- Email: [email protected]
Esophageal Stents for Leaks and Perforations
TECHNIQUES MY WAY
Esophageal Stents for Leaks and Perforations Yiyang Dai, MD,* Sascha S. Chopra, MD,† Markus Steinbach, MD,* Sören Kneif, MD,* and Michael Hünerbein, MD, PhD* Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak. Semin Thoracic Surg 23:159-162 © 2011 Elsevier Inc. All rights reserved. PATIENT SELECTION Inclusion Criteria Anastomotic Leaks After Esophagectomy Indication for stenting is usually limited to patients with leaks involving ⬍30% of the esophageal circumference and without extensive necrosis of the gastric conduit. Both indicate a technical surgical problem, ie, ischemia or tension that eventually results in stenosis. The best result of stenting can be obtained in straight anastomoses, ie, esophagogastrostomy and gastric pull-up, esophagojejunostomy, whereas a poor outcome is often observed after jejunal pouch reconstruction.1 Stenting can potentially reduce the morbidity and mortality in patients with intrathoracic leaks significantly, but it is not required in cervical leaks. Cervical leaks can be managed by opening the neck wound and repeated lavage.
kocytosis, elevation of C-reactive protein, fever, and deterioration of general condition). Exclusion Criteria The exclusion criteria for stenting are similar for postoperative esophageal anastomotic leaks and perforations. Patients with gross destruction of the esophageal anatomy, large leaks, and extensive necrosis, ie, conduit necrosis, ischemic gastric tube, and a nonviable anastomosis, are not suitable for endoscopic stent treatment.
*Department of Surgery and Surgical Oncology, Helios Hospital, Berlin, Germany. †Department of General, Visceral and Transplantation Surgery, Charite Campus, Virchow Hospital, University of Medicine, Berlin, Germany.
DIAGNOSTIC EVALUATION Esophageal leaks and perforations can be confirmed by a water-soluble contrast esophagogram. However, contrast-enhanced (oral and intravenous) computed tomography (CT) scan provides more information on the size of the leak and periesophageal inflammation or abscess formation. Moreover, CT might guide placement of drainage tubes in mediastinal abscess cavities if necessary. The most important examination is immediate endoscopy to diagnose the leak and to assess the size of the leak and the extent of necrosis around the anastomosis. It is helpful to perform endoscopy in combination with fluoroscopy. Contrast injection through the gastroscope allows visualization of the anastomotic leak and mediastinal fistula or abscess cavity. Immediately afterward the stent can be placed with precision under fluoroscopic guidance. In our practice, if there is clinical suspicion of a leak, endoscopy with stent insertion is performed as the first measure. Then a CT scan is obtained to document the extent of mediastinitis and to insert drainage catheters in leak cavities.
Address reprint requests to Michael Hünerbein, MD, PhD, Helios Klinikum Berlin-Buch, Stellvertretender Chefarzt, Klinik für Allgemein, Viszeral- und Onkologische Chirurgie, Schwanebecker Chaussee 50, 13125 Berlin. Germany. E-mail: [email protected]
STENT SELECTION A fully covered stent should always be used so that it can be removed without damaging the esophageal wall (Table 1).2
Esophageal Perforation Esophageal perforations occur in patients after dilatation of malignant or benign stenoses, after laparoscopic fundoplication, and in patients with spontaneous perforation (Boerhaave syndrome). Stenting of esophageal perforation should be limited to patients with viable-appearing mucosa and a clinical course characterized by systemic inflammation (leu-
1043-0679/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2011.08.004
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ESOPHAGEAL STENTS FOR LEAKS AND PERFORATIONS Table 1. Summary of Esophageal Stent Choice for Anastomotic Leaks and Perforations Material Anastomotic leak Perforation
Nitinol X* X*
Covered
Silicone X† X†
Totally X X
Partially
Flare Upper X‡ X‡
Double X§ X§
*Mid and distal esophagus. †Proximal esophagus. ‡Polyflex. §SX-Ella.
Most patients are treated by insertion of self-expanding plastic stents (Polyflex; Boston Scientific, Natick, MA). The Polyflex stent consists of an integral polyester braid that is completely covered with a silicone membrane (flare diameter, 25 mm; body diameter, 21 mm; length, 12 or 15 cm). Radiopaque markers at both ends and in the middle of the stent are used for fluoroscopic visualization. The silicone coating prevents ingrowth and overgrowth of granulation tissue. Only long stents are used because short stents have higher tendency to migrate.3 More recently, we have used a self-expanding double-flared metal (nitinol) stent that is fully covered (SX-Ella, Ella-CS, Hradec Králové, Czech Republic). The stent flares have a diameter of 30 mm, and the body has a diameter of 25 mm (Fig. 1). The large diameter of the stent promises reliable closure of leaks in large-volume conduits. Another advantage is the presence of retrieval loops at both ends of the stent (Fig. 1). It is therefore no problem to move the stent endoscopically in the proximal or distal direction, which facilitates assessment of healing without stent removal. The Polyflex plastic stent should be favored in the proximal esophagus because the material is very soft and does not cause foreign body sensations.
STENT PLACEMENT TECHNIQUE Stent placement is performed by a surgeon under endoscopic and fluoroscopic control in the Department of Surgical Endoscopy. The patient is placed in left lateral decubitus position. With the patient under conscious sedation with propofol 70-300 mg, endoscopy is performed to localize the leak and to rinse the periesophageal cavity. The localization of the leak in relation to anatomical landmarks is documented by radiograph. A stiff guidewire (Amplatz super stiff; Boston Scientific) is placed into the duodenum, and the stent applicator is introduced over the guidewire. The stent is deployed with at least 5-cm overlap proximal and distal to the leak. Usually the stent is positioned somewhat more proximally because there is a tendency for distal migration. Correct placement of the stent and successful leak occlusion are then confirmed by endoscopy and contrastenhanced fluoroscopy with water-soluble contrast. Perianastomotic and pleural drainage is obtained by existing chest drains or by insertion of additional drains under CT guidance. SOURCE CONTROL It is crucial to drain the leakage cavity with chest tubes because the stent prevents internal drainage.
Figure 1. The Ella stent is a fully covered self-expanding metal stent with a diameter of 3 cm at the flared ends. Retrieval loops at both ends allow to reposition the stent endoscopically in both directions, ie, proximal and distal.
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Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 2
ESOPHAGEAL STENTS FOR LEAKS AND PERFORATIONS All patients receive intravenous broad-spectrum antibiotics (intravenous tazobactam 4.5 g every 8 hours). POSTSTENT MANAGEMENT Most patients receive a 3-lumen gastrojejunal tube for enteral feeding and gastric drainage. In nonventilated patients the gastric tube is removed after 3-4 days, and oral nutrition is then started. Complete healing of the leak is documented by endoscopy, contrast studies, and CT (Fig. 2). In some patients with a gastric conduit or a colonic interposition, there is backflow of contrast around the stent in Trendelenburg position; these patients are instructed to keep an upright position as much as possible. Every 2 days a chest radiograph is performed to confirm the correct position of the stent (Fig. 3). After 2 weeks the stent is removed or repositioned to assess healing of the leak. Retrieval of plastic stents is performed endoscopically by using a rat tooth forceps (2 teeth). The stent is grasped at the proximal end and gently pulled out. Usually ⬍10 minutes are required for this procedure. If necessary,
Figure 3. Chest radiograph of patient with esophageal perforation. The self-expanding metal stent (arrows) covers the complete middle esophagus.
another plastic stent can be introduced as described above. Metal stents are grasped with a rat tooth forceps and pulled down into the stomach or jejunum by using the distal retrieval loop. According to endoscopic assessment of healing of the leak, the stent is
Table 2. Clinical Results in 40 Patients After Stenting of Esophageal Leaks
Figure 2. (A) CT scan of patient after esophageal perforation showing extensive mediastinal emphysema (solid arrows). Open arrow, esophagus. (B) Follow-up CT scan after insertion of covered self-expanding metal stent. There is complete remission of the mediastinal emphysema.
Clinical Results Treatment success Intensive care unit stay (d) Hospital stay (d) Other therapy Reoperation* Interventional drainage Tracheotomy Time to oral intake (d)† Time to leak healing (d) In-hospital mortality
Anastomotic Leak (n ⫽ 33) 30 (91%) 20 (0-79)
Esophageal Perforation (n ⫽ 7) 6 (85%) 21 (0-91)
43 (9-115)
32 (9-91)
3 (9%) 13 (39%)
0 (0%) 6 (85%)
13 (39%) 3 (0-19)
1 (14%) 3.1 (1-9)
30 (7-62)
16 (6-26)
3 (9%)
2 (28%)
Values are expressed as mean (range or percentage). *For stent failure. †Nonventilated patients.
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 2
161
ESOPHAGEAL STENTS FOR LEAKS AND PERFORATIONS then either repositioned or removed by using the proximal retrieval loop. In contrast to others,4 we favor removal of the stent as soon as possible to avoid complications such as stent-induced perforation. OUTCOMES Self-expanding plastic stents were successfully inserted in 40 patients with acute esophageal leaks. There were no technical failures or procedure-related complications. Plastic stents had a tendency to migrate (approximately 20%), but it was easy to reposition the stent endoscopically by using a forceps. The patients were allowed oral intake of fluid immediately after stent placement, and a solid diet was started 3-5 days later. Repeated stenting was necessary in 33 of 40 patients. Plastic stents were always removed approximately 14 days after placement to assess healing of the leak. A second stent was inserted if the leak was not completely closed. The mean number of stents per patient was 3.2. The mean time to healing was 30 days. Our results are summarized in Table 2. Complete sealing of the leak immediately after stenting was observed in 35 of 40 patients (87%).
1. Dai Y, Chopra SS, Hünerbein M: Management of esophageal anastomotic leaks, perforations and fistulae with self expanding plastic stents. J Thorac Cardiovasc Surg 141(5):1213-1217, 2011 2. Doniec JM, Schniewind B, Kahlke V, et al: Therapy of anastomotic leaks by means of covered self
162
In-hospital mortality was 12.5% (5 of 40 patients; pneumonia and severe sepsis). The mean follow-up time is now 16 months (range, 1-61 months), and 70% of the patients were alive at last follow-up. Two patients developed a stricture 6 months after successful treatment of esophagogastric anastomotic leak caused by necrosis of the proximal gastric tube and underwent reoperation. Three patients with esophagogastric anastomotic leaks in the upper third of the esophagus required repeated endoscopic balloon dilations after healing of the leak. CONCLUSIONS Short-time stenting with self-expanding covered stents is an effective treatment for thoracic esophageal anastomotic leaks and esophageal perforations. Nonoperative treatment with stents must be rapidly instituted in patients with isolated esophagogastric anastomotic leakage to minimize mediastinal and pleural contamination. Adequate mediastinal and pleural drainage is crucial to reduce septic and respiratory complications. Surgical re-exploration must be considered if clinical improvement is not achieved with nonoperative treatment.5
expanding metallic stents after esophagectomy. Endoscopy 35:652-658, 2003 3. Hünerbein M, Stroszczynski C, Moesta KT, et al: Treatment of anastomotic leaks after esophagectomy with self expanding plastic stents. Ann Surg 240:801-807, 2004 4. Langer FB, Wenzl E, Prager G, et al: Manage-
ment of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 79:398-403, 2005 5. Urschel JD: Esophagogastrostomy anastomotic leaks complicating esophagectomy: A review. Am J Surg 169:634-640, 1995
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 2
Esophageal Stents for Leaks and Perforations Yiyang Dai, MD,* Sascha S. Chopra, MD,† Markus Steinbach, MD,* Sören Kneif, MD,* and Michael Hünerbein, MD, PhD* Stenting of esophageal leaks, ie, anastomotic leaks or perforations, might be a minimally invasive alternative to surgery in most clinical situations. However, it must be emphasized that surgery should be considered if stent treatment in combination with drainage and antibiotics does not improve the clinical condition of the patient. Stent insertion should be performed as soon as possible after diagnosis of the leak. Semin Thoracic Surg 23:159-162 © 2011 Elsevier Inc. All rights reserved. PATIENT SELECTION Inclusion Criteria Anastomotic Leaks After Esophagectomy Indication for stenting is usually limited to patients with leaks involving ⬍30% of the esophageal circumference and without extensive necrosis of the gastric conduit. Both indicate a technical surgical problem, ie, ischemia or tension that eventually results in stenosis. The best result of stenting can be obtained in straight anastomoses, ie, esophagogastrostomy and gastric pull-up, esophagojejunostomy, whereas a poor outcome is often observed after jejunal pouch reconstruction.1 Stenting can potentially reduce the morbidity and mortality in patients with intrathoracic leaks significantly, but it is not required in cervical leaks. Cervical leaks can be managed by opening the neck wound and repeated lavage.
kocytosis, elevation of C-reactive protein, fever, and deterioration of general condition). Exclusion Criteria The exclusion criteria for stenting are similar for postoperative esophageal anastomotic leaks and perforations. Patients with gross destruction of the esophageal anatomy, large leaks, and extensive necrosis, ie, conduit necrosis, ischemic gastric tube, and a nonviable anastomosis, are not suitable for endoscopic stent treatment.
*Department of Surgery and Surgical Oncology, Helios Hospital, Berlin, Germany. †Department of General, Visceral and Transplantation Surgery, Charite Campus, Virchow Hospital, University of Medicine, Berlin, Germany.
DIAGNOSTIC EVALUATION Esophageal leaks and perforations can be confirmed by a water-soluble contrast esophagogram. However, contrast-enhanced (oral and intravenous) computed tomography (CT) scan provides more information on the size of the leak and periesophageal inflammation or abscess formation. Moreover, CT might guide placement of drainage tubes in mediastinal abscess cavities if necessary. The most important examination is immediate endoscopy to diagnose the leak and to assess the size of the leak and the extent of necrosis around the anastomosis. It is helpful to perform endoscopy in combination with fluoroscopy. Contrast injection through the gastroscope allows visualization of the anastomotic leak and mediastinal fistula or abscess cavity. Immediately afterward the stent can be placed with precision under fluoroscopic guidance. In our practice, if there is clinical suspicion of a leak, endoscopy with stent insertion is performed as the first measure. Then a CT scan is obtained to document the extent of mediastinitis and to insert drainage catheters in leak cavities.
Address reprint requests to Michael Hünerbein, MD, PhD, Helios Klinikum Berlin-Buch, Stellvertretender Chefarzt, Klinik für Allgemein, Viszeral- und Onkologische Chirurgie, Schwanebecker Chaussee 50, 13125 Berlin. Germany. E-mail: [email protected]
STENT SELECTION A fully covered stent should always be used so that it can be removed without damaging the esophageal wall (Table 1).2
Esophageal Perforation Esophageal perforations occur in patients after dilatation of malignant or benign stenoses, after laparoscopic fundoplication, and in patients with spontaneous perforation (Boerhaave syndrome). Stenting of esophageal perforation should be limited to patients with viable-appearing mucosa and a clinical course characterized by systemic inflammation (leu-
1043-0679/$-see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1053/j.semtcvs.2011.08.004
159
ESOPHAGEAL STENTS FOR LEAKS AND PERFORATIONS Table 1. Summary of Esophageal Stent Choice for Anastomotic Leaks and Perforations Material Anastomotic leak Perforation
Nitinol X* X*
Covered
Silicone X† X†
Totally X X
Partially
Flare Upper X‡ X‡
Double X§ X§
*Mid and distal esophagus. †Proximal esophagus. ‡Polyflex. §SX-Ella.
Most patients are treated by insertion of self-expanding plastic stents (Polyflex; Boston Scientific, Natick, MA). The Polyflex stent consists of an integral polyester braid that is completely covered with a silicone membrane (flare diameter, 25 mm; body diameter, 21 mm; length, 12 or 15 cm). Radiopaque markers at both ends and in the middle of the stent are used for fluoroscopic visualization. The silicone coating prevents ingrowth and overgrowth of granulation tissue. Only long stents are used because short stents have higher tendency to migrate.3 More recently, we have used a self-expanding double-flared metal (nitinol) stent that is fully covered (SX-Ella, Ella-CS, Hradec Králové, Czech Republic). The stent flares have a diameter of 30 mm, and the body has a diameter of 25 mm (Fig. 1). The large diameter of the stent promises reliable closure of leaks in large-volume conduits. Another advantage is the presence of retrieval loops at both ends of the stent (Fig. 1). It is therefore no problem to move the stent endoscopically in the proximal or distal direction, which facilitates assessment of healing without stent removal. The Polyflex plastic stent should be favored in the proximal esophagus because the material is very soft and does not cause foreign body sensations.
STENT PLACEMENT TECHNIQUE Stent placement is performed by a surgeon under endoscopic and fluoroscopic control in the Department of Surgical Endoscopy. The patient is placed in left lateral decubitus position. With the patient under conscious sedation with propofol 70-300 mg, endoscopy is performed to localize the leak and to rinse the periesophageal cavity. The localization of the leak in relation to anatomical landmarks is documented by radiograph. A stiff guidewire (Amplatz super stiff; Boston Scientific) is placed into the duodenum, and the stent applicator is introduced over the guidewire. The stent is deployed with at least 5-cm overlap proximal and distal to the leak. Usually the stent is positioned somewhat more proximally because there is a tendency for distal migration. Correct placement of the stent and successful leak occlusion are then confirmed by endoscopy and contrastenhanced fluoroscopy with water-soluble contrast. Perianastomotic and pleural drainage is obtained by existing chest drains or by insertion of additional drains under CT guidance. SOURCE CONTROL It is crucial to drain the leakage cavity with chest tubes because the stent prevents internal drainage.
Figure 1. The Ella stent is a fully covered self-expanding metal stent with a diameter of 3 cm at the flared ends. Retrieval loops at both ends allow to reposition the stent endoscopically in both directions, ie, proximal and distal.
160
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 2
ESOPHAGEAL STENTS FOR LEAKS AND PERFORATIONS All patients receive intravenous broad-spectrum antibiotics (intravenous tazobactam 4.5 g every 8 hours). POSTSTENT MANAGEMENT Most patients receive a 3-lumen gastrojejunal tube for enteral feeding and gastric drainage. In nonventilated patients the gastric tube is removed after 3-4 days, and oral nutrition is then started. Complete healing of the leak is documented by endoscopy, contrast studies, and CT (Fig. 2). In some patients with a gastric conduit or a colonic interposition, there is backflow of contrast around the stent in Trendelenburg position; these patients are instructed to keep an upright position as much as possible. Every 2 days a chest radiograph is performed to confirm the correct position of the stent (Fig. 3). After 2 weeks the stent is removed or repositioned to assess healing of the leak. Retrieval of plastic stents is performed endoscopically by using a rat tooth forceps (2 teeth). The stent is grasped at the proximal end and gently pulled out. Usually ⬍10 minutes are required for this procedure. If necessary,
Figure 3. Chest radiograph of patient with esophageal perforation. The self-expanding metal stent (arrows) covers the complete middle esophagus.
another plastic stent can be introduced as described above. Metal stents are grasped with a rat tooth forceps and pulled down into the stomach or jejunum by using the distal retrieval loop. According to endoscopic assessment of healing of the leak, the stent is
Table 2. Clinical Results in 40 Patients After Stenting of Esophageal Leaks
Figure 2. (A) CT scan of patient after esophageal perforation showing extensive mediastinal emphysema (solid arrows). Open arrow, esophagus. (B) Follow-up CT scan after insertion of covered self-expanding metal stent. There is complete remission of the mediastinal emphysema.
Clinical Results Treatment success Intensive care unit stay (d) Hospital stay (d) Other therapy Reoperation* Interventional drainage Tracheotomy Time to oral intake (d)† Time to leak healing (d) In-hospital mortality
Anastomotic Leak (n ⫽ 33) 30 (91%) 20 (0-79)
Esophageal Perforation (n ⫽ 7) 6 (85%) 21 (0-91)
43 (9-115)
32 (9-91)
3 (9%) 13 (39%)
0 (0%) 6 (85%)
13 (39%) 3 (0-19)
1 (14%) 3.1 (1-9)
30 (7-62)
16 (6-26)
3 (9%)
2 (28%)
Values are expressed as mean (range or percentage). *For stent failure. †Nonventilated patients.
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 2
161
ESOPHAGEAL STENTS FOR LEAKS AND PERFORATIONS then either repositioned or removed by using the proximal retrieval loop. In contrast to others,4 we favor removal of the stent as soon as possible to avoid complications such as stent-induced perforation. OUTCOMES Self-expanding plastic stents were successfully inserted in 40 patients with acute esophageal leaks. There were no technical failures or procedure-related complications. Plastic stents had a tendency to migrate (approximately 20%), but it was easy to reposition the stent endoscopically by using a forceps. The patients were allowed oral intake of fluid immediately after stent placement, and a solid diet was started 3-5 days later. Repeated stenting was necessary in 33 of 40 patients. Plastic stents were always removed approximately 14 days after placement to assess healing of the leak. A second stent was inserted if the leak was not completely closed. The mean number of stents per patient was 3.2. The mean time to healing was 30 days. Our results are summarized in Table 2. Complete sealing of the leak immediately after stenting was observed in 35 of 40 patients (87%).
1. Dai Y, Chopra SS, Hünerbein M: Management of esophageal anastomotic leaks, perforations and fistulae with self expanding plastic stents. J Thorac Cardiovasc Surg 141(5):1213-1217, 2011 2. Doniec JM, Schniewind B, Kahlke V, et al: Therapy of anastomotic leaks by means of covered self
162
In-hospital mortality was 12.5% (5 of 40 patients; pneumonia and severe sepsis). The mean follow-up time is now 16 months (range, 1-61 months), and 70% of the patients were alive at last follow-up. Two patients developed a stricture 6 months after successful treatment of esophagogastric anastomotic leak caused by necrosis of the proximal gastric tube and underwent reoperation. Three patients with esophagogastric anastomotic leaks in the upper third of the esophagus required repeated endoscopic balloon dilations after healing of the leak. CONCLUSIONS Short-time stenting with self-expanding covered stents is an effective treatment for thoracic esophageal anastomotic leaks and esophageal perforations. Nonoperative treatment with stents must be rapidly instituted in patients with isolated esophagogastric anastomotic leakage to minimize mediastinal and pleural contamination. Adequate mediastinal and pleural drainage is crucial to reduce septic and respiratory complications. Surgical re-exploration must be considered if clinical improvement is not achieved with nonoperative treatment.5
expanding metallic stents after esophagectomy. Endoscopy 35:652-658, 2003 3. Hünerbein M, Stroszczynski C, Moesta KT, et al: Treatment of anastomotic leaks after esophagectomy with self expanding plastic stents. Ann Surg 240:801-807, 2004 4. Langer FB, Wenzl E, Prager G, et al: Manage-
ment of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 79:398-403, 2005 5. Urschel JD: Esophagogastrostomy anastomotic leaks complicating esophagectomy: A review. Am J Surg 169:634-640, 1995
Seminars in Thoracic and Cardiovascular Surgery ● Volume 23, Number 2