Esophageal stent placement for the treatment of perforation, fistula, or anastomotic leak

Patient-Reported Long-Term Outcome is Superior After Treatment with Self-Expanding Metallic Stents in Esophageal Perforations

BACKGROUND AND AIMS

Esophageal perforations are life threatening. Since the 1990s, placing of covered esophageal stents has become an alternative to surgery. Theoretically, this minimally invasive approach has several benefits; however, little data are available on long-term outcome in these patients. We aimed to evaluate how patient-reported outcome differed between full surgery and placement of self-expanding metallic stents when treating primary benign esophageal perforations.

MATERIAL AND METHODS

Of 48 patients treated at our hospital in 2000-2015, 23 were alive and asked to answer three questionnaires. We used a short clinical questionnaire, the QLQ-OG25 from the European Organization for Research and Treatment of Cancer and a simplified quality-of-life instrument, the Check Your Health. Non-parametric statistics were used to evaluate differences between the two groups.

RESULTS

In all, 20 (87%) individuals (13 men, 64 years of age) responded. At survey, surgical patients had lost 13 kg of initial weight, compared to no weight loss in the self-expanding metallic stents group (p = 0.01). This involuntary weight loss worried patients according to the QLQ-OG25; otherwise patient-experience measures did not differ between groups. For quality of life, surgical patients scored significantly lower physical health, emotional well-being, social functioning, and overall quality of life after treatment, but after stenting no differences were seen.

CONCLUSIONS

In contrast to stenting, surgical treatment was associated with involuntary, and worrisome, weight loss as well as reduced quality of life. We therefore believe that self-expanding metallic stents should be used when possible in treating benign esophageal perforations.

Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract

Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.

Encephalitis as a complication of a spinal-esophageal fistula due to discitis

In patients with back or scapular pain, if there is evidence of neurological symptoms, fever, chills, malaise, or other signs of infection, the work-up should consider the possibility of a spinal-esophageal fistula.

Successful conservative treatment of spontaneous intrathoracic esophageal perforation using a temporary covered esophageal stent with a check valve: a case report

Background

Spontaneous esophageal perforation is a potentially life-threatening condition with high morbidity and mortality rates. While surgical treatment has been employed for esophageal perforation, we have adopted conservative treatment with an esophageal stent for patients in a poor physical condition because we consider controlling sepsis and improving the physical status are the highest priorities; additionally, the surgical trauma could be fatal for these patients.

Case presentation

A 60-year-old male complaining of left chest and back pain after vomiting was transferred to a local hospital. Computed tomography and chest X-ray examinations showed left tension pneumothorax, pneumomediastinum, and bilateral pleural effusion suspicious of spontaneous intrathoracic esophageal perforation. He was transferred to our hospital for further treatment. After arrival, he developed septic shock with acute respiratory failure. We considered that surgical treatment was too invasive and chose conservative treatment with an esophageal stent. Under general anesthesia, we first inserted a 20-Fr. trocar in the left posterior pleural space, and a large volume of the dark pleural effusion was discharged. We then performed endoscopy and found a pinhole perforation in the left posterolateral wall of the lower esophagus. We inserted both a silicon-covered esophageal stent with a check valve and a double elemental diet (W-ED) tube. We then inserted an 18-Fr. trocar into the left anterior wall. These procedures were performed less than 24 h after onset. As intensive medical care, the patient was administered broad-spectrum antibiotics and catecholamine. The two trocars and the W-ED tube were under continuous suction at − 5 cmH₂O and at − 20 cmH₂O every 30 s. On the 6th day, we inserted an additional thoracic drainage tube into the left pleura under CT guidance. The patient was discharged from the ICU to the general ward on the 7th day. We removed the stent almost triweekly, and the esophageal perforation was completely healed on the 45th day. He was discharged home on the 70th day.

Conclusion

Conservative treatment with a temporary self-expanding covered stent with a check valve, sufficient drainage, and W-ED tube nutrition was useful and effective in this unstable case of spontaneous intrathoracic esophageal perforation.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Esophageal Stent Insertion for Postesophagectomy Anastomosis Site Leakage

In Ivor Lewis operation, anastomosis site leakage is a critical complication. Interventional approach utilizing covered metal stent has been introduced for the management of this complication. This patient was diagnosed as esophageal cancer and underwent robot-assisted Ivor Lewis operation. Due to symptoms suggesting anastomosis site leakage, video-assisted thoracoscopic surgery exploration was performed without identification of gross leakage site. On esophagogastroduodenoscopy, anastomosis site leakage was detected and esophageal stent was placed. Four weeks later, the stent was removed, and the patient could intake all his diet orally without discomfort. Esophageal stent insertion can be an option to manage postesophagectomy leakage problem.

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.

A propensity-matched comparison of cost and outcomes after esophageal stent placement or primary surgical repair for iatrogenic esophageal perforation

OBJECTIVES

Esophageal stent placement has been shown to be a safe and effective treatment for acute esophageal perforation in selected patients. However, a comparison between surgical repair and stent placement has not been reported. This investigation compares the outcomes and costs of the 2 treatment modalities.

METHODS

The Premiere database for a single health system's hospitals was used to identify patients undergoing treatment for an acute intrathoracic esophageal perforation over a 4-year period. Patient cohorts for stent placement or surgical repair were formed using propensity matching. The 2 cohorts were compared for length of stay, morbidity, mortality, and costs.

RESULTS

Between 2009 and 2012, 60 patients undergoing esophageal stent placement or surgical repair were propensity matched. Mean patient age and Charlson comorbidity scores did not differ significantly (P = .4 and P = .4, respectively). Significant differences in morbidity (4% vs 43%; P = .02), mean length of stay (6 vs 11 days; P = .0007), time to oral intake (3 vs 8 days; P = .0004), and cost ($91,000 vs $142,000; P < .0001) were identified in the esophageal stent cohort when compared with patients receiving surgical repair. Operative mortality did not differ significantly.

CONCLUSIONS

Esophageal stent placement for the treatment of an acute esophageal perforation seems to be as effective as surgical repair when compared between propensity-matched patients. However, stent placement resulted in a shorter length of stay, lower rates of morbidity, and lower costs when compared with traditional surgical repair.

Predictors for failure of stent treatment for benign esophageal perforations - a single center 10-year experience

AIM: To investigate possible predictors for failed self-expandable metallic stent (SEMS) therapy in consecutive patients with benign esophageal perforation-rupture (EPR).

METHODS: All patients between 2003-2013 treated for EPR at the Karolinska University Hospital, a tertiary referral center, were studied with regard to initial management with SEMS. Patients with malignancy as an underlying cause and those with anastomotic leakages were excluded. Sealing of the perforation with a covered SEMS was the primary strategy whenever feasible. Stent therapy failure was defined as a radical change of treatment strategy due to uncontrolled mediastinitis, which in this setting consisted of emergency esophagectomy with end-esophagostomy or death as a consequence of the perforation and subsequent uncontrolled sepsis. Patient and lesion characteristics were analyzed and are presented as median and interquartile range. Possible predictors for failed stent therapy were analyzed with uni-variate logistic regression, while variables with P < 0.2 were further analyzed with multi-variate logistic regression.

RESULTS: Of the total number of 48 patients presenting with EPR, 40 patients (83.3%) were treated with SEMS at the time of admission, with an intention to heal the perforation. Twenty-three patients had Boerhaave’s syndrome (58%), 16 had an iatrogenic perforation (40%) and 1 had external trauma to the esophagus (3%). The total in-hospital mortality, including the cases that had other initial treatments (n = 8), was 10.4% and 7.5% among those who were subjected to the SEMS-based strategy. In 33 of the 40 patients (82.5%) who were treated with stent, the EPR healed without further change in treatment strategy. Patients classified as treatment success received a SEMS at a median time of 1 (1-1) d after the actual EPR, compared to 3 (1-10) d among those where the initial treatment failed, P = 0.039 in uni-variate analysis and P = 0.052 in multi-variate analysis. No other significant factors emerged, indicating an increased risk for failure. Six of 7 patients, where stent treatment of the defect failed, underwent an emergency esophagectomy with end esophagostomy and one patient died.

CONCLUSION: SEMS as an upfront therapeutic strategy seems to be a successful concept, when applied to an unselected group of patients with EPR.

An analysis of esophageal stent placement for persistent leak after the operative repair of intrathoracic esophageal perforations

BACKGROUND

Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastinal necrosis. However, the leak rate after primary surgical repair is reported to range between 15% and 20% and increases to 45% and 70% in patients whose repair is delayed beyond 24 hours. This analysis reviews patients who experienced a leak after the operative repair of an esophageal perforation treated with esophageal stent placement.

METHODS

Patients undergoing esophageal stent placement for the treatment of a leak after the operative repair of an intrathoracic esophageal perforation were identified from a single institution's database, which included patients initially treated at other facilities. Patient outcomes were recorded and analyzed.

RESULTS

During a 7-year period, 32 esophageal stents were placed in 29 patients who experienced an esophageal leak after operative repair. Associated surgical procedures were simultaneously performed in 7 (24%) patients. Leak occlusion occurred in 27 patients (93%). Two patients required a reoperative repair. Twenty-five patients (86%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration in 5 patients (19%) required repositioning (n=2) or replacement (n=3). Stents were removed at a mean of 22±16 days after placement. Mean hospital length of stay was 8±11 days.

CONCLUSIONS

Endoluminal esophageal stent placement is a safe and effective treatment for the majority of leaks after the operative repair of an intrathoracic esophageal perforation. Stent placement resulted in rapid leak occlusion and provided the opportunity for early oral nutrition while eliminating the need for reoperative repair or esophageal exclusion in the majority of patients.

Endoscopic treatment of iatrogenic gastrointestinal perforations: an overview

In the past, the treatment of iatrogenic gastrointestinal perforations was limited to surgical management or to medical observation. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has paved the way towards the development of reliable endoscopic closure techniques, which can be applicable in accidental perforations of the gastrointestinal tract. When endoscopic treatment is feasible, hemoclips are preferred in smaller perforations, while over-the-scope-clips or a combination of hemoclips, endoloops, and glue are used in larger ones. Endoscopic stitching is rarely utilized, and endoscopic stapling has been practically abandoned. The use of self-expandable covered stents can be considered in the esophagus and duodenum. Broad spectrum antibiotics are recommended in most cases. Clinical follow-up in a medico-surgical unit is mandatory and surgical intervention should not be delayed more than 24h if clinical or biological worsening occurs. Imaging with oral contrast medium is advisable before resumption of oral feeding in the case of large perforations.