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

Self-expanding metal stents in postoperative esophageal leaks

BACKGROUND

Postoperative esophageal leaks have a high morbidity and mortality. Self-expanding metal stents (SEMS) have been used as an alternative to re-operation.

AIM

Evaluating predictors of success of SEMS in postoperative esophageal leaks.

METHODS

Retrospective study of patients with postoperative esophageal leaks referred for SEMS placement in a reference center during a period of 3 years. Technical success was defined as closure of the leak in barium swallow at 15 days. Clinical success was considered as endoscopic and/or radiographic confirmation of closure after stent removal.

RESULTS

Thirteen patients placed SEMS. Median follow-up was 58 days. Leaks had a median size of 20 mm. Time between surgery and SEMS placement was 20 days. One patient died 2 days after SEMS placement and one had worsening of the fistula after SEMS expansion. Time till stent migration was 9 days. Technical success was achieved in 9 of 11 patients, with clinical success without recurrence in 5 patients. All leaks with less than 20 mm were solved endoscopically. Technical and clinical success was higher when time between surgery and SEMS placement was lower, even though without statistical significance (respectively, p = 0.228 and 0.374). In the 8 patients who died during follow-up, median survival was 59 days.

CONCLUSIONS

Technical success of SEMS was higher than 80%; however, due to high morbidity and mortality, only 45% of patients had their stent removed. Lower time from diagnosis to SEMS placement and leak size less than 20 mm may be associated with better results.

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.

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue

OBJECTIVES

To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments.

METHODS

Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection.

RESULTS

In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient.

CONCLUSIONS

Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Outcome of stent grafting for esophageal perforations: single-center experience

BACKGROUND

Recent studies showed that stent grafting is a promising technique for treatment of esophageal perforation. However, the evidence of its benefits is still scarce.

METHODS

Forty-three consecutive patients underwent stent grafting for esophageal perforation at the Oulu University Hospital, Finland. The main endpoints of this study were early and mid-term mortality. Secondary outcome endpoints were the need of esophagectomy and additional surgical procedures on the esophagus and extraesophageal structures.

RESULTS

Patients' mean age was 64.6 ± 13.4 years. The mean delay to primary treatment was 23 ± 27 h. The most frequent cause of perforation was Boerhaave's syndrome (46.5%). The thoraco-abdominal segment of the esophagus was affected in 58.1% of cases. Minor primary procedures were performed in 25 patients (58.1%) and repeat surgical procedures in 23 patients (53.5%). Forty-nine repeat stent graftings were performed in 22 patients (50%). Two patients (4.7%) underwent esophagectomy, one for unrelenting preprocedural stricture of the esophagus and another for persistent leakage of a perforated esophageal carcinoma. The mean length of stay in the intensive care unit was 6.0 ± 7.5 days and the in-hospital stay was 24.3 ± 19.6 days. In-hospital mortality was 4.6%. Three-year survival was 67.2%.

CONCLUSIONS

Stent grafting seems to be an effective less invasive technique for the treatment of esophageal perforation. Repeat stent grafting and procedures on the pleural spaces are often needed to control the site of perforation and for debridement of surrounding infected structures. Stent grafting allows the preservation of the esophagus in most of patients. The mid-term survival of these patients is suboptimal and requires further investigation.

Self-expanding plastic stent for esophageal leaks and fistulae

BACKGROUND

Self-expanding plastic stents (SEPS) have emerged as a good alternative to surgery in esophageal leaks and fistulae. There is scarce published literature regarding its efficacy in these conditions. We present our experience with SEPS in treatment of esophageal leaks and fistulae.

METHODS

Consecutive patients admitted in a tertiary referral center who underwent SEPS placement for esophageal leak or fistula between February 2012 and February 2015 were retrospectively evaluated. Patients underwent prior assessment with upper gastrointestinal endoscopic and thoracic contrast-enhanced computed tomography assessment. SEPS (25-mm flares, 21-mm diameter) were placed under fluoroscopic guidance. A silk thread tied to upper end was routed through nostril and fixed to prevent stent migration. Nasojejunal tube was inserted in all patients. Intercostal drain was inserted in the case of hydro/pyopneumothorax.

RESULTS

Twelve patients [eight male, median age 45.3 years (19 to 65 years)] were included. Etiologies were spontaneous leaks due to Boerhaave syndrome (n = 2), corrosive fistulae (n = 2), tubercular fistulae (n = 4), invasive Candida esophagitis-induced fistula (n = 1), iatrogenic leaks (n = 2; one achalasia dilatation, one obesity surgery), and pancreaticoesophageal fistula due to ruptured pancreatic pseudocyst (n = 1). Stent placement was successful in all patients with no immediate postprocedure complications. Successful healing was seen in nine patients (75 %). Stents were removed after a median time of 83.5 days (13-190 days). Stent migration was seen in four patients (33.3 %), and in two of them, it was retrieved and redeployed; none had early migration (<72 h). Reasons for SEPS failure in our cohort were failure of effective sepsis control in two patients and poor wound healing seen in one patient having multiple tubercular fistulae.

CONCLUSION

SEPS is a safe, well-tolerated treatment with good success rate (75 %) in treatment of esophageal leaks and fistulae.

Update on Enteral Stents

The recent advances in enteral stents design and composition introduced novel usage and indications, heading to a continuous addition of prostheses application in clinical practice. Since the first use to palliate malignant diseases, improving patient's quality of life, in the last decades we assisted to a large spread, often becoming a first choice treatment in GI disorders. Indeed, the clinical indication of gastrointestinal stents includes endoscopic treatment of fistula and leaks besides the well-established role of restoring lumen patency in benign and malignant conditions. Several different kind of stents have been developed, each one with its own characteristics and benefits, including self-expandable plastic and metal stents, available as uncovered, partially covered, and fully covered as well as biodegradable stents. Recently, new drug-eluting stents, working both as palliative treatment and as local chemotherapy, are under evaluation. This review aims to critically evaluate the most recently published literature about enteral stents and to address endoscopists' choice for a better patient management.

Management and outcomes of anastomotic leaks after oesophagectomy

BACKGROUND

Leaks following oesophagectomy include true anastomotic leaks, leaks from the gastrotomy and gastric conduit necrosis. Historically, these complications were associated with high mortality rates. Recent improvements in outcome have been attributed to the wider use of oesophageal stents in patient management. This study examined outcomes of patients who developed a leak in a single high-volume institution that did not use stenting as a primary treatment modality.

METHODS

All patients undergoing an oesophagectomy between January 2009 and December 2013 were included. Patients were identified from a prospectively maintained database.

RESULTS

A total of 390 oesophagectomies were performed (median age 65 (range 32-81) years). In 96·7 per cent of patients this was a two-stage subtotal oesophagectomy. Overall in-hospital and 90-day mortality rates were both 2·1 per cent (8 patients). Some 31 patients (7·9 per cent) developed a leak (median age 64·5 (range 52-80) years), of whom 27 (87 per cent) were initially managed without surgery, whereas four (13 per cent) required immediate thoracotomy. The median length of stay for patients with a leak was 41·5 (range 15-159) days; none of these patients died.

CONCLUSION

Leaks can be managed with excellent outcomes without using oesophageal stents. The results do not support the widespread adoption of endoscopic stenting.

A Newly Designed Enterocutaneous Esophageal Fistula Model in the Pig

Background Fistulas after esophagectomy are a significant cause of morbidity and mortality. Several endoscopic treatments have been attempted, with varying success. An experimental model that could validate new approaches such as cellular therapies is highly desirable. The aim of this study was to create a chronic esophageal enterocutaneous fistula model in order to study future experimental treatment options. Methods Eight pigs (six 35-kg young German and two 50-kg adult Yucatan pigs) were used. Through a left and right cervicotomy, under endoscopic view, 1 (group A, n = 6) or 2 (group B, n = 7) plastic catheters were introduced into the esophagus 30 cm from the dental arches bilaterally and left in place for 1 month. Radiologic and endoscopic fistula tract evaluations were performed at postoperative day (POD; 30) and at sacrifice (POD 45). Results Three fistulas were excluded from the study because of early (POD 5) dislodgment of the catheter, with complete fistula closure. At catheter removal (POD 30), the external orifice was larger in group B (5.2 ± 1.1 mm vs 2.6 ± 0.4 mm) with more severe inflammation (72% vs 33%). At POD 45, the external orifice was closed in all fistulas in group A and in 1/7 in group B. At necropsy, the fistula tract was still present in all animals. Yucatan pigs showed more complex tracts, with a high level of necrosis and substantial fibrotic infiltration. Conclusions In this article, we show a reproducible, safe, and effective technique to create an esophagocutaneous fistula model in a large experimental animal.

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.

Endoscopic modalities for upper gastrointestinal leaks, fistulae and perforations

Background

Endotherapy techniques are a recent addition to the suite of non‐surgical and minimally invasive strategies to manage patients with perforations, leaks and fistulae. The emergency nature of these conditions and the heterogeneity of pathologies encountered create difficulties when trying to select appropriate tools in these complex situations. The purpose of this article is to review experience at a tertiary academic centre, describe the various endoscopic tools available and the situations where they can be considered for use.

Methods

Single‐centre series and review of the published literature.

Results

Of 64 patients, 57 were successfully treated using endoscopic therapy, with surgery used only to provide drainage and suture fully covered metal stents in place to prevent migration.

Discussion

Selection of an appropriate endotherapy or stent for a patient with an oesophago‐gastric perforation or fistula requires an understanding of the anatomy and physiology underlying the patient's presentation and an understanding of the strengths and weaknesses of the available methods. Standard surgical principles of drainage, avoidance of distal obstruction and nutrition remain central to successful outcomes. A combination of surgical and endoscopic treatments may reduce the number of required treatments and can provide the ability to anchor fully covered stents to prevent them from migrating.

Endoscopic management of gastrointestinal perforations, leaks and fistulas

Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size, location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment. However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.

Endoscopic Management of Gastrointestinal Leaks and Fistulae

Gastrointestinal leaks and fistulae can be serious acute complications or chronic morbid conditions resulting from inflammatory, malignant, or postsurgical states. Endoscopic closure of gastrointestinal leaks and fistulae represents major progress in the treatment of patients with these complex presentations. The main goal of endoscopic therapy is the interruption of the flow of luminal contents across a gastrointestinal defect. In consideration of the proper endoscopic approach to luminal closure, several basic principles must be considered. Undrained cavities and fluid collections must often first be drained percutaneously, and the percutaneous drain provides an important measure of safety for subsequent endoscopic luminal manipulations. The size and exact location of the leak/fistula, as well as the viability of the surrounding tissue, must be defined. Almost all complex leaks and fistulae must be approached in a multidisciplinary manner, collaborating with colleagues in nutrition, radiology, and surgery. Currently, gastrointestinal leaks and fistulae may be managed endoscopically by using 1 or more of the following modalities: stent placement, clip closure (including through-the-scope clips and over-the-scope devices), endoscopic suturing, and the injection of tissue sealants. In this article, we discuss these modalities and review the published outcomes data regarding each approach as well as practical considerations for successful closure of luminal defects.

Predictors of Successful Endoscopic Closure of Gastrointestinal Defects: Experience from a Single Tertiary Care Center

BACKGROUND/AIMS

Endoscopic closure is technically feasible in the majority of gastrointestinal defects. The aim of this study is to evaluate the technical and clinical outcomes, and identify variables predicting successful outcomes in patients with attempted closure.

METHODS

This is a retrospective study of patients undergoing endoscopic closure of gastrointestinal defects between December 2007 and May 2013 at a single tertiary care center. Technical success (TS) was defined as successful closure of the defect at the time of endoscopy. Clinical improvement (CI) was defined as improvement in symptoms. Clinical resolution (CR) was defined as documented radiographic closure of defect or clinical resolution of symptoms. Acute defects were diagnosed within 6 weeks, while chronic defects were those that persisted for >6 weeks, prior to index therapeutic endoscopy.

RESULTS

Fifty patients underwent 77 endoscopies for leaks (n = 23), fistulas (n = 22), and perforations (n = 5). TS occurred in 46/50 (92%). Overall, 34/50 (68%) patients had CR. CR was significantly higher for acute defects as compared to chronic defects (89.7 vs. 38.1%, OR 14.1, CI 3.19-62.1, p < 0.001). Of 24 patients who required repeat attempts at endoscopic closure, 14 (58%) achieved CR. Acute defects (p = 0.04) and those with initial CI (p = 0.001) were statistically more likely to achieve CR after a repeat attempt.

CONCLUSION

TS and CR are achieved in majority of patients. Acute defects are more likely to achieve CR. In cases where a defect persists, a repeat attempt at endoscopic closure should be attempted.

Full-thickness esophageal perforation after fluoroscopic balloon dilation: incidence and management in 820 adult patients

OBJECTIVE

The purpose of this study is to investigate the incidence, management, and outcomes of esophageal perforation after fluoroscopic balloon dilation in 820 adult patients with esophageal diseases.

MATERIALS AND METHODS

Between December 1990 and April 2014, a total of 820 adult patients (age range, 21-93 years) underwent 1869 fluoroscopic balloon dilation sessions (mean, 2.3 sessions/patient; range, 1-29 sessions/patient) for esophageal diseases. We retrospectively reviewed the prospectively collected medical records and images of these patients and collected the data of patients who developed esophageal perforations after fluoroscopic balloon dilation.

RESULTS

During this period, 12 patients (six men and six women; mean age, 51 years; age range, 28-69 years) developed perforations. The perforation rate was 1.5% per patient and 0.6% per dilation. Among the first eight patients, four who were treated with surgery had perforations 2 cm or larger, and the other four who underwent fasting, parenteral alimentation, and treatment with antibiotics had perforations smaller than 2 cm. The last four patients underwent stent placement immediately after the diagnosis, regardless of the perforation's size. The median hospital stay was 11.5 days.

CONCLUSION

Fluoroscopic balloon dilation of esophageal diseases is a safe procedure with a low perforation rate. A perforation size greater than 2 cm is considered large and requires aggressive treatment. Although the number of patients with esophageal perforation we treated is relatively small and further clinical trials are needed, temporary stent placement seems to be an initial choice in the management of esophageal perforations after fluoroscopic balloon dilation.

Esophagojejunal anastomosis fistula, distal esophageal stenosis, and metalic stent migration after total gastrectomy

Esophagojejunal anastomosis fistula is the main complication after a total gastrectomy. To avoid a complex procedure on friable inflamed perianastomotic tissues, a coated self-expandable stent is mounted at the site of the anastomotic leak. A complication of stenting procedure is that it might lead to distal esophageal stenosis. However, another frequently encountered complication of stenting is stent migration, which is treated nonsurgically. When the migrated stent creates life threatening complications, surgical removal is indicated. We present a case of a 67-year-old male patient who was treated at our facility for a gastric adenocarcinoma which developed, postoperatively, an esophagojejunostomy fistula, a distal esophageal stenosis, and a metallic coated self-expandable stent migration. To our knowledge, this is the first reported case of an esophagojejunostomy fistula combined with a distal esophageal stenosis as well as with a metallic coated self-expandable stent migration.

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.

Timing of esophageal stent placement and outcomes in patients with esophageal perforation: a single-center experience

BACKGROUND

Endoscopic treatment for esophageal perforation with stenting is an alternative to surgery. There is no data on the impact of timing of esophageal stent placement and outcomes in patients with esophageal perforation.

OBJECTIVE

To determine the significance of timing of esophageal stent placement on short-term (30-day complications) and long-term clinical outcomes of patients with esophageal perforation.

METHODS

Patients with esophageal perforations who underwent endoscopic treatment with stenting from 2007 to 2012 at the Cleveland Clinic were included for the study. Main outcomes measurements were impact of time to esophageal stent placement on 30-day complications and long-term outcomes.

RESULTS

A total of 20 patients (males 40 % and females 60 %) were included. Mean age was 72.5 ± 10 years. The most common etiology for perforation was iatrogenic after endoscopy procedure in 10 (50 %) patients. The stent was in place for a median of 24.6 days in our cohort. Eight patients (40 %) had stent placement within 24 h, while the remaining 12 patients (60 %) had stent placement after 24 h. The mortality rate due to perforation related causes was 10 % (2/20) in our study. The 30-day complication rate was 10 %; 1 with stent migration and the other with chest pain. The 30-day readmission rates excluding patients who died during the initial hospitalization were 10 %. On long-term follow-up, 30 % complication rates were encountered; 3 (15 %) stent migrations, 2 (10 %) patients presented with hematemesis, and 1 (5 %) with chest pain. The timing of stent placement (within 24 h or later) did not impact the risk of complications (Odds Ratio [OR] 1.13, 95 % confidence interval 0.1-8.9, P = 0.91).

CONCLUSIONS

Endoscopic stent placement is safe and effective for treating esophageal perforations. However, the timing of stent placement on outcomes remains unclear.