophageal and gastroduodenal tracts has an established role in the successful management of malignant or benign obstructions. This Standards of Practice document provides up-to-date recommendations for the safe performance of upper gastrointestinal stent placement.

Short-term outcomes of a new gastrointestinal decompression tube combined with conservative treatment in patients with esophagojejunal anastomotic leakage after total gastrectomy

To compare the short-term outcomes of a new gastrointestinal decompression tube combined with conservative treatment in patients with esophagojejunal anastomotic leakage (EJAL) after total gastrectomy. We retrospectively analyzed the data of 81 patients with EJAL who had undergone total gastrectomy and Roux-en-Y reconstruction at Fujian Medical University Union Hospital between January 2014 and December 2021. The patients were divided into experimental (12 patients with new gastrointestinal decompression tube plus conservative treatment) and control (69 patients with conservative treatment) groups, according to the different treatment methods they received. Anatomic defect size linearly correlated with time to clinical success, hospital stay, and hospital cost in the control group. The two groups showed no significant differences in anastomotic defect size, time of defect after surgery, hospitalization cost, and time of antibiotic use. However, the time to clinical success was significantly shorter in the experimental group than in the control group (16.0 ± 8.3 vs. 23.6 ± 17.8, P = 0.04), as was the length of hospital stay (30.1 ± 6.3 vs. 36.8 ± 16.7, P = 0.017). Furthermore, when the defect size was ≥ 4 mm, the time to clinical success, hospital stay, and hospital cost in the experimental group were lower than those in the control group (P < 0.05). Placement of a new gastrointestinal decompression tube is a safe treatment. When the defect size is ≥ 4 mm, the time to clinical success, length of hospital stay, and hospital cost can be reduced.

Endoscopic Management for Post-Surgical Complications after Resection of Esophageal Cancer

Simple Summary

Flexible endoscopy has an important part in the diagnosis and treatment of postoperative complications after oncologically intended esophagectomy. Endoscopy offers the possibility of effective therapy with minimal invasiveness at the same time, and the use of endoscopic therapy procedures can avoid re-operations. In this review we present the advantages of endoscopic treatment opportunities during the last 20 years regarding patients’ treatment after esophageal cancer resection. According to prevalence and clinical relevance, four relevant postoperative complications were identified and their endoscopic treatment procedures discussed. All endoscopic therapy procedures for anastomotic bleeding, anastomotic insufficiencies, anastomotic stenosis and postoperative delayed gastric emptying are presented, including innovative developments.

Abstract

Background: Esophageal cancer (EC) is the sixth-leading cause of cancer-related deaths in the world. Esophagectomy is the most effective treatment for patients without invasion of adjacent organs or distant metastasis. Complications and relevant problems may occur in the early post-operative course or in a delayed fashion. Here, innovative endoscopic techniques for the treatment of postsurgical problems were developed during the past 20 years. Methods: Endoscopic treatment strategies for the following postoperative complications are presented: anastomotic bleeding, anastomotic insufficiency, delayed gastric passage and anastomotic stenosis. Based on a literature review covering the last two decades, therapeutic procedures are presented and analyzed. Results: Addressing the four complications mentioned, clipping, stenting, injection therapy, dilatation, and negative pressure therapy are successfully utilized as endoscopic treatment techniques today. Conclusion: Endoscopic treatment plays a major role in both early-postoperative and long-term aftercare. During the past 20 years, essential therapeutic measures have been established. A continuous development of these techniques in the field of endoscopy can be expected.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

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.

Constructing a risk prediction model for anastomotic leakage after esophageal cancer resection

Objective

The purpose of this study was to investigate a newly constructed risk prediction model for anastomotic leakage after esophageal cancer resection.

Methods

A retrospective survey of 205 patients who underwent esophageal cancer resection was conducted using a self-designed questionnaire. The influencing factors were explored by single factor analysis, and a logistic regression analysis was performed to construct the prediction equation. A receiver operating characteristic curve was used to evaluate the model.

Results

The incidence of anastomotic leakage after esophageal cancer resection was 11.73%. There were five independent risk factors entered into the regression equation. The risk prediction equation was Z = 0.108 × age + 2.011 × preoperative chemotherapy history + 3.007 ×incision redness/exudation + 2.632 × pleural effusion + 1.934 × increased white blood cell count − 12.304. According to the receiver operating characteristic curve test, the area under the curve was 0.946, the sensitivity was 0.833, the specificity was 0.912, and the Youden index was 0.745.

Conclusion

The risk model of anastomotic leakage after esophageal cancer resection had a good predictive effect that was of significance for guiding clinical observation and early-screening.

Successful closure with covered self-expandable metal stent for severe anastomotic leakage in the cervical esophagus

Anastomotic leakage is one of the major complications of esophageal surgery with a high mortality rate and significant morbidity. We describe a case of severe anastomotic leakage close to the hypopharynx after esophageal cancer resection. Despite the conservative management with external drainage, the severe leak did not improve. A fully covered self-expandable metal stent (SEMS) with short flares, which was designed for the cervical esophagus, was subsequently placed bridging the anastomosis to seal the fistula. The post-procedural course was uneventful, and the stent was endoscopically removed after three weeks without any complications. The patient was discharged home three weeks after the stent removal. Our results suggest that placement of fully covered SEMS with short flares may be a safe and effective treatment in this condition of patients.

Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report

RATIONALE

An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited.

PATIENT CONCERNS

A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close.

DIAGNOSES

Intractable esophago-bronchial fistula associated with esophageal surgery.

INTERVENTIONS AND OUTCOMES

On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case.

LESSONS

We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.

Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations: An Updated Systematic Review

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.

Self-expanding segmental radioactive metal stents for palliation of malignant esophageal strictures

BACKGROUND

Traditional metal stents are not always suitable for patients with circuitous malignant esophageal stricture.

PURPOSE

We aimed to report the safety and effectiveness of stent insertion using self-expanding segmental radioactive metal stent in the palliation of malignant esophageal stricture.

MATERIAL AND METHODS

We conducted a retrospective analysis of 22 consecutive patients who underwent insertion of segmental radioactive metal stents from November 2016 to March 2019. Technical success, dysphagia score, and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The stenting procedure was successful in all 22 patients with no procedure-related deaths. Twenty-four segmental radioactive metal stents were successfully implanted. A total of 6 (27.3%) complications were found, mainly 5 (22.7%) stent migrations. The median follow-up period was 3.3 months. Stent removal was required in 4 (12.5%) patients due to complete stent migration. The mean dysphagia score decreased significantly after stent insertion (P<0.0001). During follow up, 13 patients survived with no obvious clinical symptom and nine patients died. The mean survival was 9.9 months.

CONCLUSION

The stenting procedure using self-expanding segmental radioactive metal stents is safe and effective in dysphagia palliation of malignant esophageal stricture.

Radioactive feeding tube in the palliation of esophageal malignant obstruction

PURPOSE

A radioactive feeding tube was used to achieve both nutrition and brachytherapy for the treatment for malignant esophageal obstruction. We report the safety and effectiveness of this technique.

METHODS

We conducted a retrospective analysis of 16 consecutive patients who employed this technique from January 2015 to March 2018. The radioactive feeding tube was made by binding the ¹²⁵I seed chain on the feeding tube. Under fluoroscopic guidance, the tube was inserted into the obstructed esophagus, with the seed chain crossing over the segment of malignant esophageal obstruction. Technical success rate, dysphagia score, procedure time and complications were analyzed. Kaplan-Meier analysis was used to analyze the survival time.

RESULTS

The radioactive feeding tube was easy to prepare. The technical success rate was 100%, without serious complications such as bleeding or infection. The median procedure time of tube insertion was 44.0 min. The Kamofsky score and Neuhaus dysphagia grading were significantly improved after tube insertion (p < 0.01). On esophageal radiography, the contrast agent passed through the narrow area smoothly. Complete remission (n = 1) and partial remission (n = 13) of local tumor were obtained in 14 patients, and the local tumor control rate was 87.5% (14/16). During follow-up, four patients survived with no obvious clinical symptom and 10 patients died of cancer. The median survival was 12.0 months.

CONCLUSION

Preparation of the radioactive feeding tube is simple and easy. The insertion of this kind of tube achieves parenteral nutrition and brachytherapy simultaneously and is safe and effective in dysphagia palliation of malignant esophageal stricture. The radiological-radiotherapeutic procedure could be an alternative tool in the case of refusing other treatments by the patients.

A novel fully covered self-expandable segmental metallic stents for the treatment of refractory esophageal stenosis

Background

The conventional esophageal stent is not flexible enough for refractory or circuitous esophageal stenosis. After stent placement, the bending stress may stimulate tissue proliferation in both ends of the stent, causing restenosis, severe bleeding or fistula. A fully covered self-expandable segmental stent was designed and used to overcome such shortcoming. This study aims to study the safety and effectiveness of the fully covered self-expandable segmental metallic stents placement in palliation of dysphasia in patients with refractory esophageal stenosis.

Methods

Retrospective study of hospital records of a consecutive series of 24 patients who underwent placement of fully covered segmental stent from March 2015 to April 2018 was conducted. All procedure was performed under local anesthesia and fluoroscopic guidance. Esophagography was performed by orally take of iodine contrast agent. A 5F catheter and a stiff guide wire were introduced in the esophagus. A fully covered segmental stent was delivered and implanted along the stiff guide wire. The upper endoscopy and chest computed tomography scan were used for the assessment of the location and length of stenosis on admission and during follow-up. The technical success and complications were collected and analyzed.

Results

Stent placement was successful in all patients without procedure-related deaths. Twenty-four covered segmental stents were implanted. A total of eight major complications (33.3%) were found, and stent migration was the most common complication (16.7%). The median follow-up time was 4.5 months (interquartile range: 0.8-14.0 months). Adjustment was required in 3 patients (12.5%) due to stent migration. The mean dysphagia score before stenting and end of follow-up was 3.3±0.5 and 1.0±1.6 (P<0.0001). Four covered segmental stents were removed due to stent migration or intolerance.

Conclusions

Stenting using novel fully covered self-expandable segmental metallic stent is safe and effective in dysphagia palliation of refractory esophageal stenosis.

Modified Type of Double-Covered Self-Expandable Segmental Metallic Stents for Palliation of Esophageal Fistula

Purpose: To study the modified type of double-covered self-expandable segmental metallic stents in terms of efficacy, complications, and long-term outcomes. Patients and Methods: A retrospective review of a consecutive series of 24 patients who underwent placement of the modified stent from July 2013 to July 2018 was conducted. Twenty-five modified segmental stents were implanted. Data regarding technical success and complications were collected and analyzed. Results: Stent placement was successful in all patients with no perioperative procedure-related deaths. The median follow-up time was 10.3 months (interquartile range 6.3-23.5 months). Adjustment was required in 9 patients (37.5%) due to stent migration. The mean dysphagia scores before stenting and during follow-up were 3.6 ± 0.7 and 0.9 ± 1.6, respectively (P < .0001). Fifteen modified stents were removed due to complications or cure. Conclusion: Modified double-covered self-expandable segmental metallic stents are safe and effective for palliation of esophageal fistula.

Endoluminal Therapies for Esophageal Perforations and Leaks

Esophageal perforation has historically been a devastating condition resulting in high morbidity and mortality. The use of endoluminal therapies to treat esophageal leaks and perforations has grown exponentially over the last decade and offers many advantages over traditional surgical intervention in the appropriate circumstances. New interventional endoscopic techniques, including endoscopic clips, covered metal stents, and endoluminal vacuum therapy, have been developed over the last several years to manage esophageal perforation in an attempt to decrease the related morbidity and mortality.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

Patient Outcomes After Stent Failure for the Treatment of Acute Esophageal Perforation

BACKGROUND

Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients.

METHODS

Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed.

RESULTS

Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement.

CONCLUSIONS

Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis.

Endoscopic management of esophageal leaks

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.

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.

Naso-esophageal extraluminal drainage for postoperative anastomotic leak after thoracic esophagectomy for patients with esophageal cancer

Postoperative anastomotic leaks and subsequent mediastinal abscess are serious complications. The purpose of this study was to assess the efficacy of naso-esophageal extraluminal drainage after thoracic esophagectomy with gastric conduit reconstruction using a posterior mediastinal route. About 50 of 365 patients (13.7%) with esophageal cancer and postoperative anastomotic leak after curative esophagectomy was investigated. Beginning in June 2009, naso-esophageal extraluminal drainage by inserting a naso-esophageal aspiration tube into the abscess cavity when percutaneous abscess drainage was introduced which was ineffective or technically impossible. Twenty-five patients underwent naso-esophageal extraluminal drainage concomitantly with enteral nutrition. Twenty-one (84%) patients had major leaks, one (4%) minor leak and three (12%) had endoscopically proven conduit necrosis. None of the naso-esophageal extraluminal drainage cases (100%) required reintervention or reoperation and all experienced complete cure (100%) during hospitalization. Endoscopic balloon dilatation was performed for four patients after discharge because of anastomotic stricture. Patients with leaks were divided into two groups: current group (n = 32), treated after June 2009, and preceding group (n = 18), treated prior to the introduction of naso-esophageal extraluminal drainage. Significantly more patients in the preceding group suffered respiratory failure (28% vs. 61%, p = 0.024), and higher reoperation rate (0% vs. 17%, p = 0.042) and hospital mortality (0% vs. 22%, p = 0.013). In the current group, 31 (97%) patients experienced complete cure during hospitalization. Naso-esophageal extraluminal drainage and concomitant enteral nutritional support are less invasive, and effective and powerful methods to treat even major leakage after esophagectomy. These methods may be an alternative management to improve mortality for patients with esophageal cancer.

Fully covered metal stents for the treatment of leaks after gastric and esophageal surgery

OBJECTIVE

The use of fully covered metal stents (FCMS) for the treatment of benign conditions is increasing. The aim of our study was to assess the efficacy of FCMS in the management of post-operative leaks after gastric or esophageal surgery.

MATERIAL AND METHODS

During a three year period (2011-2013), patients who underwent a surgery related with esophageal or gastric cancer and developed a postoperative anastomotic leak treated with FCMS were prospectively included.

RESULTS

Fourteen patients were included (11 men, 3 women), with median age of 65 years. Placement of at least one stent was achieved in 13 patients (93% of cases), with initial closure of the leak in 12 of these 13 cases (92.3%). A final success (after removal of the stent) could be demonstrated in 9 cases (69.2%, intention to treat analysis); stent failed only in one case (7.7%) and there were 3 patients (23.1%) not evaluated because death before stent retrieval (not related with the endoscopic procedure). One stent were used in 9 cases (69.2%), and two in 4 (30.8%). Migration was observed in two cases (15.3%). There were no major complications related with the use of stents. There were no complications related with retrieval.

CONCLUSIONS

The placement of FCMS to achieve the leak closure after esophageal or gastric surgery is an effective and probably safe alternative feasible with minor risks.

Management and outcome of cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer

The aim of this study was to evaluate management strategies and related outcomes for cervical versus intrathoracic manifestation of cervical anastomotic leakage after transthoracic esophagectomy for cancer with gastric conduit reconstruction. Patients with esophageal cancer undergoing transthoracic esophagectomy with cervical anastomosis from October 2003 to December 2014 were identified from a prospectively acquired database. Management strategies and related outcomes among patients with anastomotic leakage confined to the neck were compared to patients with intrathoracic manifestation of anastomotic leakage. From a total of 286 patients, leakage of the cervical anastomosis occurred in 60 patients (21%) at a median time of 7 days after esophagectomy. Leakage was confined to the neck in 23 of 60 patients (38%), whereas 37 of 60 patients (62%) presented with intrathoracic spread. Leakages with intrathoracic manifestation were more frequently accompanied by a positive SIRS score compared to leakages confined to the neck (73% vs. 35%, respectively; P = 0.004). Drainage of the anastomotic leakage through the neck wound was effective in all of 23 patients (100%) with cervical manifestation. In patients with intrathoracic manifestation, mediastinal drainage through the neck was successful in 15 of 37 patients (41%), whereas 22 patients (59%) required an intervention through the thoracic cavity. Compared to patients with leakage confined to the neck, patients with intrathoracic manifestation showed prolonged intensive care unit (ICU) stay (median 6 vs. 2 days, respectively; P = 0.001), hospital stay (median 34 vs. 19 days, respectively; P < 0.001), and time to oral intake (32 vs. 23 days, respectively; P = 0.018). Intrathoracic manifestation of cervical anastomotic leakage occurs in more than half of patients with anastomotic leakage after transthoracic esophagectomy for cancer. A SIRS reaction should raise the suspicion of intrathoracic spread of leakage. Intrathoracic manifestation can be managed effectively by mediastinal drainage through the neck in 41% of patients, but a reintervention through the thoracic cavity is required in 59%. Intrathoracic manifestation of leakage results in prolonged ICU/hospital stay and delays time to oral intake compared with leakage confined to the neck.

Efficacy of the endoscopic management of postoperative fistulas of leakages after esophageal surgery for cancer: a retrospective series

BACKGROUND AND AIMS

Anastomotic leakages are severe and often lethal adverse events of surgery for esophageal cancer. The endoscopic treatment is growing up in such indications. The aim was to evaluate the efficacy and describe the strategy of the endoscopic management of anastomotic leakages/fistulas after esophageal oncologic surgery.

METHODS

Single-center retrospective study on 126 patients operated for esophageal carcinomas between 2010 and 2014. Thirty-five patients with postoperative fistulas/leakages (27 %) were endoscopically managed and included. The primary endpoint was the efficacy of the endoscopic treatment. The secondary endpoints were: delays between surgery, diagnosis, endoscopy and recovery; number of procedures; material used; and adverse events rate. Uni- and multivariate analyses were carried out to determine predictive factors of success.

RESULTS

There were mostly men, with a median age of 61.7 years ± 8.9 [43-85]. 48.6 % underwent Lewis-Santy surgery and 45.7 % Akiyama's. 71.4 % patients received neo-adjuvant chemo-radiation therapy. The primary and secondary efficacy was 48.6 and 68.6 %, respectively. The delay between surgery and endoscopy was 8.5 days [6.00-18.25]. Eighty-eight percentages of the patients were treated using double-type metallic stents, with removability and migration rates of 100 and 18 %, respectively. In the other cases, we used over-the-scope clips, naso-cystic drain or combined approach. The mean number of endoscopy was 2.6 ± 1.57 [1-10]. The mortality rate was 17 %, none being related to procedures. No predictive factor of efficacy could be identified.

CONCLUSIONS

The endoscopic management of leakages or fistulas after esophageal surgery reached an efficacy rate of 68.8 %, mostly using stents, without significant adverse events. The mortality rate could be decreased from 40-100 to 17 %.

Removable self-expanding metal stents insertion for the treatment of perforations and postoperative leaks of the esophagus

BACKGROUND

Esophageal rupture, spontaneous or iatrogenic, is associated with significant morbidity and mortality. The current study aims at highlighting the various clinical scenarios, where esophageal fully covered self-expanding removable metal stents (FCSEMS) can be used in esophageal rupture.

METHODS

In patients who underwent insertion of FCSEMS between January 2013 and June 2014, all data regarding demographics, indications, insertion, removal, and outcomes were studied retrospectively.

RESULTS

Seven patients underwent the placement of esophageal covered SEMS. Two patients had Boerhaave syndrome, two had leak following the repair of aortic aneurysm, one had extensive esophageal injury following transesophageal echocardiography, one had carcinoma esophagus with tracheaesophageal fistula, and one had dehiscence of esophagogastric anastomosis. Stent insertion was successful in all the patients; one had stent migration which was managed endoscopically. Two patients died due to underlying illness; the rest had successful removal of stents after 8-10 weeks and good outcomes.

CONCLUSION

Esophageal FCSEMS placement is safe and effective modality in management of patients with esophageal rupture.

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.

Choice of therapeutic strategies in intrathoracic anastomotic leak following esophagectomy

Background

The aim of this study was to analyze our experience with management of intrathoracic anastomotic leak after esophagectomy.

Methods

Clinical data from 33 patients who developed intrathoracic anastomotic leak were evaluated retrospectively. These patients were selected from 1867 patients undergoing resection carcinoma of the esophagus and reconstruction between January 2003 and December 2012.

Results

Surgical intervention and the reformed “three-tube method” were applied in 13 and 20 patients, respectively. The overall incidence of intrathoracic anastomotic leakage was 1.8%. The median time interval from esophagectomy to diagnosis of leak was 9.7 days. Sixteen patients were confirmed as having leakage by oral contrast computed tomography (CT). Age and interval from surgery to diagnosis of leak were identified as statistically significant parameters between contained and uncontained groups. Moreover, patients with hypoalbuminemia had a longer time to leak closure than patients without hypoalbuminemia. Six patients died from intrathoracic anastomotic leak, with a mortality rate of 18.2%. There was no statistically significant difference in the time to leak closure between patients who underwent surgical exploration and those who received conservative treatment.

Conclusions

Intrathoracic anastomotic leak after esophagectomy was associated with significant mortality. Once intrathoracic anastomotic leakage following esophagectomy was diagnosed or highly suspected, individualized management strategies should be implemented according to the size of the leak, extent of the abscess, and status of the patient. In the majority of patients with anastomotic leak, we preferred the strategy of conservative treatment.

Improving the outcomes in gastric cancer surgery

Gastric cancer remains a significant health problem worldwide and surgery is currently the only potentially curative treatment option. Gastric cancer surgery is generally considered to be high risk surgery and five-year survival rates are poor, therefore a continuous strive to improve outcomes for these patients is warranted. Fortunately, in the last decades several potential advances have been introduced that intervene at various stages of the treatment process. This review provides an overview of methods implemented in pre-, intra- and postoperative stage of gastric cancer surgery to improve outcome. Better preoperative risk assessment using comorbidity index (e.g., Charlson comorbidity index), assessment of nutritional status (e.g., short nutritional assessment questionnaire, nutritional risk screening - 2002) and frailty assessment (Groningen frailty indicator, Edmonton frail scale, Hopkins frailty) was introduced. Also preoperative optimization of patients using prehabilitation has future potential. Implementation of fast-track or enhanced recovery after surgery programs is showing promising results, although future studies have to determine what the exact optimal strategy is. Introduction of laparoscopic surgery has shown improvement of results as well as optimization of lymph node dissection. Hyperthermic intraperitoneal chemotherapy has not shown to be beneficial in peritoneal metastatic disease thus far. Advances in postoperative care include optimal timing of oral diet, which has been shown to reduce hospital stay. In general, hospital volume, i.e., centralization, and clinical audits might further improve the outcome in gastric cancer surgery. In conclusion, progress has been made in improving the surgical treatment of gastric cancer. However, gastric cancer treatment is high risk surgery and many areas for future research remain.

Self-expandable metal stent placement for closure of a leak after total gastrectomy for gastric cancer: report on three cases and review of the literature

In the setting of the curative oncological surgery, the gastric surgery is exposed to complicated upper gastrointestinal leaks, and consequently the management of this problem has become more critically focused than was previously possible. We report here three cases of placement of a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, NC, USA) in patients who underwent total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric adenocarcinoma. The promising results of our report, despite the small number of patients, suggest that early stenting (through a partially silicone-coated SEMS) is a feasible alternative to surgical treatment in this subset of patients. In fact, in the treatment of leakage after total gastrectomy, plastic stents and totally covered metallic stents may not adhere sufficiently to the esophagojejunal walls and, as a result, migrate beyond the anastomosis. However, prospective studies with a larger number of patients might assess the real effectiveness and safety of this procedure.

The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations

OBJECTIVE

The aim of this review was to assess the safety and effectiveness of esophageal stents in the management of benign esophageal perforation and in the management of esophageal anastomotic leaks.

BACKGROUND

Benign esophageal perforation and postoperative esophageal anastomotic leak are often encountered. Endoscopic placement of esophageal stent across the site of leakage might help control the sepsis and reduce the mortality and morbidity.

METHODS

All the published case series reporting the use of metallic and plastic stents in the management of postoperative anastomotic leaks, spontaneous esophageal perforations, and iatrogenic esophageal perforations were identified from MEDLINE, EMBASE, and PubMed (1990-2012). Primary outcomes assessed were technical success rates and complete healing rates. Secondary outcomes assessed were stent migration rates, stent perforation rates, duration of hospital stay, time to stent removal, and mortality rates. A pooled analysis was performed and subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.

RESULTS

A total of 27 case series with 340 patients were included. Technical and clinical success rates of stenting were 91% and 81%, respectively. Stent migration rates were significantly higher with plastic stents than with metallic stents (40/148 vs 13/117 patients, respectively; P = 0.001). Patients with metallic stents had significantly higher incidence of postprocedure strictures (P = 0.006). However, patients with plastic stents needed significantly higher number of reinterventions (P = 0.005). Mean postprocedure hospital stay varied from 8 days to 51 days. There was no significant difference in the primary or secondary outcomes when stenting was performed for anastomotic leaks or perforations.

CONCLUSIONS

Endoscopic management of esophageal anastomotic leaks and perforations with the use of esophageal stents is technically feasible. It seems to be safe and effective when performed along with mediastinal or pleural drainage. Esophageal stent can, therefore, be considered as a treatment option in the management of patients who present early after esophageal perforation or anastomotic leak with limited mediastinal or pleural contamination.

The role of esophageal stent placement in the management of postesophagectomy anastomotic leak

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.

The role of esophageal stent placement in the management of postesophagectomy anastomotic leak

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.

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.

Self-expanding metal stents or nonstent endoscopic therapy: which is better for anastomotic leaks after total gastrectomy?

BACKGROUND

Anastomotic leaks are a life-threatening complication of gastrectomies with high mortality after surgical reintervention. Endoscopic therapy using fibrin glue injection, endoclip, and other devices is an alternative to surgical intervention for anastomotic leaks. Recently, self-expanding metal stents (SEMS) were introduced to treat anastomotic leaks. The purpose of this study was to assess the clinical characteristics and therapeutic outcomes of SEMS and nonstent endoscopic therapy (NSET) for treatment of anastomotic leaks after total gastrectomy with the aim of assisting endoscopists in choosing a treatment method.

METHODS

Between July 2002 and March 2013, 13 patients treated with SEMS and 14 patients treated with NSET for anastomotic leaks after total gastrectomy were enrolled onto the study. Enrolled patients received 16 SEMS placement sessions and 21 NSET sessions.

RESULTS

No significant differences in baseline characteristics or clinical characteristics related to leakage were detected in patients with SEMS compared to NSET. The successful sealing rate at the first attempt by SEMS was significantly better than that of NSET (80.0 vs. 28.6 %, P = 0.036), whereas the successful sealing rate after multiple endoscopic treatments was not statistically different (80.0 vs. 64.3 %, P = 0.653). The main reason for reintervention with SEMS was complications and with NSET was nonseal (P = 0.004). Clinical outcomes including length of hospital stay, endoscopic treatment-related mortality, and all-cause mortality were not significantly different between the 2 groups.

CONCLUSIONS

In terms of efficacy by single effort, SEMS was superior to other methods for treating anastomotic leaks after total gastrectomy. However, complications with SEMS should be considered when choosing an endoscopic treatment method.

Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas

PURPOSE

The purpose of this study is to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks that seen after total gastrectomy-esophagojejunostomy (EJ) operations.

MATERIALS AND METHODS

Contrast radiography and endoscopy revealed EJ fistulas in 14 patients. SECMSs were implanted both fluoroscopically and endoscopically to seal fistulas. Postoperative fistula diagnosis times, postoperative covered stent implantation times, primary success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, procedure-related mortality-morbidity, and mortality related with factors other than the procedure were noted.

RESULTS

Technical success rate was 100 %. Clinical success rate was 79 %. Reduction of the fluid from surgical drains was observed in all patients. There were no procedure-related mortality. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. In one patient (7 %), stent dislocation was observed at the 10th day after the intervention. Non procedure-related mortality was 21 %. No anastomotic stricture, no in-stent stenosis was observed during the follow up period(11.09 ± 3.21 months).

CONCLUSION

From the above results we concluded that SECMS treatment for EJ fistulas is a safe, effective and technically easy procedure.

Comparison of clinical outcomes after conservative and surgical treatment of isolated anastomotic leaks after esophagectomy for esophageal cancer

The clinical course and outcome of isolated anastomotic leaks (IALs) after esophagectomy are significantly different from those of necrotic leaks. The purpose of this study was to investigate the clinical features, diagnosis, treatment, and long-term outcome in patients with IALs after esophagectomy with reconstruction for esophageal cancer. A total of 663 patients underwent esophagectomy with esophageal reconstruction because of esophageal cancer between 2000 and 2010 at the Seoul Asan Medical Center. IALs occurred in 23 patients (3.5%). All patients with IAL were male, with a median age of 61 years. Patients with IAL were divided into three groups based on their clinical course. group A comprised patients who had definite clinical symptoms and/or signs indicating mediastinal contamination or leak before routine contrast esophagography was performed. Groups B and C comprised patients who had no definite clinical symptoms and/or signs of leaks before the routine contrast examination. Furthermore, group B contained those patients who resumed oral intake because no leak was found in the routine contrast examination and was diagnosed some days after resuming oral intake. Group C contained those patients who kept fasting because the leak was found in the routine contrast examination. The median follow-up period was 30 months. The mean time to closure of the IAL was 70.1 ± 96.0 days (range 4-364). There was a 72.7% overall closure rate within 60 days. By univariate analysis, the mean time to closure of the IAL was found to be significantly longer for group A patients or in cases where the patients had an uncontained leak, leukocytosis, or empyema. However, there was no statistically significant differences in age, neoadjuvant treatment, site of anastomosis (cervical vs. thoracic), fever, or treatment of the leak. By multivariate analysis, group A was found to be an independent predictive factor for the time to closure of the IAL. Repeat contrast studies revealed no anastomotic leaks in 18 patients and the formation of contained fistula in four cases (excluding one patient who died in hospital). The four patients with a contained fistula showed no clinical symptoms or signs, and tolerated resumed oral intake. IALs were resolved in most cases with low leak-related mortality, and resolution of the leaks occurred within 2 months in the majority of patients.

[Endoscopic vacuum-assisted closure]

Anastomotic leakage in the upper and lower intestinal tract is associated with high morbidity and mortality. Within the last 10 years endoscopic treatment options have been accepted as sufficient treatment option of these surgical complications. Endoscopic vacuum assisted closure (E-VAC) is a new innovative endoscopic therapeutic option in this field. E-VAC transfers the positive effects of vacuum assisted closure (VAC) on infected cutaneous wounds to infected cavities that can only be reached endoscopically. A sponge connected to a drainage tube is endoscopically placed in the leakage and a continuous vacuum is applied. Sponge and vacuum allow removal of infected fluids and promote granulation of the leakage. This results in clean wound grounds and finally allows wound closure. Meanwhile the method was also successfully used in the treatment of necrotic pancreatitis.

The Over-The-Scope-Clip (OTSC) system is effective in the treatment of chronic esophagojejunal anastomotic leakage

INTRODUCTION

Management of postoperative esophagojejunal anastomotic leakage after total gastrectomy represents a very challenging event. Surgical repair is difficult, and conservative treatment can predispose to more severe complications. Endoclips and self-expanding stents are useful endoscopic therapeutic options but present some drawbacks. The Over-The-Scope-Clip (OTSC) system has been shown to be appropriate to close acute small gastrointestinal perforations, but its use in the treatment of chronic leakage remains controversial.

CASE SERIES

The present series reports three consecutive chronic esophagojejunal anastomotic leaks successfully treated with OTSC. In all cases, clip application was simple, safe and effective, without early and late complications.

DISCUSSION

The OTSC system may represent a new therapeutic option in the management of postoperative esophagojejunal anastomotic leakage.

Outcome and complications of long-term self-expanding esophageal stenting

Esophageal stenting with self-expanding plastic or covered metal stents is believed to be safe and effective. As data on the outcome of patients with long-term stenting are not available, this study was conducted to evaluate the safety and efficacy of long-term esophageal stenting. From 2002 to 2008, 70 patients with long-term esophageal stenting for various indications from a prospective database were included into further analysis. The median stent period was 297 (124-1980) days during a mean follow-up time of 55 ± 52.4 months. Overall complication rate was 30% with a primary success rate of 97.2%. The stent-related total reintervention rate was 17.1%. There were no correlations between stent characteristics and the risk of complication or migration. No stent-related death was observed. Our data provide evidence that long-period esophageal stenting is safe and effective for various indications.

The use of self-expanding plastic stents in the management of oesophageal leaks and spontaneous oesophageal perforations

Leakage after oesophageal anastomosis or perforation remains a challenge for the surgeon. Traditional management has been operative repair or intensive conservative management. Both treatments are associated with prolonged hospitalisation and high morbidity and mortality rates. Self-expanding metallic stents have played an important role in the palliation of malignant oesophageal strictures and the treatment of tracheoesophageal fistulae. However, self-expanding metal stents in benign oesophageal disease are associated with complications such as bleeding, food bolus impaction, stent migration, and difficulty in retrieval. The Polyflex stent is the only commercially available self-expanding plastic stent which has been used in the management of malignant oesophageal strictures with good results. This review will consider the literature concerning the use of self-expanding plastic stents in the treatment of oesophageal anastomotic leakage and spontaneous perforations of the oesophagus.

Endoscopic removal of self-expandable metal stents from the esophagus (with video)

BACKGROUND

Self-expandable metals stents (SEMSs) have increasingly been used as a temporary device to bridge chemoradiotherapy in patients with malignant esophageal disease or in patients with benign esophageal defects or stenosis.

OBJECTIVE

To evaluate the outcome of removal of SEMSs in a large cohort of patients with benign and malignant esophageal disease.

DESIGN

Observational study with standardized treatment and follow-up.

SETTING

Single university center.

PATIENTS

Between 2001 and 2010, 95 consecutive patients referred for endoscopic SEMS extraction were included.

INTERVENTIONS

Endoscopic stent removal.

MAIN OUTCOME MEASUREMENTS

Technical and functional outcome and complications.

RESULTS

A total of 124 stent extractions were undertaken in 95 patients; both partially covered (68%) and fully covered (32%) SEMSs were removed. Three patients had 2 overlapping SEMSs in place. Successful primary removal was achieved in 89%; the secondary removal rate was 96%. Uncomplicated primary removal rate was significantly higher for fully covered versus partially covered stents (P = .035) and for single versus overlapping stents (P = .033). Patients with a complicated stent removal had the stent in place significantly longer compared with patients with an uncomplicated primary stent removal (126 days vs 28 days; P = .01). Surgical removal was required in 3 patients (2.4%). Six moderate and severe complications (5%) related to the endoscopic extraction occurred.

LIMITATIONS

Retrospective, nonrandomized study design.

CONCLUSIONS

Primary endoscopic removal of an SEMS is feasible in the majority of patients with benign and malignant esophageal disease. A longer time that a stent is in place and the use of partially covered SEMSs both impede removal. Moreover, overlapping SEMSs should be avoided for temporary use because stent disintegration and subsequent complications may occur.

Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus

BACKGROUND

Placement of self-expanding metal stents (SEMS) or plastic stents (SEPS) has emerged as a minimally invasive treatment option for benign oesophageal ruptures and leaks; however, it is not clear which stent type should be preferred.

AIM

To assess clinical effectiveness and safety of treating benign oesophageal ruptures and anastomotic leaks with temporary placement of a stent with special emphasis on different stent designs.

METHODS

A pooled analysis was performed after searching PubMed and EMBASE databases for studies regarding placement of fully covered and partially covered SEMS (FSEMS and PSEMS) and SEPS for this indication. Data were pooled and evaluated for clinical outcome, complications and survival.

RESULTS

Twenty-five studies, including 267 patients with complete follow-up on outcome, were identified. Clinical success was achieved in 85% of patients and was not different between stent types (SEPS 84%, FSEMS 85% and PSEMS 86%, P = 0.97). Time of stent placement was longest for SEPS (8 weeks) followed by FSEMS and PSEMS (both 6 weeks). In total, 65 (34%) patients had a stent-related complication. Stent migration occurred more often with SEPS [n = 47 (31%)] and FSEMS [n = 7 (26%)] than with PSEMS [n = 2 (12%), P ≤ 0.001], whereas there was no significant difference in tissue in- and overgrowth between PSEMS [12% vs. 7% (FSEMS) and 3% (SEPS), P = 0.68].

CONCLUSIONS

Although there is a lack of randomised controlled trials, it seems that covered stent placement for a period of 6-8 weeks is safe and effective for benign oesophageal ruptures and anastomotic leaks to heal. As efficacy between different stent types is not significantly different, stent choice should depend on expected risk of stent migration (self-expanding plastic stents and fully covered self-expanding metal stents) and, to a minor degree, on expected risk of tissue in- or overgrowth (partially covered self-expanding metal stents).

Management of esophageal perforation and anastomotic leak by transluminal drainage

INTRODUCTION

The management of esophageal perforations and leaks remains a challenge. Although there are broad management principles, each situation may require a different surgical approach. The aim of this report was to describe the management of these esophageal crises by transluminal drainage via a transabdominal approach.

METHODS

Between 2005 and 2009, patients with anastomotic or gastric staple line leak (n = 4) or esophageal perforation (n = 2) underwent transabdominal surgery and transluminal drainage. This simple technique has, to the best of our knowledge, not been previously reported.

RESULTS

All six patients survived. The median intensive care unit and hospital stays were 12 days (range 0-32) and 63 days (range 32-99), respectively. At a median follow-up time of 25 months (range 15-60), five of the six patients remain alive and well. One patient with node positive esophageal carcinoma has died from relapsed disease.

CONCLUSIONS

Transabdominal transluminal drainage should be added to the list of potential techniques that can be employed in management of esophageal leaks and perforations. It is a valuable adjunct to the armamentarium of the esophageal surgeon for dealing with these challenging situations.

Healing occurs in most patients that receive endoscopic stents for anastomotic leakage; dislocation remains a problem

BACKGROUND & AIMS

There is controversy about the best way to treat esophageal anastomotic leakage. We evaluated the effects of treatment with self-expanding metal stents in patients with esophageal anastomotic leakage after esophagectomy or gastrectomy for cancer.

METHODS

We investigated outcomes and procedure-related complications of 115 patients who received endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy at a university hospital from 2004 to 2009. We also performed a systematic literature review on stent therapy and compared outcomes with that of other treatment regimens for esophageal anastomotic leakage.

RESULTS

Among the 115 patients who received stents, the in-hospital mortality rate was 9% and complete anastomotic healing was achieved in 70% (95% confidence interval [CI], 64%-76%). Stent dislocation occurred in 53% of the patients (95% CI, 43%-62%), in all patients with esophagocolonostomy, in 61% with esophagojejunostomy, and in 49% with esophagogastrostomy. Three percent of patients (95% CI, 1%-5%) needed laparotomy to remove dislocated stents. Elective endoscopic stent removal was performed in 80% of the patients after a median of 54 days (range 17-427 d); 12% of these patients developed symptomatic anastomotic strictures after stent removal.

CONCLUSIONS

Anastomoses completely heal in 70% of patients that receive endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy. Stent therapy should be used in the management of patients with adequately perfused esophageal anastomotic leakage. However, stent dislocation remains a common problem after surgery.

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

OBJECTIVE

Esophageal anastomotic leaks, perforations, and fistulae are associated with considerable morbidity and mortality. The aim of the present study was to assess the efficacy of self-expanding plastic stents in the treatment of esophageal leaks.

METHODS

From 2001 to 2009, 41 patients with postoperative anastomotic leaks (n = 30), esophageal perforations (n = 6), or fistulae (n = 5) were treated by endoscopic insertion of self-expanding plastic stents. The clinical outcome of the patients was analyzed, including leak healing, morbidity, and mortality.

RESULTS

Self-expanding plastic stents were successfully inserted in all 41 patients without procedure-related complications. Non-ventilated patients received oral feeding an average of 3.9 days after stent placement. Complete leak healing was obtained in 27 of 30 patients (90%) with anastomotic leaks and 5 patients (83%) with perforation. Sealing of fistulae by the stents was achieved in all 5 patients, and closure of the fistula was observed in 2 patients (40%). The mean healing time was 30 days for anastomotic leaks, 15 days for esophageal perforations, and 16 days for fistulae. Stent migration occurred in 14 cases, but endoscopic reintervention and new stent placement were successful in all cases. In-hospital mortality after treatment of esophageal leaks with stents was 10%.

CONCLUSIONS

In combination with effective interventional or surgical drainage, stenting is a viable option for the treatment of esophageal anastomotic leaks and perforations, but the success in tracheoesophageal fistula is limited.

Palliation of malignant esophageal obstruction and fistulas with self expandable metallic stents

AIM: To evaluate the efficacy of self expandable metallic stents (SEMS) in patients with malignant esophageal obstruction and fistulas.

METHODS: SEMS were implanted in the presence of fluoroscopic guidance in patients suffering from advanced and non-resectable esophageal, cardiac and invasive lung cancer between 2002 and 2009. All procedures were performed under conscious sedation. All patients had esophagus obstruction and/or fistula. In all patients who required reintervention, recurrence of dysphagia, hemorrhage, and fistula formation were indications for further endoscopy. Patients’ files were scanned retrospectively and the obtained data were analyzed using SPSS 13.0 for Windows. The χ² test was used for categorical data and was analysis of variance for non-categorical data. Patients’ long-term survival was assessed using the Kaplan-Meier method.

RESULTS: Stents were successfully implanted in 90 patients using fluoroscopic guidance. Reasons for stent implantation in these patients were esophageal stricture (77/90, 85.5%), external pressure (8/90, 8.8%) and tracheo-esophageal fistula (5/90, 5.5%). Dysphagia scores (mean ± SD) were 3.37 ± 0.52 before and 0.90 ± 0.43 after stent implantation (P = 0.002). Intermittent, non-massive hemorrhage due to the erosion caused by the distal end of the stent in the stomach occurred in only one patient who received implementation at cardio-esophageal junction. Mean survival following stenting was 134.14 d (95% confidence interval: 94.06-174.21).

CONCLUSION: SEMS placement is safe and effective in the palliation of dysphagia in selected patients with malignant esophageal strictures.

Clip closure versus endoscopic suturing versus thoracoscopic repair of an iatrogenic esophageal perforation: a randomized, comparative, long-term survival study in a porcine model (with videos)

BACKGROUND

Esophageal full-thickness wall repair is an important but unsolved issue in endoscopy. It is unknown how well endoscopic clip closure (ECC) and endoscopic closure with suturing (ECS) perform compared with the criterion standard of thoracoscopic closure (TC).

OBJECTIVE

Comparison of technical success, feasibility, long-term patency, complications, and histological quality of the different closure techniques (ECC, ECS, TC) for esophageal perforations.

DESIGN

Comparative animal study.

SETTING

Approved animal facility.

SUBJECTS

Eighteen pigs.

INTERVENTIONS

Eighteen pigs were randomized, 6 each into 3 groups (ECC, ECS, TC). After endoscopic wall incision and mediastinoscopy, closure was performed by using 1 of the 3 techniques. After 8 to 12 weeks, pre-euthanasia endoscopic, necropsy, histological, and morphometric analyses were performed.

MAIN OUTCOME MEASUREMENT

Long-term survival and histological quality of the repair.

RESULTS

The closure of the esophageal incisions was successful in all pigs. On days 2 and 6, 1 animal died of mediastinitis, 1 in the ECS group because of reflux of gastric contents into the mediastinum before the repair and 1 in the TC group because of leakage of the sutured closure (P = 1.0). No strictures were seen on prenecropsy endoscopy. At necropsy, 1 mediastinal abscess was found in an ECS animal (P = 1.0). Minor complications included periesophageal adhesions and reactive lymph nodes in 3 of 6 (ECC group) and 5 of 6 (TC and ECS groups). Histology showed muscle layer defects up to 12 mm in width and 21 mm in length, with a trend toward smaller defect size of width and length in the ECS group of animals.

LIMITATIONS

Animal study of limited size.

CONCLUSIONS

Overall, ECS and ECC performed similarly to TC. ECS showed the smallest histological defects in the long-term repair.

Successful management of cervicoesophageal anastomosis leak after microsurgical esophageal reconstruction: a case report and review of the literature

Free visceral and, more recently, free fasciocutaneous flaps are becoming increasingly common for esophageal reconstruction. However, complications of free flap conduit ischemia, specifically anastomotic leak have not been frequently discussed in the literature. This article provides a detailed description of total esophageal reconstruction with an 18 x 8.5 cm tube free radial forearm flap. A clinically significant cervical anastomosis leak was contained and healed with an innovative surgical rearrangement of local muscle flaps and closed suction drainage. We discuss the literature associated with cervical anastomotic leaks after visceral reconstruction and adapt those principles to the unique physiology of free fasciocutaneous flaps to develop a simple but reliable salvage option. This approach should be considered by reconstructive surgeons when helping other surgeons to manage an anastomotic leak after a cervical esophageal reconstruction in a similar setting.

Self-Expandable Metal Stent for Closure of a Large Leak after Total Gastrectomy

In recent years, self-expandable metallic stents (SEMSs) have emerged as a promising treatment alternative for the bridging and sealing of esophageal perforations and extensive anastomotic leaks after esophageal resection or total gastrectomy. A 56-year-old woman underwent a total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric signet ring cell carcinoma. Ten days later, esophagogastroduodenoscopy showed a 2 cm fistula in the distal end of the Roux limb of the anastomosis. This was confirmed by gastrografin esophagography. The patient was started on total parenteral nutrition. Having deemed clipping treatment for this fistula unfeasible, we decided to insert a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, N.C., USA). The stent was removed after ten days. Gastrografin esophagography showed no further contrast extravasation, and esophagogastroduodenoscopy showed closure of the fistula. No clinical complications were observed, and the patient was able to start normal per os nutrition. In conclusion, the treatment of symptomatic leaks in patients who have undergone esophagojejunostomy is challenging, and leakage from the jejunal stump can be a potentially serious complication. In the treatment of leakage after total gastrectomy, plastic stents (which are either too light or exercise too little radial force) and totally covered metallic stents may not adhere sufficiently to the esophagojeujunal walls and, as a result, migrate beyond the anastomosis. The promising results of this report suggest that early stenting, using a partially silicone-coated SEMS, is a feasible alternative to surgical treatment in this category of patients.