An Analysis of Esophageal Stent Placement for Persistent Leak After the Operative Repair of Intrathoracic Esophageal Perforations Richard K. Freeman, MD, MBA, Anthony J. Ascioti, MD, Megan Dake, PA-C, and Raja S. Mahidhara, MD

Background. Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastinal necrosis. However, the leak rate after primary surgical repair is reported to range between 15% and 20% and increases to 45% and 70% in patients whose repair is delayed beyond 24 hours. This analysis reviews patients who experienced a leak after the operative repair of an esophageal perforation treated with esophageal stent placement. Methods. Patients undergoing esophageal stent placement for the treatment of a leak after the operative repair of an intrathoracic esophageal perforation were identified from a single institution’s database, which included patients initially treated at other facilities. Patient outcomes were recorded and analyzed. Results. During a 7-year period, 32 esophageal stents were placed in 29 patients who experienced an esophageal leak after operative repair. Associated surgical

procedures were simultaneously performed in 7 (24%) patients. Leak occlusion occurred in 27 patients (93%). Two patients required a reoperative repair. Twenty-five patients (86%) were able to initiate oral nutrition within 72 hours of stent placement. Stent migration in 5 patients (19%) required repositioning (n [ 2) or replacement (n [ 3). Stents were removed at a mean of 22 ± 16 days after placement. Mean hospital length of stay was 8 ± 11 days. Conclusions. Endoluminal esophageal stent placement is a safe and effective treatment for the majority of leaks after the operative repair of an intrathoracic esophageal perforation. Stent placement resulted in rapid leak occlusion and provided the opportunity for early oral nutrition while eliminating the need for reoperative repair or esophageal exclusion in the majority of patients.

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Patients and Methods

rimary surgical repair has long been the standard initial treatment for acute perforation of the esophagus unless esophagectomy is required. Advances in surgical technique including the use of muscle buttressing have produced improved outcomes after surgical repair of an esophageal perforation. However, in centers experienced in esophageal surgery, a significant leak rate persists after surgical repair [1]. During the last decade, experience with esophageal stent placement for the treatment of esophageal perforation, fistula, and anastomotic leak have been found to be beneficial in selected patients [2]. This purpose of this investigation was to assess whether esophageal stent placement would be beneficial in the treatment of patients experiencing a continued leak after the surgical repair of an acute esophageal perforation.

Accepted for publication Jan 6, 2014. Presented at the Sixtieth Annual Meeting of the Southern Thoracic Surgical Association, Scottsdale, AZ, Oct 30–Nov 2, 2013. Address correspondence to Dr Freeman, 8433 Harcourt Rd, Indianapolis, IN 46260; e-mail: [email protected].

Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

(Ann Thorac Surg 2014;97:1715–20) Ó 2014 by The Society of Thoracic Surgeons

Patients undergoing esophageal stent placement for the treatment of an intrathoracic leak after the surgical repair of an acute esophageal perforation were identified from a comprehensive general thoracic surgery database at a single institution. The institution’s Institutional Review Board approved this protocol including the off-label use and waived individual patient consent for this investigation. Patients with a cervical or intraabdominal esophageal perforation or patients with an esophageal malignancy were excluded. Patients who underwent the surgical repair of an acute esophageal perforation performed at another facility and subsequently transferred to our care were eligible for inclusion in this study. A retrospective analysis was performed after eligible patients were identified. Patient demographics, the cause of the esophageal perforation, and type of surgical repair were recorded as well as any episodes of stent migration or revision, time to oral intake, length of stay, morbidity, mortality, and patient condition 1 month after discharge. The anatomic location, chronicity, and cause of the esophageal leaks were categorized using a classification system previously developed (Table 1). 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.011

GENERAL THORACIC

Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana

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FREEMAN ET AL ESOPHAGEAL STENT PLACEMENT AFTER OPERATIVE REPAIR

Table 1. Esophageal Leak Classification System Characteristics

GENERAL THORACIC

Location Cervical Intrathoracic Gastroesophageal junction Mechanism Iatrogenic perforation Spontaneous perforation (Boerhaave’s syndrome) Anastomotic leak Fistula Injury size

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

Surgical repair of esophageal perforation has been the mainstay of therapy for patients without associated esophageal malignancy or diffuse mediastina...
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