Ann Thorac Surg 2006;82:706-707
© 2006 The Society of Thoracic Surgeons
New technology
Invited commentary
Charles Peter Clarke, MB, BS
Department of Thoracic Surgery, Austin Health, Studley Rd, Heidelberg, Victoria 3079 Australia
(Email: clarkecp{at}bigpond.com.au).
Anastomotic leaks are a feared hazard of esophageal surgery as they are associated with a significant mortality and morbidity. Although their occurrence can be kept low by good technique, including the avoidance of tension at the anastomosis, ensuring an adequate blood supply and avoidance of postoperative hypotension, few series have a zero incidence.
When they do occur it is necessary to be sure that there is adequate drainage of the area and no distal obstruction of the conduit. Unless a prophylactic feeding jejunostomy was placed at the initial procedure maintaining adequate nutrition can be a problem. Should the patient be re-explored and the leak re-sutured, or can it be treated conservatively? Re-exploration is a further major procedure, but conservative management allows ongoing contamination of the mediastinum or pleural space with infected irritating material and can be associated with difficulties in the maintenance of nutrition.
Attempts to close the leak endoscopically with glue or stents have previously been disappointing. The current generation of stents often fail to close the leak, are prone to migration, and some are difficult to retrieve later.
Han and associates [1] have described the successful use of an ingenious covered mushroom-shaped metallic, expandable stent that reliably closed the leak, was kept in position by means of a thread attached to the ear, and was easily retrieved once the leak had closed. This prevented continued soiling of the mediastinum and allowed early resumption of feeding. If larger series confirm their reliability, they will prove a useful method of controlling leaks, and although some patients may find wearing the anchor line for a month or so irritating, it would be an improvement to the alternative.
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References
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- Han X-W, Li Y-D, Wu G, Li M-H, Ma X-X. New covered mushroom-shaped metallic stent for managing anastomotic leak after esophagogastrostomy with a wide gastric tube Ann Thorac Surg 2006;82:702-707.[Abstract/Free Full Text]
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