Diseases 86–92 Diseases of of the the Esophagus Esophagus (2016) (2015) 29, ••, ••–•• DOI: DOI: 10.1111/dote.12298 10.1111/dote.12298
Original article
Treatment of anastomotic leaks with metallic stent after esophagectomies E. Eizaguirre,1 S. Larburu,1 J. I. Asensio,1 A. Rodriguez,1 J. L. Elorza,1 F. Loyola,2 G. Urdapilleta,3 J. M. E. Navascués1 Departments of 1Esophagogastric Surgery, 2Interventional Radiology, and 3Digestive Endoscopy, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
SUMMARY. 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. KEY WORDS: anastomosis, esophagectomy, leak, stent.
INTRODUCTION
PATIENTS AND METHODS
Anastomotic leakage is one of the most serious complications of esophagectomy due to esophageal cancer. The high incidence of the anastomotic leakage raises the morbimortality of the surgery and increases the hospital stay.1,2 Classically, the treatment of anastomotic leakage has often required reoperation to control the extravasation of the intraluminal contents. In recent years, the introduction of stents has played an important role in this control because it can prevent reoperations.3 The aim of this study was to evaluate the results obtained in our patients with the placement of the stent in the anastomotic leaks, both cervical and intrathoracic leaks, in the esophageal surgery.
From June 2003 to May 2012, 113 esophagectomies were carried out because of esophageal neoplasia in the Section of the Esophagogastric Surgery in the Donostia University Hospital in San Sebastian. We have reviewed the database of all our patients in a nonrandomized case–control study that assesses the role played by the stent in the treatment of anastomotic leaks. This study include 24 patients with anastomotic leakage (21.23%), of which 13 (54.16%) were treated with metallic stent (Table 1, demographic characteristics of these patients).
Address correspondence to: Dr Emma Eizaguirre, MD, Dr. Beguiristain 117, 20080 Donostia, Basque Country, Spain. Email: [email protected] Conflicts of interest: There is no conflict of interest. 86 © 2015 International Society for Diseases of the Esophagus
Surgical technique and perioperative strategy A total of 118 patients were diagnosed with resectable esophageal tumor. According to the multidisciplinary team, all patients staging T3NxM0 were treated with preoperative chemo and radiation therapy except one patient who was treated only with chemotherapy in another hospital and another five people who did not finish the preoperative treatment or were too weak to C 2015 International Society for Diseases of the Esophagus V 1
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Table 1 Demographic characteristics of the patients
Age (average), years Sex (%) Male Female Comorbidities Smoker Ex-smoker Pulmonary pathology Drinker Cardiopathy Obesity Tumor type (%) Adenocarcinoma Epidermoid carcinoma Squamous Papilloma Benign stricture Location of tumor (%) Upper third Middle third Lower third Preoperative tumor staging (%) Benign Barret high degree T1N0M0 T2N0M0 T3N0M0 T3N1M0
Stent (n = 13)
No stent (n = 11)
P value
55, 69
62, 45
0.072
13 (100%) 0
11 (100%) 0
— —
3 (23.07%) 7 (53.84%) 4 (30.76%) 1 (7.69%) 1 (7.69%) 1 (7.69%)
3 (27.27%) 2 (18.18%) 6 (54.54%) 3 (27.27%) 2 (18.18%) 1 (9.09%)
0.162
9 (69.23%) 2 (15.38%) 1 (7.69%) 1 (7.69%)
4 (36.36%) 7 (63.63%) 0 0
0.087 — — —
1 (7.69%) 6 (46.15%) 6 (46.15%)
4 (36.36%) 6 (54.54%) 1 (9.09%)
0.110 — —
1 (7.69%) 0 3 (23.07%) 1 (7.69%) 5 (38.46%) 3 (23.07%)
0 1 (9.09%) 0 1 (9.09%) 7 (63.63%) 2 (18.18%)
0.506 — — — — —
receive chemoradiation. Two weeks before the surgery, 23 of these 118 patients with resectable esophageal tumor underwent an embolization of the left gastric artery in an attempt to improve the perfusion of the gastroplasty at the time of the surgery. Of the 118 patients with esophageal tumor, a three-field esophagectomy was carried out in 67 patients, Ivor-Lewis esophagectomy in 34 patients, transhiatal esophagectomy in 12 patients, and endoscopic resection in 1 patient; 4 patients had locally advanced tumor or peritoneal carcinomatosis so surgery was rejected. Of the 113 patients who underwent an esophagectomy, 24 (21.23%) had anastomotic leak. The diagnosis of anastomotic leak was made by means of the clinical symptoms, contrast radiology (computerized tomography [CT] or esophagogram), or endoscopy that we have been using since 2010 (Figs 1–3). Cervical leaks are classified into four types: leak type I is called the subclinical leak that is diagnosed by contrast radiology in an asymptomatic patient, type II presents with only local symptoms (fistula leading to the neck), type III is the one in which the content of the leak drains to the chest, causing respiratory symptoms, and type IV is the one in which a necrosis of gastroplasty is identified. Intrathoracic leaks are classified into three types, with the same criteria as in the neck, except for type II, which does not exist in the thorax.4 C 2015 International Society for Diseases of the Esophagus V
0.045 0.200 0.439 0.902
The therapeutic management of the leak is decided based on an algorithm that we have published recently.4 The indication of the stent should be considered a priority for type III leaks where the spill to the chest can cause respiratory catastrophes.
Fig. 1
Esophagobronchial fistula. © 2015 International Society for Diseases of the Esophagus
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3
Mann–Whitney test for comparison of averages of numerical variables that not follow a normal distribution and the χ2 Pearson test for qualitative data. Fisher analysis was performed with small samples. It was considered statistically significant if P ≤ 0.05.
RESULTS
Fig. 2 Anastomotic fistula.
Stenting technique The Interventional Radiology Department uses the SX-ELLA Stent Esophageal HV BIOMED® (ELLACS, Hradec Kralove, Czech Republic) metallic stent. This stent has a diameter of 20 mm and a length that can vary from 85 to 135 mm. It is covered with polyethylene in order to present greater resistance to acid reflux. The placement is carried out in radiology under general anesthesia. With the help of endoscopy, radiologists place the stent under fluoroscopy vision through the delivery system equipped with a special splittable olive (‘in rocket delivery’), allowing its expansion. The stent is removed approximately 6–8 weeks after the placement. Statistical analysis The statistical analysis was performed with SPSS software (IBM España SA, Madrid, Spain), using the
The leak rate was 21.23% (24/113); 20.6% (7/34) in intrathoracic anastomoses and 21.5% (17/79) in cervical anastomoses. In the 24 anastomotic leaks, the surgical technique used was: three-field esophagectomy in 14 patients (58.3%), esophagectomy in accordance with IvorLewis technique in 7 patients (29.1%), and transhiatal esophagectomy in 3 patients (12.5%). In 17 of the 24 leaks (70.8%), minimally invasive techniques were used. Of the 24 leakages, nine patients (37.5%) were embolized preoperatively. Of the 24 patients with leakage, 17 (71%) had a cervical anastomosis and 7 had an intrathoracic anastomosis (29%). In eight patients the anastomosis was mechanical side-side type Collard, another eight were Orringer type side-side semi-mechanical, six manual end-side, and two mechanical end-side. Anastomotic leaks were diagnosed between the 2nd and the 15th postoperative day (average 7.6th day). These were classified as Type I, Type II, Type III, and Type IV (Table 2). In 13 patients (54.1%), a stent was placed as part of the treatment. All patients started oral tolerance between the 2nd and 4th day after the placement. Of the remaining 11 patients, 1 patient required emergency surgery and the other 10 were managed with conservative treatment consisting of oral intake, wound drain in the case of local symptoms, nasogastric tube, parenteral nutrition, and antibiotics. Table 3 summarizes the clinical-surgical characteristics of these patients. In the series, the stent placement has not presented any complications of migration, perforation, or hemorrhage. However, one patient, after placing the stent, showed bile reflux that caused pneumonia through aspiration. In another patient, despite the stent, the hole of the fistula increased, producing a large mediastinal abscess leading to reoperation and resection of the gastroplasty. Of the patients with
Table 2
Fig. 3 No fistula with a stent. © 2015 International Society for Diseases of the Esophagus
TYPE TYPE TYPE TYPE
Classification of the anastomotic leaks
I II III IV
Stent
No stent
Total
2 3 8 0
3 5 2 1
5 8 10 1
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Table 3 Variables of the two groups Total leaks Preoperative chemoradiotherapy Yes No Only chemotherapy Embolization Yes No Anastomosis Cervical Thoracic Type anastomosis E-S manual S-S mechanic Mechanical circular Orringer Postoperative day of the fístulae (days) Average Median Stricture Cervical Thoracic Reoperation per anastomotic fistulae (%) Preservation of the digestive continuity Hospital stay (days) Average Median Mortality (%)
Stent (n = 13)
No stent (n = 11)
P value
14 9 1
7 (50%) 5 (55.5%) 1
7 (50%) 4 (45.5%) 0
0.170 — — —
9 15
5 (55.5%) 8 (53.3%)
4 (45.5%) 7 (46.6%)
0.916 —
17 7
8 (47.05%) 5 (71.42%)
9 (52.94%) 2 (28.57%)
0.276 Fisher analysis (0.386)
6 8 2 8
3 (50%) 4 (50%) 1 (50%) 5 (62.5%)
3 (50%) 4 (50%) 1 (50%) 3 (37.5%)
6 5 1 2 22
8.38 7 4 (30.7%) 3 1 1 (7.69%) 12 (92.3%)
7.09 7 2 (18.18%) 2 0 1 (9.09%) 10 (90.9%)
0.901 — — — — — — — 0.621 — 0.475 0.642
44.84 34 1
25.72 28 1
0.104 — 0.902
2
E-S, end-side anastomosis; S-S, side-side anastomosis.
fistula, 91.6% maintain digestive continuity (92.3% with stent and 90.9% without stent). The stent was effective and closed the anastomotic leakage in 12 of the 13 patients, as it was proved through endoscopy when it was removed after the 6th week of the placement. Four patients (30.7%) treated with stent and two patients (18.18%) treated without stent presented anastomotic stricture that required an average of three dilations. Two patients died in the postoperative course. The first died a month after the surgery, suffering an acute respiratory distress syndrome to which was added a nosocomial infection. The second patient also died a month after surgery. It was due to a dehiscence of the anastomotic suture in an Ivor-Lewis surgery. Despite stenting, underwent a purulent mediastinitis and after resurgery with the resection of the gastric plastia and the drainage of the chest cavity, the patient experienced sepsis by Staphylococcus aureus and Candida and a severe systemic inflammatory response syndrome. As for the aforementioned variables, there were no statistically significant differences between patients treated with or without stent (Table 3).
DISCUSSION Surgery is a potentially curative treatment for esophageal cancer. However, it has high morbidity and mortality associated with, above all, complications such as anastomotic leak5 and respiratory probC 2015 International Society for Diseases of the Esophagus V
lems. With the presence of a leak, the required artificial feeding period, the average stay in the ICU, and finally the hospital stay are lengthened.6,7 The determinants of anastomotic leak can be derived from the patients’ conditions such as malnutrition and immunosuppression or derived from the surgical technique like insufficient perfusion of the plasty, the diameter of the gastric conduit, and anastomosis tension.8 Many authors in the literature9–12 show a reduced leak rate and improved perfusion of the gastric conduit after embolization or ligation of the left gastric artery 1 or 2 weeks before the surgery. In our cases, the leak rate in embolized patients was 39.1% (9/23) and 16.7% (15/90) in nonembolized patients. However, we are analyzing if this apparent difference is because of the embolization or due to other factors such as the type of esophagectomy (Ivor-Lewis vs. total esophagectomy), due to the small diameter of the plasty (3–4 cm), or due to the features noted above. The location of the leak, its extension, the presence or absence of necrosis of the gastroplasty, the time of the progression, and the systemic response indicate the severity of the case.13 The leak rate after esophagectomies is 21.23% in our series (20.6% in intrathoracic anastomoses and 21.5% in cervical anastomoses). It is high, but in the literature, the incidence of thoracic anastomotic leaks is 3–25%7,13 and 10–25% at the cervical region.6,14 On the other hand, Luketich et al.15 shows 5% and 4% at cervical and thoracic anastomotic leaks rates, respectively, in a review of over a thousand © 2015 International Society for Diseases of the Esophagus
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esophagectomies. However, he presents the anastomotic leaks requiring surgery, but we do not know the real anastomotic leak rate. Because of that, a good classification1,16 of leaks is critical for the therapeutic management of these, which can vary from a simple conservative approach17 in Type I to reoperation in type IV. It is in the type III leaks, both cervical and intrathoracic, in which it is essential to control the leak into the pleural cavity, where the minimally invasive techniques such as intraluminal and submucosal application of glue fibrin, the placement of metal clips, or endoscopic intraluminal stenting have gained prominence in the last decade.18–21 Different groups in the literature like Turkyilmaz et al.1 or Griffin et al.22 have suggested diagnostic and therapeutic algorithms. In our center, among the minimally invasive techniques mentioned above, we only work with the stent in accordance with an algorithm that we have published recently.4 Historically, the permanent metallic stent has been used as a palliative treatment in unresectable esophageal tumors to prevent the obstruction of the lumen of the digestive tract or in tracheoesophageal fistulas.23 Metallic stent covering is in order to resist the acid reflux for long-term implantation. Currently, the indications have been increased, and it has been observed they may be useful in the treatment of the esophagogastric anastomotic leaks.1 The covered metal stent may be a therapeutic option that is feasible, safe, and effective in treating anastomotic fistulas after esophagectomies without adding significant morbidity and mortality, ensuring an uninterrupted digestive tract.3 There are also plastic stents. These stents are characterized by a smooth surface that facilitates retrieval but favors migration. On the other hand, the metallic covered stent that we used has an antimigration collar that prevents the displacement. In patients with an anastomotic leak after esophagectomy who have not developed a sepsis, the stent may prevent reoperation as observed in our study. An early diagnosis of the leak is crucial. In our center, we began using the stent in 2003. In the beginning, we had no specific indication protocol, but over the years, we have been refining the indications to establish the algorithm with which we currently work. We consider type III leaks, both cervical and intrathoracic, as absolute indication for stent implantation and as a relative indication in type II cervical fistulas, where we will implant the stent in longstanding fistulas or if the size of the fistula are considerable (see the algorithm). The stent, therefore, plays an important role in intrathoracic fistulas and less in the neck, because neck fistulaes are easier to control and have less impact on the patient’s symptoms.13 Even in the stent placement, it is important to have good drainage of the cervical, mediastinal, or pleural abscess, whether by opening the cervical incision or placing a chest tube. In our case, we have © 2015 International Society for Diseases of the Esophagus
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placed the stent in 47.05% (8/17) of cervical leaks and in 71.42% (5/7) of intrathoracic leaks. This five patients would have been reoperated on if we had not treated them with a stent, and they would probably have had an esophagostomy, gastrostomy, and yeyunostomy. Ye et al. propose stenting anastomotic leaks after surgery for esophageal carcinoma in thoracic fistulas as long as the patients’ symptoms allow it. They indicate reoperation in the case of: an early anastomotic leak, necrosis of gastroplasty and encapsulated empyema, poorly drained with routinary methods, and significant toxic symptoms.24 At the moment of the implantation of the stent, the radiologists confirm that there is no residual leak with the swallow of contrast. In our series, patients initiated oral tolerance on the second to the fourth day after stent placement; however, other authors such as Dai et al.25 begin the oral intake immediately after the stenting. If the patients continue with infection symptoms, we do CT controls with oral contrast, so we can see if there is any abscess without drainage and/or if the stent is effective, at the same time. We do not know exactly how long the leaks take to heal with the stent, but after 6–8 weeks, it is completely closed. In the case of patients without stent, it varies from 5 to 30 days. There have been multiple adverse effects and complications such as pain, nausea, acid reflux, bowel obstruction, hemorrhage, perforation of viscera, or stent displacement26 due to the stent implantation and extraction. The stents may require their own reintervention because of stent migration, patient discomfort, or a persistent leak.26 Siersema27 presented 11 cases in which they use metal stents and one stent removal was very difficult, causing tracheoesophageal fistula. Roy-Choudhury et al.28 presented a study of 10 patients with gastroesophageal fistula where metallic stent have been placed, and in four of these patients, there were complications such as bleeding and difficulty in eating. In our 13 cases, most of them, especially those with cervical stents, present local pressure in the first 2 days that is well controlled with analgesics. We observed only two complications in our patients: pneumonia per aspiration and a decubitus of the stent that forced a bipolar exclusion of the plasty. None of the cases has needed to be replaced because of migration of the stent. In the literature, the rate of plastic stent migration is 10–35%.29–31 Of the patients, 92.3% with a stent and 90.9% without a stent preserve digestive continuity. Even if there is no difference between the two groups, we think that some patients with stent would have required reoperation with probable disconnection of the digestive tract. The follow-up period is ongoing in these patients. For the first 3 years after surgery, we see the patients every 6 months with blood tests and TC. After that, we see them every year. If the patient refers C 2015 International Society for Diseases of the Esophagus V
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dysphagia, we apply for an endoscopy and esophagogram. Among the long-term complications, we have observed that 4 patients treated with stent (30.7%) and only 2 of the 11 patients treated without stent (18.18%) presented anastomotic stricture. The endoscopists do the dilations on average three times in each patient. Several authors like Dai et al. (2009 and 2011), Dormann et al., and Schubert et al.25,29,32,33 present their experiences with plastic stents made of polyester and covered by a silicone membrane, and it seems that they have fewer complications than with metal stents. According to Langer et al.,34 after the stent placement, the average of the hospital stay decreases, giving an average of 8 days prior to discharge. RoyChoudhury et al.28 show an average stay of 17 days after the stent placement in their study. Our average hospital stay is 44.84 days in stented patients (median 34 days) and 25.72 days in patients without stent (median 28 days). This increase in the average stay in the patients with stent could be because the indication of the stent was performed on patients with more severe and major clinical impact of the anastomotic leakage such as the intrathoracic leakage. There is no difference in the length of stay if we compare cervical leaks with thoracic leaks (36.9 and 38.1 days, respectively). The removal of the stent was performed by the interventional radiologist and endoscopist on the sixth week of the placement. This is because after that period, it is more difficult to remove the stent because of the integration of the stent to the cicatricial tissue.27 Radecke et al.30 and Dai et al.25 removed the stent on the 14th day of the placement, but it should be noted that unlike us, these authors work with plastic stents. Dai et al.25 presented the study with the highest number of stents with 4.5% of mortality rate in the 22 patients. In our review of 13 fistulaes with stenting, one patient died (mortality = 7.69%). The presented report has many limitations. First is the small number of cases reported because of the fact that this esophageal disease is not very common in our hospital (14 cases/year). Second, it is a retrospective study and stenting was not performed according to a protocol. It has been used as a noninvasive tool that prevented reoperations in some patients. Later, after analyzing the results, we performed an intervention algorithm. Third, the cases of patients in whom the stent was placed and in whom the treatment was conservative are not comparable. All patients with thoracic anastomotic leak in whom the stent was placed (five cases) would have been reoperated on for drainage or for exclusion of the anastomosis. On the other hand, the reason why the patients with thoracic fistulas were treated without stent was that the diagnosis of fistulas was radiological with no clinical consequences for the patient. In addition, nine patients with cerC 2015 International Society for Diseases of the Esophagus V
vical fistulas and without stent developed favorably because the control of the fistula at this level was sufficient with conservative treatment. The eight patients with an anastomotic leak in the neck and who were stented would probably not be suited to this treatment today, unless the fistulas output was very big. In conclusion, the expandable metallic stent may be a therapeutic treatment in anastomotic leaks after esophagectomies. However, the stent is not indicated in all fistulaes, but only in those of great size in the neck or in intrathoracic ones. In our experience, the stent has prevented reoperations, which involved high morbidity and mortality. However, the average hospital stay has not decreased. In this review, we wanted to present our experience with the use of the stent in the esophageal fistulae, hoping to learn from other working groups and improve the results indicated.
References 1 Turkyilmaz A, Eroglu A, Aydyn Y, Tekinbas C, Muharrem Erol M, Karaoglanoglu N. The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. Dis Esophagus 2009; 22: 119–26. 2 Abunasra H, Lewis S, Beegs L, Duffy J, Beegs D, Morgans F. Predictors of operative death after oesophagectomy for carcinoma. Br J Surg 2005; 92: 1029–33. 3 Nguyen T, Donohue P, Smith B, Reavis K, Nguyen X, Stamos M. Management of gastrointestinal leaks after minimally invasive esophagectomy: conventional treatments vs. endoscopic stenting. J Gastrointest Surg 2011; 15: 1952–60. 4 Larburu S, Gonzales J, Elorza J L et al. Fístula cervical postesofaguectomía: diagnóstico y tratamiento. Cir Esp 2013; 91: 31–7. 5 Peel A L, Taylor E W. Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical Infection Study Group. Ann R Coll Surg Engl 1991; 73: 385–8. 6 Urschel J D. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995; 169: 634–40. 7 Whooley B P, Law S, Alexandrou A, Murthy S C, Wong J. Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer. Am J Surg 2001; 181: 198–203. 8 Dewar L, Gelfand G D, Finley R J et al. Factor affecting cervical anastomotic leak and stricture formation following esophagogastrectomy and gastric tube interposition. Am J Surg 1992; 163: 484–9. 9 Akiyama S, Kodera Y, Sekigucho H et al. Preoperative embolization therapy for esophageal operation. J Surg Oncol 1998; 69: 219–23. 10 Nguyen N T, Longoria M, Sabio A et al. Preoperative laparoscopic ligation of the left gastric vessels in preparation for esophagectomy. Ann Thorac Surg 2006; 81: 2318–20. 11 Holscher A H, Schneider P M, Gutschow C, Schroder W. Laparoscopic ischemic conditioning of the stomach for esophageal replacement. Ann Surg 2007; 245: 241–6. 12 Veeramootoo D, Shore A, Shields B et al. Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy. Surg Endosc 2010; 24: 1126–31. 13 Blewett C J, Miller J D, Young J E et al. Anastomotic leaks after esophagectomy for esophageal cancer: a comparison of thoracic and cervical anastomoses. Ann Thorac Cardiovasc Surg 2001; 7: 75–8. 14 Orringer M B, Marshall B, Iannettoni M D. Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 1999; 230: 392–400. © 2015 International Society for Diseases of the Esophagus
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15 Luketich J, Pennathur A, Awais O et al. Outcomes after minimally invasive esophagectomy; review of over 1000 patients. Ann Surg 2012; 256: 95–103. 16 Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, van Raemdonck D. Anastomotic complications after esophagectomy. Dig Surg 2002; 19: 92–8. 17 Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg 1998; 85: 1446–9. 18 Pross M, Manger T, Reinheckel T, Mirow L, Kunz D, Lippert H. Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses. Gastrointest Endosc 2000; 51: 73–6. 19 Brown T H, Nicholson D A, Irving M H, Bancewics J. Use of a self expanding metal stent for oesophagogastric fistulation. Br J Surg 1995; 82: 663–4. 20 Bethge N, Sommer A, Vakil N. Treatment of esophageal fistulas with a new polyurethane-covered, self-expanding mesh stent: a prospective study. Am J Gastroenterol 1995; 90: 2143–6. 21 Freeman R K, Ascioti A J, Wozniak T C. Postoperative leak management with the Polyflex esophageal stent. J Thorac Cardiovasc Surg 2007; 133: 333–8. 22 Griffin S M, Lamb P J, Dresner S M, Richardson D L, Hayes N. Diagnosis and management o fa mediastinal leak following radical oesophagectomy. Br J Surg 2001; 88: 1346–51. 23 Siddiqui A, Salkar A, Beltz S et al. Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012; 76: 44–51. 24 Ye H, Huang W, Wu Y et al. Personalized management of anastomotic leak after surgery for esophageal carcinoma. Chin Med Sci J 2012; 27: 35–40. 25 Dai Y Y, Gretschel S, Dudeck O, Rau B, Schlag P M, Hünerbein M. Treatment of oesophageal anastomotic leaks by
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temporary stenting with self-expanding plastic stents. Br J Surg 2009; 96: 887–91. David E A, Kim M P, Blackmon S H. Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage. Am J Surg 2011; 202: 796– 801. Siersema P D. Treatment of esophageal perforations and anastomotic leaks: the endoscopist is stepping into the area. Gastrointest Endosc 2005; 65: 897–900. Roy-Choudhury S H, Nicholson A A, Wedwood K R et al. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stent. AJR Am J Roentgenol 2001; 176: 161–5. Dai Y, Chopra S, Kneif S, Hünerbein M. Management of esophageal anastomotic leaks, perforations and fistulae with self-expanding plastic stents. J Thorac Cardiovasc Surg 2011; 141: 1213–17. Radecke K, Lang H, Frilling A, Gerken G, Treichel U. Successful sealing of benign esophageal leaks after temporary placement of a self-expanding plastic stent without fluoroscopic guidance. Z Gastroenterol 2006; 44: 1031–8. Conigliaro R, Battaglia G, Repici A et al. Polyflex stents for malignant oesophageal and oesophagogastric stricture: a prospective, multicentric study. Eur J Gastroenterol Hepatol 2007; 19: 195–203. Dormann A J, Eisendrath P, Wigginghaus B, Huchzermeyr H, Deviere J. Palliation of esophageal carcinoma with a new selfexpanding plastic stent. Endoscopy 2003; 35: 207–11. Schubert D, Scheidbach H, Kuhn R et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stent. Gastrointest Endosc 2005; 61: 891–6. Langer F B, Wenzl E, Prager G et al. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 2005; 79: 398–404.
C 2015 International Society for Diseases of the Esophagus V
Original article
Treatment of anastomotic leaks with metallic stent after esophagectomies E. Eizaguirre,1 S. Larburu,1 J. I. Asensio,1 A. Rodriguez,1 J. L. Elorza,1 F. Loyola,2 G. Urdapilleta,3 J. M. E. Navascués1 Departments of 1Esophagogastric Surgery, 2Interventional Radiology, and 3Digestive Endoscopy, Donostia University Hospital, Donostia-San Sebastian, Basque Country, Spain
SUMMARY. 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. KEY WORDS: anastomosis, esophagectomy, leak, stent.
INTRODUCTION
PATIENTS AND METHODS
Anastomotic leakage is one of the most serious complications of esophagectomy due to esophageal cancer. The high incidence of the anastomotic leakage raises the morbimortality of the surgery and increases the hospital stay.1,2 Classically, the treatment of anastomotic leakage has often required reoperation to control the extravasation of the intraluminal contents. In recent years, the introduction of stents has played an important role in this control because it can prevent reoperations.3 The aim of this study was to evaluate the results obtained in our patients with the placement of the stent in the anastomotic leaks, both cervical and intrathoracic leaks, in the esophageal surgery.
From June 2003 to May 2012, 113 esophagectomies were carried out because of esophageal neoplasia in the Section of the Esophagogastric Surgery in the Donostia University Hospital in San Sebastian. We have reviewed the database of all our patients in a nonrandomized case–control study that assesses the role played by the stent in the treatment of anastomotic leaks. This study include 24 patients with anastomotic leakage (21.23%), of which 13 (54.16%) were treated with metallic stent (Table 1, demographic characteristics of these patients).
Address correspondence to: Dr Emma Eizaguirre, MD, Dr. Beguiristain 117, 20080 Donostia, Basque Country, Spain. Email: [email protected] Conflicts of interest: There is no conflict of interest. 86 © 2015 International Society for Diseases of the Esophagus
Surgical technique and perioperative strategy A total of 118 patients were diagnosed with resectable esophageal tumor. According to the multidisciplinary team, all patients staging T3NxM0 were treated with preoperative chemo and radiation therapy except one patient who was treated only with chemotherapy in another hospital and another five people who did not finish the preoperative treatment or were too weak to C 2015 International Society for Diseases of the Esophagus V 1
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Table 1 Demographic characteristics of the patients
Age (average), years Sex (%) Male Female Comorbidities Smoker Ex-smoker Pulmonary pathology Drinker Cardiopathy Obesity Tumor type (%) Adenocarcinoma Epidermoid carcinoma Squamous Papilloma Benign stricture Location of tumor (%) Upper third Middle third Lower third Preoperative tumor staging (%) Benign Barret high degree T1N0M0 T2N0M0 T3N0M0 T3N1M0
Stent (n = 13)
No stent (n = 11)
P value
55, 69
62, 45
0.072
13 (100%) 0
11 (100%) 0
— —
3 (23.07%) 7 (53.84%) 4 (30.76%) 1 (7.69%) 1 (7.69%) 1 (7.69%)
3 (27.27%) 2 (18.18%) 6 (54.54%) 3 (27.27%) 2 (18.18%) 1 (9.09%)
0.162
9 (69.23%) 2 (15.38%) 1 (7.69%) 1 (7.69%)
4 (36.36%) 7 (63.63%) 0 0
0.087 — — —
1 (7.69%) 6 (46.15%) 6 (46.15%)
4 (36.36%) 6 (54.54%) 1 (9.09%)
0.110 — —
1 (7.69%) 0 3 (23.07%) 1 (7.69%) 5 (38.46%) 3 (23.07%)
0 1 (9.09%) 0 1 (9.09%) 7 (63.63%) 2 (18.18%)
0.506 — — — — —
receive chemoradiation. Two weeks before the surgery, 23 of these 118 patients with resectable esophageal tumor underwent an embolization of the left gastric artery in an attempt to improve the perfusion of the gastroplasty at the time of the surgery. Of the 118 patients with esophageal tumor, a three-field esophagectomy was carried out in 67 patients, Ivor-Lewis esophagectomy in 34 patients, transhiatal esophagectomy in 12 patients, and endoscopic resection in 1 patient; 4 patients had locally advanced tumor or peritoneal carcinomatosis so surgery was rejected. Of the 113 patients who underwent an esophagectomy, 24 (21.23%) had anastomotic leak. The diagnosis of anastomotic leak was made by means of the clinical symptoms, contrast radiology (computerized tomography [CT] or esophagogram), or endoscopy that we have been using since 2010 (Figs 1–3). Cervical leaks are classified into four types: leak type I is called the subclinical leak that is diagnosed by contrast radiology in an asymptomatic patient, type II presents with only local symptoms (fistula leading to the neck), type III is the one in which the content of the leak drains to the chest, causing respiratory symptoms, and type IV is the one in which a necrosis of gastroplasty is identified. Intrathoracic leaks are classified into three types, with the same criteria as in the neck, except for type II, which does not exist in the thorax.4 C 2015 International Society for Diseases of the Esophagus V
0.045 0.200 0.439 0.902
The therapeutic management of the leak is decided based on an algorithm that we have published recently.4 The indication of the stent should be considered a priority for type III leaks where the spill to the chest can cause respiratory catastrophes.
Fig. 1
Esophagobronchial fistula. © 2015 International Society for Diseases of the Esophagus
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Mann–Whitney test for comparison of averages of numerical variables that not follow a normal distribution and the χ2 Pearson test for qualitative data. Fisher analysis was performed with small samples. It was considered statistically significant if P ≤ 0.05.
RESULTS
Fig. 2 Anastomotic fistula.
Stenting technique The Interventional Radiology Department uses the SX-ELLA Stent Esophageal HV BIOMED® (ELLACS, Hradec Kralove, Czech Republic) metallic stent. This stent has a diameter of 20 mm and a length that can vary from 85 to 135 mm. It is covered with polyethylene in order to present greater resistance to acid reflux. The placement is carried out in radiology under general anesthesia. With the help of endoscopy, radiologists place the stent under fluoroscopy vision through the delivery system equipped with a special splittable olive (‘in rocket delivery’), allowing its expansion. The stent is removed approximately 6–8 weeks after the placement. Statistical analysis The statistical analysis was performed with SPSS software (IBM España SA, Madrid, Spain), using the
The leak rate was 21.23% (24/113); 20.6% (7/34) in intrathoracic anastomoses and 21.5% (17/79) in cervical anastomoses. In the 24 anastomotic leaks, the surgical technique used was: three-field esophagectomy in 14 patients (58.3%), esophagectomy in accordance with IvorLewis technique in 7 patients (29.1%), and transhiatal esophagectomy in 3 patients (12.5%). In 17 of the 24 leaks (70.8%), minimally invasive techniques were used. Of the 24 leakages, nine patients (37.5%) were embolized preoperatively. Of the 24 patients with leakage, 17 (71%) had a cervical anastomosis and 7 had an intrathoracic anastomosis (29%). In eight patients the anastomosis was mechanical side-side type Collard, another eight were Orringer type side-side semi-mechanical, six manual end-side, and two mechanical end-side. Anastomotic leaks were diagnosed between the 2nd and the 15th postoperative day (average 7.6th day). These were classified as Type I, Type II, Type III, and Type IV (Table 2). In 13 patients (54.1%), a stent was placed as part of the treatment. All patients started oral tolerance between the 2nd and 4th day after the placement. Of the remaining 11 patients, 1 patient required emergency surgery and the other 10 were managed with conservative treatment consisting of oral intake, wound drain in the case of local symptoms, nasogastric tube, parenteral nutrition, and antibiotics. Table 3 summarizes the clinical-surgical characteristics of these patients. In the series, the stent placement has not presented any complications of migration, perforation, or hemorrhage. However, one patient, after placing the stent, showed bile reflux that caused pneumonia through aspiration. In another patient, despite the stent, the hole of the fistula increased, producing a large mediastinal abscess leading to reoperation and resection of the gastroplasty. Of the patients with
Table 2
Fig. 3 No fistula with a stent. © 2015 International Society for Diseases of the Esophagus
TYPE TYPE TYPE TYPE
Classification of the anastomotic leaks
I II III IV
Stent
No stent
Total
2 3 8 0
3 5 2 1
5 8 10 1
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Table 3 Variables of the two groups Total leaks Preoperative chemoradiotherapy Yes No Only chemotherapy Embolization Yes No Anastomosis Cervical Thoracic Type anastomosis E-S manual S-S mechanic Mechanical circular Orringer Postoperative day of the fístulae (days) Average Median Stricture Cervical Thoracic Reoperation per anastomotic fistulae (%) Preservation of the digestive continuity Hospital stay (days) Average Median Mortality (%)
Stent (n = 13)
No stent (n = 11)
P value
14 9 1
7 (50%) 5 (55.5%) 1
7 (50%) 4 (45.5%) 0
0.170 — — —
9 15
5 (55.5%) 8 (53.3%)
4 (45.5%) 7 (46.6%)
0.916 —
17 7
8 (47.05%) 5 (71.42%)
9 (52.94%) 2 (28.57%)
0.276 Fisher analysis (0.386)
6 8 2 8
3 (50%) 4 (50%) 1 (50%) 5 (62.5%)
3 (50%) 4 (50%) 1 (50%) 3 (37.5%)
6 5 1 2 22
8.38 7 4 (30.7%) 3 1 1 (7.69%) 12 (92.3%)
7.09 7 2 (18.18%) 2 0 1 (9.09%) 10 (90.9%)
0.901 — — — — — — — 0.621 — 0.475 0.642
44.84 34 1
25.72 28 1
0.104 — 0.902
2
E-S, end-side anastomosis; S-S, side-side anastomosis.
fistula, 91.6% maintain digestive continuity (92.3% with stent and 90.9% without stent). The stent was effective and closed the anastomotic leakage in 12 of the 13 patients, as it was proved through endoscopy when it was removed after the 6th week of the placement. Four patients (30.7%) treated with stent and two patients (18.18%) treated without stent presented anastomotic stricture that required an average of three dilations. Two patients died in the postoperative course. The first died a month after the surgery, suffering an acute respiratory distress syndrome to which was added a nosocomial infection. The second patient also died a month after surgery. It was due to a dehiscence of the anastomotic suture in an Ivor-Lewis surgery. Despite stenting, underwent a purulent mediastinitis and after resurgery with the resection of the gastric plastia and the drainage of the chest cavity, the patient experienced sepsis by Staphylococcus aureus and Candida and a severe systemic inflammatory response syndrome. As for the aforementioned variables, there were no statistically significant differences between patients treated with or without stent (Table 3).
DISCUSSION Surgery is a potentially curative treatment for esophageal cancer. However, it has high morbidity and mortality associated with, above all, complications such as anastomotic leak5 and respiratory probC 2015 International Society for Diseases of the Esophagus V
lems. With the presence of a leak, the required artificial feeding period, the average stay in the ICU, and finally the hospital stay are lengthened.6,7 The determinants of anastomotic leak can be derived from the patients’ conditions such as malnutrition and immunosuppression or derived from the surgical technique like insufficient perfusion of the plasty, the diameter of the gastric conduit, and anastomosis tension.8 Many authors in the literature9–12 show a reduced leak rate and improved perfusion of the gastric conduit after embolization or ligation of the left gastric artery 1 or 2 weeks before the surgery. In our cases, the leak rate in embolized patients was 39.1% (9/23) and 16.7% (15/90) in nonembolized patients. However, we are analyzing if this apparent difference is because of the embolization or due to other factors such as the type of esophagectomy (Ivor-Lewis vs. total esophagectomy), due to the small diameter of the plasty (3–4 cm), or due to the features noted above. The location of the leak, its extension, the presence or absence of necrosis of the gastroplasty, the time of the progression, and the systemic response indicate the severity of the case.13 The leak rate after esophagectomies is 21.23% in our series (20.6% in intrathoracic anastomoses and 21.5% in cervical anastomoses). It is high, but in the literature, the incidence of thoracic anastomotic leaks is 3–25%7,13 and 10–25% at the cervical region.6,14 On the other hand, Luketich et al.15 shows 5% and 4% at cervical and thoracic anastomotic leaks rates, respectively, in a review of over a thousand © 2015 International Society for Diseases of the Esophagus
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esophagectomies. However, he presents the anastomotic leaks requiring surgery, but we do not know the real anastomotic leak rate. Because of that, a good classification1,16 of leaks is critical for the therapeutic management of these, which can vary from a simple conservative approach17 in Type I to reoperation in type IV. It is in the type III leaks, both cervical and intrathoracic, in which it is essential to control the leak into the pleural cavity, where the minimally invasive techniques such as intraluminal and submucosal application of glue fibrin, the placement of metal clips, or endoscopic intraluminal stenting have gained prominence in the last decade.18–21 Different groups in the literature like Turkyilmaz et al.1 or Griffin et al.22 have suggested diagnostic and therapeutic algorithms. In our center, among the minimally invasive techniques mentioned above, we only work with the stent in accordance with an algorithm that we have published recently.4 Historically, the permanent metallic stent has been used as a palliative treatment in unresectable esophageal tumors to prevent the obstruction of the lumen of the digestive tract or in tracheoesophageal fistulas.23 Metallic stent covering is in order to resist the acid reflux for long-term implantation. Currently, the indications have been increased, and it has been observed they may be useful in the treatment of the esophagogastric anastomotic leaks.1 The covered metal stent may be a therapeutic option that is feasible, safe, and effective in treating anastomotic fistulas after esophagectomies without adding significant morbidity and mortality, ensuring an uninterrupted digestive tract.3 There are also plastic stents. These stents are characterized by a smooth surface that facilitates retrieval but favors migration. On the other hand, the metallic covered stent that we used has an antimigration collar that prevents the displacement. In patients with an anastomotic leak after esophagectomy who have not developed a sepsis, the stent may prevent reoperation as observed in our study. An early diagnosis of the leak is crucial. In our center, we began using the stent in 2003. In the beginning, we had no specific indication protocol, but over the years, we have been refining the indications to establish the algorithm with which we currently work. We consider type III leaks, both cervical and intrathoracic, as absolute indication for stent implantation and as a relative indication in type II cervical fistulas, where we will implant the stent in longstanding fistulas or if the size of the fistula are considerable (see the algorithm). The stent, therefore, plays an important role in intrathoracic fistulas and less in the neck, because neck fistulaes are easier to control and have less impact on the patient’s symptoms.13 Even in the stent placement, it is important to have good drainage of the cervical, mediastinal, or pleural abscess, whether by opening the cervical incision or placing a chest tube. In our case, we have © 2015 International Society for Diseases of the Esophagus
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placed the stent in 47.05% (8/17) of cervical leaks and in 71.42% (5/7) of intrathoracic leaks. This five patients would have been reoperated on if we had not treated them with a stent, and they would probably have had an esophagostomy, gastrostomy, and yeyunostomy. Ye et al. propose stenting anastomotic leaks after surgery for esophageal carcinoma in thoracic fistulas as long as the patients’ symptoms allow it. They indicate reoperation in the case of: an early anastomotic leak, necrosis of gastroplasty and encapsulated empyema, poorly drained with routinary methods, and significant toxic symptoms.24 At the moment of the implantation of the stent, the radiologists confirm that there is no residual leak with the swallow of contrast. In our series, patients initiated oral tolerance on the second to the fourth day after stent placement; however, other authors such as Dai et al.25 begin the oral intake immediately after the stenting. If the patients continue with infection symptoms, we do CT controls with oral contrast, so we can see if there is any abscess without drainage and/or if the stent is effective, at the same time. We do not know exactly how long the leaks take to heal with the stent, but after 6–8 weeks, it is completely closed. In the case of patients without stent, it varies from 5 to 30 days. There have been multiple adverse effects and complications such as pain, nausea, acid reflux, bowel obstruction, hemorrhage, perforation of viscera, or stent displacement26 due to the stent implantation and extraction. The stents may require their own reintervention because of stent migration, patient discomfort, or a persistent leak.26 Siersema27 presented 11 cases in which they use metal stents and one stent removal was very difficult, causing tracheoesophageal fistula. Roy-Choudhury et al.28 presented a study of 10 patients with gastroesophageal fistula where metallic stent have been placed, and in four of these patients, there were complications such as bleeding and difficulty in eating. In our 13 cases, most of them, especially those with cervical stents, present local pressure in the first 2 days that is well controlled with analgesics. We observed only two complications in our patients: pneumonia per aspiration and a decubitus of the stent that forced a bipolar exclusion of the plasty. None of the cases has needed to be replaced because of migration of the stent. In the literature, the rate of plastic stent migration is 10–35%.29–31 Of the patients, 92.3% with a stent and 90.9% without a stent preserve digestive continuity. Even if there is no difference between the two groups, we think that some patients with stent would have required reoperation with probable disconnection of the digestive tract. The follow-up period is ongoing in these patients. For the first 3 years after surgery, we see the patients every 6 months with blood tests and TC. After that, we see them every year. If the patient refers C 2015 International Society for Diseases of the Esophagus V
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dysphagia, we apply for an endoscopy and esophagogram. Among the long-term complications, we have observed that 4 patients treated with stent (30.7%) and only 2 of the 11 patients treated without stent (18.18%) presented anastomotic stricture. The endoscopists do the dilations on average three times in each patient. Several authors like Dai et al. (2009 and 2011), Dormann et al., and Schubert et al.25,29,32,33 present their experiences with plastic stents made of polyester and covered by a silicone membrane, and it seems that they have fewer complications than with metal stents. According to Langer et al.,34 after the stent placement, the average of the hospital stay decreases, giving an average of 8 days prior to discharge. RoyChoudhury et al.28 show an average stay of 17 days after the stent placement in their study. Our average hospital stay is 44.84 days in stented patients (median 34 days) and 25.72 days in patients without stent (median 28 days). This increase in the average stay in the patients with stent could be because the indication of the stent was performed on patients with more severe and major clinical impact of the anastomotic leakage such as the intrathoracic leakage. There is no difference in the length of stay if we compare cervical leaks with thoracic leaks (36.9 and 38.1 days, respectively). The removal of the stent was performed by the interventional radiologist and endoscopist on the sixth week of the placement. This is because after that period, it is more difficult to remove the stent because of the integration of the stent to the cicatricial tissue.27 Radecke et al.30 and Dai et al.25 removed the stent on the 14th day of the placement, but it should be noted that unlike us, these authors work with plastic stents. Dai et al.25 presented the study with the highest number of stents with 4.5% of mortality rate in the 22 patients. In our review of 13 fistulaes with stenting, one patient died (mortality = 7.69%). The presented report has many limitations. First is the small number of cases reported because of the fact that this esophageal disease is not very common in our hospital (14 cases/year). Second, it is a retrospective study and stenting was not performed according to a protocol. It has been used as a noninvasive tool that prevented reoperations in some patients. Later, after analyzing the results, we performed an intervention algorithm. Third, the cases of patients in whom the stent was placed and in whom the treatment was conservative are not comparable. All patients with thoracic anastomotic leak in whom the stent was placed (five cases) would have been reoperated on for drainage or for exclusion of the anastomosis. On the other hand, the reason why the patients with thoracic fistulas were treated without stent was that the diagnosis of fistulas was radiological with no clinical consequences for the patient. In addition, nine patients with cerC 2015 International Society for Diseases of the Esophagus V
vical fistulas and without stent developed favorably because the control of the fistula at this level was sufficient with conservative treatment. The eight patients with an anastomotic leak in the neck and who were stented would probably not be suited to this treatment today, unless the fistulas output was very big. In conclusion, the expandable metallic stent may be a therapeutic treatment in anastomotic leaks after esophagectomies. However, the stent is not indicated in all fistulaes, but only in those of great size in the neck or in intrathoracic ones. In our experience, the stent has prevented reoperations, which involved high morbidity and mortality. However, the average hospital stay has not decreased. In this review, we wanted to present our experience with the use of the stent in the esophageal fistulae, hoping to learn from other working groups and improve the results indicated.
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15 Luketich J, Pennathur A, Awais O et al. Outcomes after minimally invasive esophagectomy; review of over 1000 patients. Ann Surg 2012; 256: 95–103. 16 Lerut T, Coosemans W, Decker G, De Leyn P, Nafteux P, van Raemdonck D. Anastomotic complications after esophagectomy. Dig Surg 2002; 19: 92–8. 17 Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg 1998; 85: 1446–9. 18 Pross M, Manger T, Reinheckel T, Mirow L, Kunz D, Lippert H. Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses. Gastrointest Endosc 2000; 51: 73–6. 19 Brown T H, Nicholson D A, Irving M H, Bancewics J. Use of a self expanding metal stent for oesophagogastric fistulation. Br J Surg 1995; 82: 663–4. 20 Bethge N, Sommer A, Vakil N. Treatment of esophageal fistulas with a new polyurethane-covered, self-expanding mesh stent: a prospective study. Am J Gastroenterol 1995; 90: 2143–6. 21 Freeman R K, Ascioti A J, Wozniak T C. Postoperative leak management with the Polyflex esophageal stent. J Thorac Cardiovasc Surg 2007; 133: 333–8. 22 Griffin S M, Lamb P J, Dresner S M, Richardson D L, Hayes N. Diagnosis and management o fa mediastinal leak following radical oesophagectomy. Br J Surg 2001; 88: 1346–51. 23 Siddiqui A, Salkar A, Beltz S et al. Placement of fully covered self-expandable metal stents in patients with locally advanced esophageal cancer before neoadjuvant therapy. Gastrointest Endosc 2012; 76: 44–51. 24 Ye H, Huang W, Wu Y et al. Personalized management of anastomotic leak after surgery for esophageal carcinoma. Chin Med Sci J 2012; 27: 35–40. 25 Dai Y Y, Gretschel S, Dudeck O, Rau B, Schlag P M, Hünerbein M. Treatment of oesophageal anastomotic leaks by
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temporary stenting with self-expanding plastic stents. Br J Surg 2009; 96: 887–91. David E A, Kim M P, Blackmon S H. Esophageal salvage with removable covered self-expanding metal stents in the setting of intrathoracic esophageal leakage. Am J Surg 2011; 202: 796– 801. Siersema P D. Treatment of esophageal perforations and anastomotic leaks: the endoscopist is stepping into the area. Gastrointest Endosc 2005; 65: 897–900. Roy-Choudhury S H, Nicholson A A, Wedwood K R et al. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stent. AJR Am J Roentgenol 2001; 176: 161–5. Dai Y, Chopra S, Kneif S, Hünerbein M. Management of esophageal anastomotic leaks, perforations and fistulae with self-expanding plastic stents. J Thorac Cardiovasc Surg 2011; 141: 1213–17. Radecke K, Lang H, Frilling A, Gerken G, Treichel U. Successful sealing of benign esophageal leaks after temporary placement of a self-expanding plastic stent without fluoroscopic guidance. Z Gastroenterol 2006; 44: 1031–8. Conigliaro R, Battaglia G, Repici A et al. Polyflex stents for malignant oesophageal and oesophagogastric stricture: a prospective, multicentric study. Eur J Gastroenterol Hepatol 2007; 19: 195–203. Dormann A J, Eisendrath P, Wigginghaus B, Huchzermeyr H, Deviere J. Palliation of esophageal carcinoma with a new selfexpanding plastic stent. Endoscopy 2003; 35: 207–11. Schubert D, Scheidbach H, Kuhn R et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stent. Gastrointest Endosc 2005; 61: 891–6. Langer F B, Wenzl E, Prager G et al. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 2005; 79: 398–404.
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