Ann Thorac Surg 2008;85:354-356. doi:10.1016/j.athoracsur.2007.06.044
© 2008 The Society of Thoracic Surgeons
How To Do It
Self-Expandable Covered Metal Tracheal Type Stent for Sealing Cervical Anastomotic Leak After Esophagectomy and Gastric Pull-Up: Pitfalls and Possibilities
Joerg Lindenmann, MD*,
Veronika Matzi, MD,
Christian Porubsky, MD,
Udo Anegg, MD,
Oliver Sankin, MD,
Sabine Gabor, MD,
Nicole Neuboeck, MD,
Alfred Maier, MD,
Freyja Maria Smolle-Juettner, MD
Division of Thoracic and Hyperbaric Surgery, Department of Surgery, Medical University Graz, Graz, Austria
Accepted for publication June 15, 2007.
* Address correspondence to Dr Lindenmann, Department of Surgery, Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Auenbruggerplatz 29, Graz, 8036, Austria (Email: jo.lindenmann{at}meduni-graz.at).
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Abstract
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From January 2003 to June 2006, 6 patients with leakage of the cervical esophagogastrostomy after esophagectomy and gastric pull-up underwent endoscopic stenting using the self-expandable covered tracheal type device. Anastomotic healing was satisfactory. Stent extraction was performed after an average interval of 91 days. Initial stent migration occurred in 2 patients and post-extraction stenosis developed in 3 patients. Insertion of a self-expandable covered metal tracheal stent represents a safe approach resulting in immediate closure and subsequent healing of cervical anastomotic leakage.
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Introduction
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The choice of the management of leakage of the cervical esophagogastrostomy depends on the patient’s condition and the extent of the leakage. Conservative treatment is eventually successful in most small dehiscences, whereas redo surgery has been suggested for large leaks. We believe that the use of a covered metal tracheal type stent for occlusion of the leakage has not been previously described.
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Technique
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Between January 2003 and June 2006, 6 patients with cervical anastomotic leak after transhiatal or transthoracic esophagectomy and gastric pull-up underwent stenting using the self-expandable tracheal type covered metal stent.
Leakages occurred at intervals between 10 and 14 days postoperatively (mean, 12.3 ± 1.6 days postoperatively). The extent of the lekages ranged from about 10% to 30% of the anastomotic circumference (Fig 1). Peri-anastomotic abscess formation was detected in five instances. In these cases, the cervical wound was reopened for evacuation of pus and debris. The site was left open for the daily change of dressings and secondary wound closure.
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Fig 1. Endoscopic view of an anastomotic dehiscence from the cervical esophago-gastrostomy after esophagectomy and gastric pull-up with the inserted guidewire. The extent of the dehiscence is about 30% of the overall anastomotic circumference.
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A self-expandable covered metal tracheal stent (Boston Scientific Ultraflex; Boston Scientific Corp, Natick, MA) was used in all cases. This type of stent is a compound of a metal wire mesh completely covered by a silicone membrane. We used 60-mm long devices with an outer diameter of 20 or 22 mm.
Stent insertion was performed endoscopically under fluoroscopic control. Care was taken to position the upper rim of the stent at least 1.5 cm below the upper esophageal sphincter. After deploying the stent, the applicator and guidewire were removed (Fig 2) and control endoscopy was performed (Fig 3). Broad spectrum intravenous antibiotic treatment was initiated and oral intake was stopped until the effectiveness of leak occlusion had been documented by fluoroscopy on the following day (Fig 4). In case of successful stenting, oral nutrition with a semi-liquid diet was started on the first postinterventional day.
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Fig 3. Occlusion of the leakage by the self-expandable covered metal tracheal stent. Note the stent fully expanded with its proximal margin below the upper esophageal sphincter.
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Fig 4. Control fluoroscopy 24 hours after endoscopic stent insertion. Note the successfully occluded leakage and the fully expanded stent.
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The patients were discharged for outpatient care when their course was uneventful throughout the following week. The cervical wound was surgically closed before discharge in 5 patients and the wound was minor and left for spontaneous closure and daily change of dressings in 1 patient. One week after stent insertion, each patient underwent a physical examination, a chest roentgenogram, and an esophagogram. Depending on the initial extent of the dehiscence, endoscopic stent extraction was scheduled after 2 to 6 weeks.
Stent migration occurred on the post-interventional days 1 and 6 in 2 patients. These patients underwent stent removal and re-stenting using the same type of stent with a larger outer diameter.
The devices were removed after a mean of 91 days (range, 12 to 230 days) in the 4 patients who had definitive successful stenting. One patient did not show up for stent extraction. After 145 days another patient declined stent extraction for more than 7 months. Endoscopy, as well as contrast swallow, showed complete healing of the anastomosis in all of the patients. The local mucosal condition was nearly undamaged; even after 230 days of stenting there was no evidence of endoluminal hyperproliferative granulation tissue (Fig 5).
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Fig 5. Endoscopic view of the sealed anastomotic leakage after stent extraction 6 weeks after stent insertion. Complete mucosal healing was obtained.
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After stent extraction, an anastomotic stricture developed within 3 to 20 weeks in 3 of 6 patients. All strictures were successfully treated by endoscopic dilatation. The need for dilation after stent extraction did not correlate with previous re-stenting.
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Comment
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According to recent literature, anastomotic leakage of the cervical esophagogastrostomy is reported in 10% to 30% of patients after esophagectomy and reconstruction with gastric pull-up [1]. Ischemia of the gastric fundus and errors in surgical technique [2] are major causative factors. Although self-expanding plastic stents and self-expanding covered metal esophageal stents (SEMS) for sealing postoperative anastomotic esophageal leaks have been repeatedly reported in the literature [3–8], we believe that the use of a single, totally covered metal tracheal stent in the management of leakage from the cervical esophagogastrostomy has never been previously described.
The effectiveness of leak occlusion and stent functionality depends on stent size and correct placement of the tracheal stent. Initially we used tracheal stents with diameters of 20 and 22 mm. However, stent dislocation occurred in 2 of 6 patients, and diameters of 24 mm had to be chosen. In comparison, authors using plastic stents obtained migration rates ranging from 17% to 38% [3–8]. The proximal stent ostium has to be placed well below the upper esophageal sphincter to prevent dysphagia, reflux, and aspiration.
The high expansion force and elasticity of the tracheal stent allow for hourglass-like deformation, even in presence of a distinct anastomotic ring. The device should be adapting tightly to the anastomotic region and to the esophageal wall, which is mandatory for an uneventful healing.
Leak occlusion was possible in all of our patients, whereas other authors report occlusion rates ranging from 33% to 92% [3–7]. Although some authors prefer esophageal stents with lengths ranging from 90 to 150 mm [3, 4], in our opinion, 60 mm is sufficient for a tracheal stent to enable uneventful healing of the anastomotic leakage.
Patient comfort after stenting was high. The flexible texture of the stent hardly caused any local discomfort. One day after insertion, oral intake of fluids, semi-solids, and well chewed food was possible without any problems, and healing of the anastomosis and the cervical wound, respectively, were uneventful.
A certain yield to peristaltic movements and to changes of intraluminal pressure persists in the stented region, which may be the reason why no events of bolus impaction were observed.
After stent removal the mucosal surface was intact in all cases. Late complications after stenting (such as tracheal compression, fistula, bleeding, or ulcer [4, 7]) were not observed in our patients. Nevertheless, bouginage due to stricture developing within the first 5 months after stent removal was required in 3 patients.
Our results suggest that management of leakage from cervical esophagogastrostomy by stenting, using the self-expandable covered metal tracheal type stent, might reduce mortality, morbidity, and hospitalization.
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References
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- Hsu HH, Chen JS, Huang PM, Lee JM, Lee YC. Comparison of manual and mechanical cervical esophagogastric anastomosis after esophageal resection for squamous cell carcinoma: a prospective randomized controlled trial Eur J Cardiothorac Surg 2004;25:1097-1101.[Abstract/Free Full Text]
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- Langer FB, 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.[Abstract/Free Full Text]
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- Schubert D, Scheidbach H, Kuhn R, et al. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents Gastrointest Endosc 2005;61:891-896.[Medline]
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- Doniec JM, Schniewind B, Kahlke V, Kremer B, Grimm H. Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy Endoscopy 2003;35:652-658.[Medline]
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Abstract
Introduction
