Ann Thorac Surg 2005;79:404
© 2005 The Society of Thoracic Surgeons
INVITED COMMENTARY
Rudy Lackner, MD
University of Nebraska, Nebraska Medical Center, Omaha, NE 68198-4030
(E-mail: rlackner{at}unmc.edu).
Technologic advances have facilitated the management of many postsurgical complications. When applied to the correct patient, at the appropriate time, these techniques can facilitate recovery of the patient and avoid the morbidity and possible mortality associated with an operative reintervention, often in a critically ill patient. Crucial to the success of these endeavors is early intervention when a complication develops, and also the ability to recognize the failure of nonoperative intervention early enough in the course to resort to an alternate plan to salvage the situation.
Langer and colleagues report on the use of stents to manage esophageal anastomotic leaks, both cervical and intrathoracic. Despite many modifications, this complication still occurs in 10% to 33% of resections. The authors utilized the Polyflex stent (Willy Ruesch GMBH, Kernan, Germany) to endoscopically manage this vexing, and potentially lethal complication. The goals of stenting appeared twofold; one to prevent death from continued soiling of the mediastinum, and one for the cervical anastomoses, prevention of the strictures often associated with a cervical leak.
This report clearly describes the good, the bad, and the ugly associated with this technique. The good is those patients whose leaks were successfully managed nonoperatively. Their leaks were sealed and no further operative intervention was required. The bad were the patients who succumbed despite having been stented, leaving one to question the timeliness and adequacy of the intervention. Would takedown of the anastomosis and/or diversion been the optimum choice? The ugly may be seen in an early and a late phase. The early phase occurring in the patients whose anastomoses were further disrupted by stent placement, thus requiring an emergent operation to achieve any chance of survival. The late phase we can foresee in the group of patients left with those "benign" stents in place. Gaissert and colleagues [1] have recently described the problems resulting from the placement of stents in the airway in lieu of definitive surgical repair. One has to be concerned regarding the development of vascular and airway fistulas in the patients left stented indefinitely. Stenosis of the esophagus proximal to these stents will not leave us much room to work, and result in a miserable existence for the patient.
As esophageal surgeons we should keep an open mind to the use of these devices in the management of our postoperative complications, but not be lulled into a false sense of security that a nonoperative approach is always better than a well done operation.
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References
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- Gaissert HA, Grillo HC, Wright CD, et al. Complications of benign tracheobronchial strictures by self-expanding metal stents J Thorac Cardiovasc Surg 2003;126:744-747.[Abstract/Free Full Text]
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