Therapy of Anastomotic Leaks by Means of Covered Self-Expanding Metallic Stents after Esophagogastrectomy

Background and Study Aims: The mortality rate for surgical revision of gastroesophageal anastomotic leakage after resection for cancer approximates 60 %. The efficacy of endoscopically placed covered metallic stents for treatment of gastroesophageal leakage was evaluated.
Patients and Methods: Between June 1996 and June 2002 we treated 21 patients with proven gastroesophageal leakage; 18 had anastomotic leakage and three patients had perforation for different reasons. The extent of the leaks ranged from one-quarter of the intestinal circumference to its complete dehiscence. The average time from surgery to detection of leakage was 6.1 days (range 3 - 15 days). Mortality, healing rate, length of hospital stay, and complications were assessed.
Results: The insertion of stents was performed endoscopically under radiological guidance without any complication in all patients. In 9.5 % (2/21) of patients complete sealing of the leak was not achieved. The mortality associated with anastomotic leakage was 23.8 % (5/21). In 80.1 % (17/21) patients complete healing of the leakage was achieved. The average hospital stay was 67 days (range 14 - 158 days). Of 23 stents, 13 (56.5 %) were removed, and three patients developed stenosis after removal.
Conclusion: The treatment of gastroesophageal leakage with covered stents appears to reduce mortality and the complication rate associated with major leakage. Therefore this technique seems to be a reasonable alternative in the treatment of clinically relevant anastomotic leakage.

References

• 1 Heitmiller R F, Fischer A, Liddicoat J R. Cervical esophagogastric anastomosis: results following esophagectomy for carcinoma.  Dis Esophagus. 1999;  12 264-269
• 2 Boyle M J, Franceschi D, Livingstone A S. Transhiatal versus transthoracic esophagectomy: complication and survival rates.  Am Surg. 1999;  65 1137-1141, discussion 1141 - 1142
• 3 Zieren H U, Muller J M, Pichlmaier H. Prospective randomized study of one- or two-layer anastomosis following oesophageal resection and cervical oesophagogastrostomy (see comments).  Br J Surg. 1993;  80 608-611
• 4 Gelfand G A, Finley R J, Nelems B. et al . Transhiatal esophagectomy for carcinoma of the esophagus and cardia. Experience with 160 cases.  Arch Surg. 1992;  127 1164-1167, discussion 1167 - 1168
• 5 Karl R C, Schreiber R, Boulware D. et al . Factors affecting morbidity, mortality, and survival in patients undergoing Ivor Lewis esophagogastrectomy.  Ann Surg. 2000;  231 635-643
• 6 Nguyen N T, Follette D M, Wolfe B M. et al . Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy.  Arch Surg. 2000;  135 920-925
• 7 King R M, Pairolero P C, Trastek V F. et al . Ivor Lewis esophagogastrectomy for carcinoma of the esophagus: early and late functional results.  Ann Thorac Surg. 1987;  44 119-122
• 8 Paterson I M, Wong J. Anastomotic leakage: an avoidable complication of Lewis-Tanner oesophagectomy.  Br J Surg. 1989;  76 127-129
• 9 Schmid A, Thybusch A, Kremer B, Henne-Bruns D. Differential effects of radical D2-lymphadenectomy and splenectomy in surgically treated gastric cancer patients.  Hepatogastroenterology. 2000;  47 579-585
• 10 Urschel J D. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review.  Am J Surg. 1995;  169 634-640
• 11 Lang H, Piso P, Stukenborg C. et al . Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma.  Eur J Surg Oncol. 2000;  26 168-171
• 12 Patil P K, Patel S G, Mistry R C. et al . Cancer of the esophagus: esophagogastric anastomotic leak - a retrospective study of predisposing factors.  J Surg Oncol. 1992;  49 163-167
• 13 Giuli R, Gignoux M. Treatment of carcinoma of the esophagus. Retrospective study of 2400 patients.  Ann Surg. 1980;  192 44-52
• 14 Rodella L, Laterza E, de Manzoni G. et al . Endoscopic clipping of anastomotic leakages in esophagogastric surgery.  Endoscopy. 1998;  30 453-456
• 15 Infante M, Valente M, Andreani S. et al . Conservative management of esophageal leaks by transluminal endoscopic drainage of the mediastinum or pleural space.  Surgery. 1996;  119 46-50
• 16 Adler D G, McAfee M, Gostout C J. Closure of an esophagopleural fistula by using fistula tract coagulation and an endoscopic suturing device.  Gastrointest Endosc. 2001;  54 652-653
• 17 Ell C, May A, Hahn E G. Gianturco-Z stents in the palliative treatment of malignant esophageal obstruction and esophagotracheal fistulas [published erratum appears in Endoscopy 1995; 27 : 714].  Endoscopy. 1995;  27 495-500
• 18 Dorta G, Binek J, Blum A L. et al . Comparison between esophageal Wallstent and Ultraflex stents in the treatment of malignant stenoses of the esophagus and cardia.  Endoscopy. 1997;  29 149-154
• 19 Bruckner M, Grimm H, Nam V C, Soehendra N. Experience with a transnasally fixed endoprosthesis for treating esophageal anastomotic leakage.  Surg Endosc. 1991;  5 185-188
• 20 Roy-Choudhury S H, Nicholson A A, Wedgwood K R. et al . Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents.  Am J Roentgenol. 2001;  176 161-165
• 21 Bone R C, Sibbald W J, Sprung C L. The ACCP-SCCM consensus conference on sepsis and organ failure.  Chest. 1992;  101 1481-1483
• 22 Matory Y L, Burt M. Esophagogastrectomy: reoperation for complications.  J Surg Oncol. 1993;  54 29-33
• 23 Pross M, Manger T, Reinheckel T. et al . Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses.  Gastrointest Endosc. 2000;  51 73-76
• 24 Song H Y, Park S I, Do Y S. et al . Expandable metallic stent placement in patients with benign esophageal strictures: results of long-term follow-up.  Radiology. 1997;  203 131-136
• 25 Abe T, Tangoku A, Hayashi H. et al . Esophageal perforation and mediastinal abscess following placement of a covered self-expanding metallic stent and radiation therapy in a cancer patient.  Surg Endosc. 1999;  13 1044-1046