Treating Benign Esophageal Ruptures and Anastomotic Leaks
Treating Benign Esophageal Ruptures and Anastomotic Leaks
In total, 52 patients treated with 83 covered self-expandable stents were included in three different hospitals (University Medical Center Utrecht n = 25, Medical College of Wisconsin, Milwaukee n = 15 and Antonius Ziekenhuis Nieuwegein n = 12). Clinical characteristics of the patients are shown in Table 1. More than half of the patients had an anastomotic leak after gastrectomy with esophagojejunostomy (n = 15), (transhiatal) esophagectomy with gastric tube formation (n = 9), gastric bypass (n = 6) or resection of an esophageal diverticulum (n = 1). Iatrogenic esophageal ruptures occurred during the following procedures: pneumatic dilation (n = 6), tracheal intubation (n = 3), esophageal stenting for benign strictures (n = 2), Nissen fundoplication (n = 1), a Belsey Mark IV procedure (n = 1) and medianoscopic biopsy taking (n = 1). Other causes included Boerhaave syndrome (n = 4), a rupture following radiation therapy (n = 1), spontaneous rupture above an impacted food bolus (n = 1) and disruption of a mediastinal abscess (n = 1). Most patients (n = 41 (79%)) received antibiotic treatment. In 24 (46%) patients, concurrent drainage of the pleural cavity (n = 12), mediastinum (n = 4) or both (n = 8) was performed either surgically (n = 18 (75%)) or radiologically (n = 6 (25%)).
In total, 83 stents (median 1, range 1–10) were placed, of which 61 (74%) were PSEMS, 15 (18%) FSEMS and 7 (8%) SEPS. The median number of days of stent placement was 39 days (range 1–742). In one patient with an anastomatic leak after (transhiatal) esophagectomy, a total of 10 stents was placed resulting in a total stenting time of 742 days.
Median follow up was 470 days (range 25–1200 days).
Eighty-two of 83 (99%) stents were successfully placed (Table 2). In one patient, a PSEMS was placed too proximally and could not be repositioned. Therefore, a second PSEMS was placed inside the stent during the same procedure which successfully covered the leak.
In total, 71 (86%) stents were endoscopically removed after a median of 25 (range 1–197) days (PSEMS 24 (1–197) days, FSEMS 23 (1–120) days, SEPS 42 (14–90) days) (p = 0.50). Of these, 52 were removed according to the scheduled treatment plan, while the other 19 were removed earlier due to the occurrence of complications (Table 2). Endoscopic stent removal was successful in all but eight patients with a PSEMS due to tissue in- and/or overgrowth. In four of these patients, a FSEMS was placed inside the PSEMS to achieve pressure necrosis, after which the stent could be removed successfully (stent-in-stent method). In one patient, the stent was successfully removed during a follow-up endoscopic procedure 4 days later. In one patient esophagectomy was performed for removal of the stent. In two patients, a rupture occurred during stent removal, which necessitated placement of another stent during the same procedure to seal the rupture. These two stents could be removed uneventfully, 17 and 23 days after placement.
Clinical success was achieved in 34 (76%, ITT: 65%) patients (PSEMS: 73%, ITT: 69%; FSEMS: 83%, ITT: 56%; SEPS: 83%, ITT: 71%, p = 0.33) after a median of 1 (range 1–5) stent and a median stenting time of 39 (range 7–120) days (Figure 1, Table 2). Of the other 18 patients, 4 patients underwent surgical treatment (3 esophagectomy, 1 surgical repair), 2 patients had further conservative treatment, 7 died before stent removal. One (2%) patient treated with FSEMS died from a stent-related death (severe hemorrhage); this patient refused further interventions. Another four patients died from rupture-related causes (sepsis), one patient from underlying malignant disease and one patient from active euthanasia.
(Enlarge Image)
Figure 1.
Endoscopic view: A Iatrogenic rupture following pneumodilation, B Partially covered metal stent placed in the esophageal lumen sealing the rupture, C Healed rupture after stent removal.
In total, 33 complications in 24 patients (46%) occurred (tissue in- and/or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (n = 6), food obstruction (n = 3), severe retrosternal pain (n = 2), esophageal rupture due to stent removal (n = 2) and hemorrhage (n = 2)) (Table 3). Stent migration occurred most frequently with FSEMS (20%), followed by SEPS (14%) and PSEMS (10%), while tissue in- and/or overgrowth was only seen with PSEMS (11%). Ruptured stent covers were only seen with Ultraflex stents. In addition, severe pain and food obstruction were also only seen in patients treated with PSEMS. In both patients with unbearable pain, the stent was removed after 1 and 6 days. One patient underwent surgical treatment (n = 1), while the other patient had conservative treatment (n = 1). One hemorrhage occurred with a FSEMS and the other with a PSEMS. One patient died (see above), while the hemorrhage in the other patient was treated successfully with adrenaline injections. Two esophageal ruptures occurred during removal of PSEMS. Ruptures occurred at the site of the uncovered stent meshes and these were treated with a second stent (see above).
Results
Clinical Characteristics
In total, 52 patients treated with 83 covered self-expandable stents were included in three different hospitals (University Medical Center Utrecht n = 25, Medical College of Wisconsin, Milwaukee n = 15 and Antonius Ziekenhuis Nieuwegein n = 12). Clinical characteristics of the patients are shown in Table 1. More than half of the patients had an anastomotic leak after gastrectomy with esophagojejunostomy (n = 15), (transhiatal) esophagectomy with gastric tube formation (n = 9), gastric bypass (n = 6) or resection of an esophageal diverticulum (n = 1). Iatrogenic esophageal ruptures occurred during the following procedures: pneumatic dilation (n = 6), tracheal intubation (n = 3), esophageal stenting for benign strictures (n = 2), Nissen fundoplication (n = 1), a Belsey Mark IV procedure (n = 1) and medianoscopic biopsy taking (n = 1). Other causes included Boerhaave syndrome (n = 4), a rupture following radiation therapy (n = 1), spontaneous rupture above an impacted food bolus (n = 1) and disruption of a mediastinal abscess (n = 1). Most patients (n = 41 (79%)) received antibiotic treatment. In 24 (46%) patients, concurrent drainage of the pleural cavity (n = 12), mediastinum (n = 4) or both (n = 8) was performed either surgically (n = 18 (75%)) or radiologically (n = 6 (25%)).
In total, 83 stents (median 1, range 1–10) were placed, of which 61 (74%) were PSEMS, 15 (18%) FSEMS and 7 (8%) SEPS. The median number of days of stent placement was 39 days (range 1–742). In one patient with an anastomatic leak after (transhiatal) esophagectomy, a total of 10 stents was placed resulting in a total stenting time of 742 days.
Median follow up was 470 days (range 25–1200 days).
Stent Placement and Removal
Eighty-two of 83 (99%) stents were successfully placed (Table 2). In one patient, a PSEMS was placed too proximally and could not be repositioned. Therefore, a second PSEMS was placed inside the stent during the same procedure which successfully covered the leak.
In total, 71 (86%) stents were endoscopically removed after a median of 25 (range 1–197) days (PSEMS 24 (1–197) days, FSEMS 23 (1–120) days, SEPS 42 (14–90) days) (p = 0.50). Of these, 52 were removed according to the scheduled treatment plan, while the other 19 were removed earlier due to the occurrence of complications (Table 2). Endoscopic stent removal was successful in all but eight patients with a PSEMS due to tissue in- and/or overgrowth. In four of these patients, a FSEMS was placed inside the PSEMS to achieve pressure necrosis, after which the stent could be removed successfully (stent-in-stent method). In one patient, the stent was successfully removed during a follow-up endoscopic procedure 4 days later. In one patient esophagectomy was performed for removal of the stent. In two patients, a rupture occurred during stent removal, which necessitated placement of another stent during the same procedure to seal the rupture. These two stents could be removed uneventfully, 17 and 23 days after placement.
Outcome and Survival
Clinical success was achieved in 34 (76%, ITT: 65%) patients (PSEMS: 73%, ITT: 69%; FSEMS: 83%, ITT: 56%; SEPS: 83%, ITT: 71%, p = 0.33) after a median of 1 (range 1–5) stent and a median stenting time of 39 (range 7–120) days (Figure 1, Table 2). Of the other 18 patients, 4 patients underwent surgical treatment (3 esophagectomy, 1 surgical repair), 2 patients had further conservative treatment, 7 died before stent removal. One (2%) patient treated with FSEMS died from a stent-related death (severe hemorrhage); this patient refused further interventions. Another four patients died from rupture-related causes (sepsis), one patient from underlying malignant disease and one patient from active euthanasia.
(Enlarge Image)
Figure 1.
Endoscopic view: A Iatrogenic rupture following pneumodilation, B Partially covered metal stent placed in the esophageal lumen sealing the rupture, C Healed rupture after stent removal.
Complications
In total, 33 complications in 24 patients (46%) occurred (tissue in- and/or overgrowth (n = 8), stent migration (n = 10), ruptured stent cover (n = 6), food obstruction (n = 3), severe retrosternal pain (n = 2), esophageal rupture due to stent removal (n = 2) and hemorrhage (n = 2)) (Table 3). Stent migration occurred most frequently with FSEMS (20%), followed by SEPS (14%) and PSEMS (10%), while tissue in- and/or overgrowth was only seen with PSEMS (11%). Ruptured stent covers were only seen with Ultraflex stents. In addition, severe pain and food obstruction were also only seen in patients treated with PSEMS. In both patients with unbearable pain, the stent was removed after 1 and 6 days. One patient underwent surgical treatment (n = 1), while the other patient had conservative treatment (n = 1). One hemorrhage occurred with a FSEMS and the other with a PSEMS. One patient died (see above), while the hemorrhage in the other patient was treated successfully with adrenaline injections. Two esophageal ruptures occurred during removal of PSEMS. Ruptures occurred at the site of the uncovered stent meshes and these were treated with a second stent (see above).
