Successful Sealing of Benign Esophageal Leaks after Temporary Placement of a Self-Expanding Plastic Stent without Fluoroscopic Guidance

Zusammenfassung

Einleitung: Wir beschreiben unsere Erfahrung mit dem passageren Einsatz eines selbstexpandierenden Plastikstents (SEPS) bei Patienten mit nichtmaligner Ösophagusleckage. Material und Methoden: Zwischen November 2001 und Mai 2005 wurden 10 Patienten mit einer iatrogenen Perforation (n = 4), einer Leckage nach einem ösophagochirurgischen Eingriff (n = 5) und mehreren ösophagomediastinalen Fisteln nach Laugenverätzung (n = 1) durch den passageren Einsatz eines SEPS behandelt. Bei 8/10 Patienten erfolgte die Stentplatzierung aufgrund der Notfallsituation ohne Durchleuchtungskontrolle. Die Stententfernung erfolgte mittels einer Stentfasszange. Ergebnisse: Die Leckagenlokalisation befand sich im proximalen (n = 1), mittleren (n = 6) und distalen (n = 3) Ösophagus. Die mittlere Leckagengröße betrug 2 cm. Eine Stentplatzierung ohne Durchleuchtungskontrolle war in allen Fällen erfolgreich. Die mittlere Dauer der Stenttherapie betrug 55,5 Tage (Spanne 15 - 438 Tage). Ein Verschluss der Leckage zeigte sich nach komplikationsloser Stententfernung bei 7/10 Patienten. Insgesamt verstarben 4 Patienten während der Nachbeobachtungszeit. Keiner dieser Todesfälle war stentassoziiert. Diskussion: Der passagere Einsatz eines SEPS ist eine sichere und erfolgreiche Methode zur Abdichtung nichtmaligner Ösophagusleckagen. Eine Platzierung des Stents ohne Durchleuchtungskontrolle ist möglich. Bei Perforationen von begrenztem Ausmaß und ohne ausgeprägte Mediastinitis stellt der Einsatz eines SEPS eine schonende Primärtherapie dar.

Abstract

Introduction: We report on our experience with the temporary use of a self-expanding plastic stent (SEPS) in the treatment of non-malignant esophageal leaks. Material and Methods: Between November 2001 and May 2005 ten patients with iatrogenic esophageal perforations (n = 4), post-surgical leaks (n = 5) and esophago-mediastinal fistulas after caustic injury (n = 1) were treated by temporary SEPS placement. In eight out of ten patients SEPS placement was done without fluoroscopy due to the emergency setting. Stent removal was performed with a rat-toothed forceps. Results: Leaks were located in the proximal (n = 1), middle (n = 6) and distal (n = 3) parts of the esophagus. The mean leakage size was 2 cm. Stent placement without fluoroscopy was always successful. The median duration of stent therapy was 55.5 days (range 15 438). In 7/10 cases the SEPS was readily removed, showing complete healing of the former leak. Four patients died during the follow-up. However, their deaths were not related to the stent therapy. Discussion: The temporary use of the SEPS represents a safe method for sealing benign esophageal leaks. In the emergency-setting SEPS placement without fluoroscopy is feasible and the stent can be easily removed. In contained perforations without severe mediastinitis of the mid esophagus the SEPS should be discussed as a gentle first-line therapy.

Schlüsselwörter

Ösophagusstent - Ösophagusleckage - Ösophagusfistel - Anastomoseninsuffizienz

Key words

esophageal stent - esophageal leak - esophageal perforation - esophageal anastomotic insufficiency

References

• 1 Knyrim K, Wagner H J, Bethge N. et al . A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer.  N Engl J Med. 1993;  329 1302-1307
• 2 De Palma G D, di Matteo E, Romano G. et al . Plastic prosthesis versus expandable metal stents for palliation of inoperable esophageal thoracic carcinoma: a controlled prospective study.  Gastrointest Endosc. 1996;  43 478-482
• 3 Roseveare C D, Patel P, Simmonds N. et al . Metal stents improve dysphagia, nutrition and survival in malignant oesophageal stenosis: a randomized controlled trial comparing modified Gianturco Z-stents with plastic Atkinson tubes.  Eur J Gastroenterol Hepatol. 1998;  10 653-657
• 4 May A, Ell C. Palliative treatment of malignant esophagorespiratory fistulas with Gianturco-Z stents. A prospective clinical trial and review of the literature on covered metal stents.  Am J Gastroenterol. 1998;  93 532-535
• 5 Wenger U, Luo J, Lundell L. et al . A nationwide study of the use of self-expanding stents in patients with esophageal cancer in Sweden.  Endoscopy. 2005;  37 329-334
• 6 Wadhawa R P, Kozarek R A, France R E. et al . Use of self-expandable metallic stents in benign GI disease.  Gastrointest Endosc. 2003;  58 207-212
• 7 Low D E, Kozarek R A. Removal of esophageal expandable metal stents. Description of technique and review of potential applications.  Surg Endosc. 2003;  17 990-996
• 8 Siersema P D, Homs M Y, Haringsma J. et al . Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus.  Gastrointest Endosc. 2003;  58 356-661
• 9 Lang H, Sotiropoulos G C, Saner F H. et al . Benign esophagorespiratory fistula complicated by deep impaction of stent mesh in the esophageal wall.  Endoscopy. 2005;  37 185-186
• 10 Bethge N, Vakil N. A prospective trial of a new self-expanding plastic stent for malignant esophageal obstruction.  Am J Gastroenterol. 2001;  96 1350-1354
• 11 Decker P, Lippler J, Decker D. et al . Use of the Polyflex stent in the palliative therapy of esophageal carcinoma.  Surg Endosc. 2001;  15 1444-1447
• 12 Dormann A J, Eisendrath P, Wigginghaus B. et al . Palliation of esophageal carcinoma with a new self-expanding plastic stent.  Endoscopy. 2003;  35 207-211
• 13 Costamagna G, Shah S K, Tringali A. et al . Prospective evaluation of a new self-expanding plastic stent for inoperable esophageal strictures.  Surg Endosc. 2003;  17 891-895
• 14 Radecke K, Gerken G, Treichel U. Impact of a self-expanding, plastic esophageal stent on various esophageal stenoses, fistulas, and leakages: a single-center experience in 39 patients.  Gastrointest Endosc. 2005;  61 812-818
• 15 Siersema P D. Treatment of esophageal perforations and anastomotic leaks: the endoscopist is stepping into the arena.  Gastrointest Endosc. 2005;  61 897-900
• 16 Repici A, Romagnoli R, Reggio D. et al . Successful closure of a postsurgical benign esophagomediastinal fistula by temporary placement of a polyester, expandable stent: case report and review.  Gastrointest Endosc. 2002;  56 747-750
• 17 Petruzziello L, Tringali A, Riccioni M E. et al . Successful early treatment of Boerhaave’s syndrome by endoscopic placement of a temporary self-expandable plastic stent without fluoroscopy.  Gastrointest Endosc. 2003;  58 608-612
• 18 Gelbmann C M, Ratiu N L, Rath H C. et al . Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks.  Endoscopy. 2004;  36 695-699
• 19 Hünerbein M, Stroszczynski C, Moesta K T. et al . Treatment of thoracic anastomostic leaks after esophagectomy with self-expanding plastic stents.  Ann Surg. 2004;  240 801-807
• 20 Langer F B, Wenzl E, Prager G. et al . Mangement of postoperative esophageal leaks with the polyflex self-expanding covered plastic stent.  Ann Thorac Surg. 2005;  79 398-404
• 21 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
• 22 Dormann A J, Wigginghaus B, Deppe H. et al . Successful treatment of esophageal perforation with a removable self-expanding plastic stent.  Am J Gastroenterol. 2001;  96 923-924
• 23 Evrard S, Le Moine O, Lazaraki G. et al . Self-expanding plastic stents for benign esophageal lesions.  Gastrointest Endosc. 2004;  60 894-900
• 24 Urschel J D. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review.  Am J Surg. 1995;  169 634-640
• 25 Alanezi K, Urschel J D. Mortality secondary to esophageal anastomotic leak.  Ann Thorac Cadiovasc Surg. 2004;  10 71-75
• 26 Brinster C J, Singhal S, Lawrence L. et al . Evolving options in the management of esophageal perforation.  Ann Thorac Surg. 2004;  77 1475-1483
• 27 Amir A I, v Dullemen H, Plikker T h. Selective approach in the treatment of esopageal perforations.  Scand J Gastroenterol. 2004;  39 418-422
• 28 Vogel S B, Rout W R, Martin T D. et al . Esophageal perforation in adults: aggressive, conservative treatment lowers morbidity and mortality.  Ann Surg. 2005;  241 1016-1021
• 29 Ackroyd R, Watson D I, Devitt P G. et al . Expandable metallic stents should not be used in the treatment of benign esophageal strictures.  J Gastroenterol Hepatol. 2001;  16 484-487
• 30 Lee J G, Hsu R, Leung J W. Are self-expanding metal mesh stents useful in the treatment of benign esophageal stenoses and fistulas? An experience of four cases.  Am J Gastroenterol. 2000;  95 1920-1925
• 31 Repici A, Conio M, De Angelis C. et al . Temporary placement of an expandable polyester silicone-covered stent for treatment of refractory esophageal strictures.  Gastrointest Endosc. 2004;  60 513-519
• 32 Eggebrecht H, Baumgart D, Radecke K. et al . Aortoesophageal fistula secondary to stent-graft repair of the thoracic aorta.  J Endovasc Ther. 2004;  11 161-167
• 33 Garcia-Cano J. (letter) Esophageal insertion of polyflex stents without fluoroscopy in peptic stenosis.  Endoscopy. 2005;  35 400