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Esophageal stenting possibly appropriate as primary therapy for esophageal anastomotic leaks, perforations, study findings suggest

Saturday, October 18 2008 | Comments
Evidence Grade 7 What's This?
By Courtneay Parsons

Results of a recent retrospective study suggest that early intervention with esophageal stenting may be an appropriate approach to the management of esophageal anastomotic leaks and perforations.

Dr. Jonathan D'Cunha with the Division of Thoracic and Foregut Surgery at the University of Minnesota noted that esophageal leaks and perforations are potentially one of the most morbid complications seen in thoracic and foregut surgery, and that there is no unified approach to treatment. He and his colleagues evaluated the utility of covered, removable stents in this patient population, with a goal of proposing an effective stent-based approach to treatment.

They conducted a retrospective review of their patient database and identified 20 patients (age range, 19-83 yrs) who underwent stenting primarily with covered, removable stents for an esophageal leak (n=16) or a perforation (n=4). The median time from the initial procedure to the first stent placement was 16 days (range, 0-434 days). Routine stent exchange was performed every 3 to 4 weeks. Of the 20 patients included in the analysis who received stents, 12 (60%) had associated procedures to achieve source control of infection, usually in the chest.

The stents were placed conventionally (according to manufacturer specifications) or in a "dumb-bell" fashion, using 2 stents with the flares at opposite ends.

In these 20 patients, the physicians used a total of 54 stents (mean, 2.7 per patient), including 41 Polyflex stents, 12 Alimaxx stents, and 1 Ultraflex stent.

The stents were successful in 13 patients (65%), with success defined as endoscopic defect closure, a negative esophagram, and resumption of oral intake. Dr. D'Cunha noted that the success rate in the last 13 patients treated was 85%, suggesting that the results improved as the surgeons gained experience. The median time to resolution/success was 23 days (range, 13-58 days).

There were 7 treatment failures, including 4 technical failures, 2 undrained abscesses, and 1 retrograde leak. Complications included 2 stent migrations, 1 stent erosion, 1 leak enlargement, 1 death from a gastroaortic fistula, and 2 patients with strictures requiring 1 dilation each.

Based on his experience with these patients, Dr. D'Cunha recommended an approach that involves stenting early (with success dependent on complete leak occlusion), proper drainage of the infection, adequate follow-up surveillance, and early and aggressive stent exchange to evaluate healing.

"[S]tents are having an emerging role in the management of these complicated patients and potentially can reduce the morbidity and mortality associated with traditional approaches," Dr. D'Cunha commented. "This represents what we believe is a novel approach to a potentially very morbid problem." (Part of: General Surgery 1 Paper Session GS58.)

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