Skip to main content

Advertisement

SpringerLink
Log in

Treatment of Thoracic Esophageal Anastomotic Leaks and Esophageal Perforations with Endoluminal Stents: Efficacy and Current Limitations

  • original article
  • Published:
Journal of Gastrointestinal Surgery Aims and scope

Abstract

Background

Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center.

Methods

Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured.

Results

Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%).

Conclusions

Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10:71–75.

    PubMed  Google Scholar 

  2. Beitler AL, Urschel JD. Comparison of stapled and hand-sewn esophagogastric anastomoses. Am J Surg 1998;175:337–340.

    Article  PubMed  CAS  Google Scholar 

  3. Griffin SM, Lamb PJ, Dresner SM, Richardson DL, Hayes N. Diagnosis and management of a mediastinal leak following radical oesophagectomy. Br J Surg 2001;88:1346–1351.

    Article  PubMed  CAS  Google Scholar 

  4. Siewert JR, Stein HJ, Bartels H. Anastomotic leaks in the upper gastrointestinal tract [German]. Chirurg 2004;75:1063–1070.

    Article  PubMed  CAS  Google Scholar 

  5. Martin LW, Swisher SG, Hofstetter W, Correa AM, Mehran RJ, Rice DC, Vaporciyan AA, Walsh GL, Roth JA. Intrathoracic leaks following esophagectomy are no longer associated with increased mortality. Ann Surg 2005;242:392–399.

    PubMed  Google Scholar 

  6. Muir AD, White J, McGuigan JA, McManus KG, Graham AN. Treatment and outcomes of oesophageal perforation in a tertiary referral centre. Eur J Cardiothorac Surg 2003;23:799–804.

    Article  PubMed  CAS  Google Scholar 

  7. Zwischenberger JB, Savage C, Bidani A. Surgical aspects of esophageal disease: perforation and caustic injury. Am J Respir Crit Care Med 2002;165:1037–1040.

    PubMed  Google Scholar 

  8. Eroglu A, Can Kurkçuogu I, Karaoganogu N, Tekinbaş C, Yimaz O, Başog M. Esophageal perforation: the importance of early diagnosis and primary repair. Dis Esophagus 2004;17:91–94.

    Article  PubMed  Google Scholar 

  9. Brinster CJ, Singhal S, Lee L, Marshall MB, Kaiser LR, Kucharczuk JC. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004;77:1475–1483.

    Article  PubMed  Google Scholar 

  10. Page RD, Shackcloth MJ, Russell GN, Pennefather SH. Surgical treatment of anastomotic leaks after oesophagectomy. Eur J Cardiothorac Surg 2005;27:337–343.

    Article  PubMed  Google Scholar 

  11. Crestanello JA, Deschamps C, Cassivi SD, Nichols FC, Allen MS, Schleck C, Pairolero PC. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg 2005;129:254–260.

    Article  PubMed  Google Scholar 

  12. Amir AI, van Dullemen H, Plukker JT. Selective approach in the treatment of esophageal perforations. Scand J Gastroenterol 2004;39:418–422.

    Article  PubMed  CAS  Google Scholar 

  13. Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg 1998;85:1446–1449.

    Article  PubMed  CAS  Google Scholar 

  14. Wehrmann T, Stergiou N, Vogel B, Riphaus A, Köckerling F, Frenz MB. Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series. Gastrointest Endosc 2005;62:344–349.

    Article  PubMed  Google Scholar 

  15. Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169:634–640.

    Article  PubMed  CAS  Google Scholar 

  16. Pross M, Manger T, Reinheckel T, Mirow L, Kunz D, Lippert H. Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses. Gastrointest Endosc 2000;51:73–76.

    Article  PubMed  CAS  Google Scholar 

  17. Hunerbein M, Stroszczynski C, Moesta KT, Schlag PM. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents. Ann Surg 2004;240:801–807.

    Article  PubMed  Google Scholar 

  18. Doniec JM, Schniewind B, Kahlke V, Kremer B, Grimm H. Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy. Endoscopy 2003;35:652–658.

    Article  PubMed  CAS  Google Scholar 

  19. Gelbmann CM, Ratiu NL, Rath HC, Rogler G, Lock G, Schölmerich J, Kullmann F. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 2004;36:695–699.

    Article  PubMed  CAS  Google Scholar 

  20. Roy-Choudhury SH, Nicholson AA, Wedgwood KR, Mannion RA, Sedman PC, Royston CM, Breen DJ. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. AJR Am J Roentgenol 2001;176:161–165.

    PubMed  CAS  Google Scholar 

  21. Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, Lippert H, Pross M. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents. Gastrointest Endosc 2005;61:891–896.

    Article  PubMed  Google Scholar 

  22. Johnsson E, Lundell L, Liedman B. Sealing of esophageal perforation or ruptures with expandable metallic stents: a prospective controlled study on treatment efficacy and limitations. Dis Esophagus 2005;18:262–266.

    Article  PubMed  CAS  Google Scholar 

  23. Langer FB, Wenzl E, Prager G, Salat A, Miholic J, Mang T, Zacherl J. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 2005;79:398–403.

    Article  PubMed  Google Scholar 

  24. Siersema PD, Homs MY, Haringsma J, Tilanus HW, Kuipers EJ. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc 2003;58:356–361.

    Article  PubMed  Google Scholar 

  25. Freeman RK, Van Woerkom JM, Ascioti AJ. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation. Ann Thorac Surg 2007;83:2003–2007.

    Article  PubMed  Google Scholar 

  26. Freeman RK, Ascioti AJ, Wozniak TC. Postoperative esophageal leak management with the Polyflex esophageal stent. J Thorac Cardiovasc Surg 2007;133:333–338.

    Article  PubMed  Google Scholar 

  27. Kauer WK, Stein HJ, Dittler HJ, Siewert JR. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Surg Endosc 2008;22:50–53.

    Article  PubMed  Google Scholar 

  28. Segalin A, Bonavina L, Lazzerini M, De Ruberto F, Faranda C, Peracchia A. Endoscopic management of inveterate esophageal perforations and leaks. Surg Endosc 1996;10:928–932.

    Article  PubMed  CAS  Google Scholar 

  29. Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608–611.

    Article  PubMed  CAS  Google Scholar 

  30. Dumonceau JM, Devière J. Treatment of Boerhaave’s syndrome using the ultraflex self-expandable stent. Gastrointest Endosc 2000;51:773–774.

    PubMed  CAS  Google Scholar 

  31. Fernandez FF, Richter A, Freudenberg S, Wendl K, Manegold BC. Treatment of endoscopic esophageal perforation. Surg Endosc 1999;13:962–966.

    Article  PubMed  CAS  Google Scholar 

  32. Mitchell JD. Anastomotic leak after esophagectomy. Thorac Surg Clin 2006;16:1–9.

    Article  PubMed  Google Scholar 

  33. Peters JH, Craanen ME, van der Peet DL, Cuesta MA, Mulder CJ. Self-expanding metal stents for the treatment of intrathoracic esophageal anastomotic leaks following esophagectomy. Am J Gastroenterol 2006;101:1393–1395.

    Article  PubMed  Google Scholar 

  34. Truong S, Bohm G, Klinge U, Stumpf M, Schumpelick V. Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc 2004;18:1105–1108.

    Article  PubMed  CAS  Google Scholar 

  35. 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.

    Article  PubMed  Google Scholar 

  36. Lang H, Piso P, Stukenborg C, Raab R, Jähne J. 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.

    Article  PubMed  CAS  Google Scholar 

  37. Fischer A, Thomusch O, Benz S, von Dobschuetz E, Baier P, Hopt UT. Nonoperative treatment of 15 benign esophageal perforations with self-expandable covered metal stents. Ann Thorac Surg 2006;81:467–472.

    Article  PubMed  Google Scholar 

  38. Raijman I. Endoscopic management of esophagorespiratory fistulas: expanding our options with expandable stents. Am J Gastroenterol 1998;93:496–499.

    Article  PubMed  CAS  Google Scholar 

  39. Ramirez FC, Dennert B, Zierer ST, Sanowski RA. Esophageal self-expandable metallic stents–indications, practice, techniques, and complications: results of a national survey. Gastrointest Endosc 1997;45:360–364.

    Article  PubMed  CAS  Google Scholar 

  40. Song HY, Park SI, Jung HY, Kim SB, Kim JH, Huh SJ, Kim TH, Kim YK, Park S, Yoon HK, Sung KB, Min YI. Benign and malignant esophageal strictures: treatment with a polyurethane-covered retrievable expandable metallic stent. Radiology 1997;203:747–752.

    PubMed  CAS  Google Scholar 

  41. Wadhwa RP, Kozarek RA, France RE, Brandabur JJ, Gluck M, Low DE, Traverso LW, Moonka R. Use of self-expandable metallic stents in benign GI diseases. Gastrointest Endosc 2003;58:207–212.

    Article  PubMed  Google Scholar 

  42. Lee SH. The role of oesophageal stenting in the non-surgical management of oesophageal strictures. Br J Radiol 2001;74:891–900.

    PubMed  CAS  Google Scholar 

  43. Han XW, Li YD, Wu G, Li MH, Ma XX. New covered mushroom-shaped metallic stent for managing anastomotic leak after esophagogastrostomy with a wide gastric tube. Ann Thorac Surg 2006;82:702–706.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of General Surgery, University of Muenster, Waldeyerstr.1, 48149, Muenster, Germany

    Emile Rijcken, Rudolf Mennigen, Norbert Senninger & Matthias Bruewer

  2. Department of General Surgery, Unit of Surgical Endoscopy, University of Muenster, Muenster, Germany

    Dirk Tuebergen

  3. Department of Surgery, Royal College of Surgeons in Ireland, Dublin, Ireland

    Ann M. Hopkins

Authors
  1. Dirk Tuebergen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Emile Rijcken
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Rudolf Mennigen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Ann M. Hopkins
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Norbert Senninger
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Matthias Bruewer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Matthias Bruewer.

Additional information

Dirk Tuebergen and Emile Rijcken contributed equally to this work.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Tuebergen, D., Rijcken, E., Mennigen, R. et al. Treatment of Thoracic Esophageal Anastomotic Leaks and Esophageal Perforations with Endoluminal Stents: Efficacy and Current Limitations. J Gastrointest Surg 12, 1168–1176 (2008). https://doi.org/10.1007/s11605-008-0500-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11605-008-0500-4

Keywords

Search

Navigation