Anastomotic leakage after gastroesophageal resection for cancer ENDOSCOPY CORNER

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1 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2011;9: ENDOSCOPY CORNER Healing Occurs in Most Patients That Receive Endoscopic Stents for Anastomotic Leakage; Dislocation Remains a Problem MARCUS FEITH,* SONJA GILLEN,* TIBOR SCHUSTER, JÖRG THEISEN,* HELMUT FRIESS,* and RALF GERTLER* *Department of Surgery, Institute of Medical Statistics and Epidemiology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany BACKGROUND & AIMS: There is controversy about the best way to treat esophageal anastomotic leakage. We evaluated the effects of treatment with self-expanding metal stents in patients with esophageal anastomotic leakage after esophagectomy or gastrectomy for cancer. METHODS: We investigated outcomes and procedure-related complications of 115 patients who received endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy at a university hospital from 2004 to We also performed a systematic literature review on stent therapy and compared outcomes with that of other treatment regimens for esophageal anastomotic leakage. RESULTS: Among the 115 patients who received stents, the in-hospital mortality rate was 9% and complete anastomotic healing was achieved in 70% (95% confidence interval [CI], 64% 76%). Stent dislocation occurred in 53% of the patients (95% CI, 43% 62%), in all patients with esophagocolonostomy, in 61% with esophagojejunostomy, and in 49% with esophagogastrostomy. Three percent of patients (95% CI, 1% 5%) needed laparotomy to remove dislocated stents. Elective endoscopic stent removal was performed in 80% of the patients after a median of 54 days (range d); 12% of these patients developed symptomatic anastomotic strictures after stent removal. CONCLUSIONS: Anastomoses completely heal in 70% of patients that receive endoscopic stents for anastomotic leakage after esophagectomy or gastrectomy. Stent therapy should be used in the management of patients with adequately perfused esophageal anastomotic leakage. However, stent dislocation remains a common problem after surgery. Keywords: Esophageal Cancer; Gastric Cancer; Cancer Therapy; Cancer Surgery. Anastomotic leakage after gastroesophageal resection for cancer is reported to occur with an incidence between 2% and 40% and to be responsible for about 50% of postoperative mortality. 1 4 The most efficient treatment of anastomotic leakage after esophagectomy or gastrectomy, however, remains controversial. The spectrum of established therapeutic options range from reoperation with discontinuity resection, diversion, or re-anastomosis to conservative treatment with perianastomotic drainage, parenteral nutrition, naso-intestinal decompression, and broad-spectrum antibiotics. Both surgical and conservative treatment options, however, are associated with high mortality rates and extensively long intensive care unit and hospital stays. 1 8 In the search for optimized management, the endoscopic placement of stents has been introduced in the management of anastomotic leakages in the past decade. Although the permanent endoscopic placement of self-expanding metal stents has long been established in the palliative treatment of esophagotracheal fistula and malignant obstruction in the upper gastrointestinal tract, 9,10 the removal of stents after temporary therapeutic use has not been reasonably possible until the emergence of completely covered stents. First reports on the use of covered stents in the management of postoperative esophageal anastomotic leakages are promising, however, they are limited to very small case series in heterogeneous patient cohorts Moreover, complications of stent therapy for anastomotic leakage are mentioned rather anecdotally. The aim of this observational study was to describe our experience in the use of covered self-expanding stents in the management of anastomotic leakage after resection for carcinoma of the esophagus or esophagogastric junction. We analyzed the outcome of stent therapy and report on stent-related complications. We also performed a literature review on stent therapy for esophageal anastomotic leakage and compared stent therapy with other conservative and surgical treatment regimens. Patients and Methods Study Cohort Between 2003 and 2009, there were 1296 patients who underwent esophagectomy or trans-hiatally extended gastrectomy for carcinomas of the esophagus or esophagogastric junction in the Department of Surgery at the Klinikum Rechts der Isar, Technische Universität München, as a national referral center for these tumor entities. In 115 patients (9%; 95% confidence interval [CI], 7.4% 10.5%), a fully covered self-expanding metal stent was placed endoscopically as the first treatment option for postoperative anastomotic leakage. These 115 patients comprise the study cohort of this report. The median age was 61 years (range, y). Thirty-eight patients (33%) had squamous cell carcinomas of the esophagus and 77 patients (67%) had adenocarcinomas of the esophagus or esophagogastric junction. Surgery was performed after neoadjuvant chemotherapy or chemoradiotherapy in 89 patients (77%). Stent therapy was performed in 28 patients (24%) after trans-hiatally extended gastrectomy with Roux-en-Y esophagojejunostomy, in 84 patients (73%) after esophagectomy and gastric tube pull-up, and in 3 patients (3%) after esophagectomy and colonic interposition (Table 1). All 115 leakages were located directly at the anastomosis of the remaining esophagus to the pulled-up jejunum (n 28), the pulled-up gastric tube (n 84), or the interposed colon (n 3). Abbreviations used in this paper: CI, confidence interval; CT, computed tomography by the AGA Institute /$36.00 doi: /j.cgh

2 Table 1. Literature Review of 8 Case Series on Stent Therapy for Esophageal Leakage With at Least 10 Patients With Anastomotic Leakage After Esophagectomy or Gastrectomy for Cancer Roy-Choudhury et al 12 Doniec et al 13 Schubert et al 14 Langer et al 15 Kauer et al 16 Tuebergen et al 17 Patients, n Leakage OE GE a /leakage 14/0/0 18/1/2 11/1/0 21/3/0 10/0/0 22/2/8 15/2/14 22/0/0 133/9/24 others b /perforation, n Stent type Multiple c Ultraflex Polyflex Polyflex Choo Multiple d Ultraflex Polyflex Median time to diagnosis, d (range) 13.5 (3 28) 6 (3 15) 6 (3 12) n.r. n.r. n.r. e,f n.r. 6.5 (1 13) Median time to stenting, d (range) 19.5 (9 34) 6 (3 15) 6 (3 12) 19 (4 65) n.r. 14 (0 611) n.r. g n.r. h Complication of stent placement 0% (0/14) 0% (0/21) 0% (0/12) 8% i (2/24) 0% (0/10) 0% (0/32) 0% (0/31) 0% (0/22) 1% (2/166) Primary sealing of leakage 100% (14/14) 90% (19/21) 100% (12/12) 80% j (16/20) 90% (9/10) 78% (25/32) 84% (26/31) 95% (21/22) 88% (142/162) Healing of leakage 93% k (13/14) 81% (17/21) 92% (11/12) n.r. 70% (7/10) 78% (25/32) n.r. 95% (21/22) 85% (94/111) Re-operations 0% (0/14) 0% (0/21) 0% (0/12) 13% (3/24) 0% (0/10) 25% (8/32) 6% (2/31) 9% (2/22) 9% (15/166) In-hospital mortality 7% (1/14) 29% (6/21) 0% (0/12) 25% (6/24) 20% (2/10) 16% (5/32) 6% (2/31) 5% (1/22) 14% (23/166) Patients with stent dislocation n.r. l 5% (1/21) 17% (2/12) 29% (7/24) 40% (4/10) 6% (2/32) 3% (1/31) 23% (5/22) 14% (22/152) Elective stent removal No Yes Yes No m /yes n Yes Yes Yes Yes NOTE. Ultraflex (Boston Scientific, Natick, MA); Gianturco Rosch Z (Cook, Bjaeverskov, Denmark); Polyflex (Rüsch, Kernen, Germany); and Telestep Wallstent (Schneider, Minneapolis, MN). n.r, not reported. a Leakage after esophagectomy or gastrectomy for cancer. b Leakage after other surgeries. c Ultraflex, Gianturco Rosch Z, Telestep Wallstent. d Ultraflex, Choo, Flex-stent. e Time from surgery to diagnosis was 10 days (range, 2 49 d). f Time from perforation to diagnosis 4 days (range, 0 24 d). g Stent placement was performed within the first 24 hours of diagnosis in 14 of 31 patients (45%). h Time from diagnosis to stenting was 2.7 days (0 14 d). i In 2 of 24 patients, initial stent misplacement led to enlargement of leakage. j Sixteen of 18 patients, 4 patients not evaluable with contrast swallow. k With stent in place, not confirmed by contrast swallow in all patients. l Nineteen stents placed in 14 patients. m Not recommended after esophagectomy. n Recommended after gastrectomy. Leers et al 18 Dai et al 19 Total March 2011 STENT THERAPY FOR ESOPHAGEAL ANASTOMOTIC LEAK 203

3 204 FEITH ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 3 Diagnosis and Management of Anastomotic Leakage Our diagnostic and therapeutic management of esophageal anastomotic leakage is outlined in Figure 1. Anastomotic healing was monitored primarily by clinical means. Only in case of clinical suspicion of anastomotic leakage did the patient undergo flexible upper endoscopy. If endoscopy revealed a complete ischemia or necrosis of the anastomosed jejunum, gastric conduit, or interposed colon, the patient immediately underwent re-operation with discontinuity resection of the primary reconstruction. Stent therapy was performed only in patients with adequate perfusion of the anastomotic region. Figure 1. Diagnostic and therapeutic management of esophageal anastomotic leakage.

4 March 2011 STENT THERAPY FOR ESOPHAGEAL ANASTOMOTIC LEAK 205 Figure 2. (A) Example of a used, fully covered Choo stent. (B) Example of a fully covered Niti-S Stent. For stent therapy, 1 of 2 types of fully covered self-expanding metal stents was placed by an experienced interventional endoscopist: a Choo stent (diameter shaft, 18 mm; diameter proximal throat, 24 mm; M.I. Tech, Seoul, Korea) (Figure 2A)in 109 patients or, since 2006, a Niti-S stent (diameter shaft, 20 mm; diameter proximal throat, 28 mm; Taewoong Medical, Seoul, Korea) (Figure 2B) in 6 patients. The design of both stents includes a retrieval lasso at both ends for removal and adjustment of the stent. For endoscopic stent placement, all patients received intravenous sedation with midazolam 2 to 10 mg combined with diisopropylphenol 20 to 200 mg. No patient required general anesthesia with intubation for the endoscopic procedure. After the leakage was identified endoscopically and marked by a radiopaque marker, the stent was placed transorally with a guidewire. Per our normal routine, the stent was checked by contrast swallow 1 day later to allow for complete expansion of the stent. If complete sealing of the leakage was achieved, enteral feeding was started orally with soft food in stable patients or through enteral probes in intensive care patients (Figure 3). Endoscopic stent therapy was always accompanied by assessment of the perianastomotic region by computed tomography (CT) scan. If the intraoperatively placed drain had been removed already, or if the CT scan revealed inadequate drainage of the perianastomotic region by the intraoperatively placed drain, additional chest tubes or pigtail drains were inserted under CT guidance to completely drain all visible fluid collections in all patients. Concomitantly, all patients also received broad-spectrum antibiotic therapy. In the case of a clinically uneventful postinterventional course, no intermediate controls were performed; in fact, the stent was removed endoscopically 4 to 6 weeks later. Again, stent removal was performed under intravenous sedation with midazolam and diisopropylphenol using a single-channel endoscope. With a forceps, the proximal retrieval lasso was grasped and the stent was pulled out. Complete healing of the leakage was assessed by endoscopy, and a post stent-extraction contrast swallow. In patients with residual leakage after routine stent removal, a new stent was placed or an alternative endoscopic therapy such as application of fibrin glue or hemostatic clips was used. In the case of clinical signs of persistent leakage in the postinterventional course, repeated endoscopies, contrast swallows, or CT scans were performed immediately on-demand and further interventions were performed as necessary. Methods Clinical data of patients with esophageal and gastric cancer were entered prospectively in our gastroesophageal database. Assuming that all stents were positioned correctly at initial stent placement, any kind of incorrect stent position in the further course was defined as stent dislocation. Because stent dislocations were encountered at different time points, we distinguished early, intermediate, and late dislocations. Incomplete sealing of the leakage at routine contrast swallow 1 day after stent placement was assumed to be caused by (minor) stent dislocation and was classified as early dislocation. Intermediate stent dislocations occurred after routine postinterventional contrast swallow and before complete healing of the leakage. Early and intermediate stent dislocations with persistent leakage required re-endoscopy with stent repositioning or stent removal with placement of a new stent. Late stent dislocations occurred after complete healing of the leakage and thus required no re-stenting. We analyzed our clinical database and the medical files of 115 consecutive patients with stent therapy. In addition, we performed a systematic literature review on the management of

5 206 FEITH ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 3 Figure 3. (A) Endoscopic view of anastomotic leakage in an esophagojejunostomy. (B) Coverage of the anastomotic leakage with a covered self-expanding metal stent. (C) Contrast swallow of anastomotic leakage of an esophagojejunostomy. (D) Contrast swallow after stent placement of the anastomotic leakage and drainage with a chest tube. esophageal anastomotic leakage with endoscopic stent placement. To minimize the heterogeneity of the patient cohorts of the available studies, only studies that comprised at least 10 patients undergoing stent therapy after esophagectomy or gastrectomy for cancer were included. Results The median interval between surgery and diagnosis of anastomotic leakage with endoscopic stent placement was 8 days (range, 3 21 d). Outcome of Stent Therapy Stent placement was technically feasible in all 115 patients without procedure-related morbidity or mortality. Routine contrast swallow 1 day after stent placement was impossible in 21 of 115 patients (18%) because of their septic status. In the remaining 94 patients, contrast swallow showed complete sealing of the leakage in 70 patients (74%) and persistent leakage in 24 patients (26%). All patients with incomplete sealing of the leakage underwent re-endoscopy with repositioning of the stent, stent extraction and placement of a new stent, or placement of an additional second stent overlapping the first stent. Complete healing of the leakage as diagnosed by endoscopy and contrast swallow after stent removal 4 to 6 weeks after stent placement was achieved in 80 of 115 patients (70%; 95% CI, 64% 76%). This was achieved after placement of 1 stent in 59 of 115 patients (51%), 2 stents in 16 of 43 patients (37%), and after placement of 3 or more stents in 5 of 20 patients (25%) (range, 3 10 stents). Thus, the rate of healing decreased with increasing numbers of stents applied. Anastomotic healing was independent of the type of stent. In 35 of 115 patients (30%; 95% CI, 23% 37%), stent therapy did not result in complete healing of the leakage. However, such complete healing finally could be achieved in 9 patients (8%) by additional endoscopic application of fibrin glue or hemostatic clips for asymptomatic persisting minor anastomotic leakage after routine stent removal. In another 4 patients (3%), stent therapy also did not result in complete healing but induced the formation of a stable, almost asymptomatic, fistula with which the patients could be discharged from the hospital. Twelve

6 March 2011 STENT THERAPY FOR ESOPHAGEAL ANASTOMOTIC LEAK 207 Figure 4. Abdominal radiograph showing a dislocated stent stuck at the Roux-en-Y anastomosis in a patient after gastrectomy. patients (10%) with progressive septic symptoms during stent therapy underwent reoperation, the anastomosis disconnected, and the primary reconstruction was removed. Only 2 of them (2%) underwent reconstruction secondarily with colonic interposition after clinical stabilization. Of the remaining 10 patients undergoing reoperation, 2 (2%) died in the postoperative course, 5 (4%) died of tumor progress after discharge from the hospital, and 3 (3%) are still alive but not in condition for further reconstructive surgery. Finally, another 8 patients (7%) who did not undergo reoperation died in the course of stent therapy during their primary hospital stay with 5 of them (4%) showing perpetuating septic course, 2 of them (2%) dying of acute cardiac failure, and 1 patient (1%) dying of fulminant pulmonary embolism resulting from a deep venous thrombosis. Overall, the in-hospital mortality rate was 9% (10 of 115 patients). Complications of Stent Therapy Stent perforation was seen in 1 of 115 patients (1%). In this case, the stent, which was correctly placed over a leaking esophagogastrostomy, perforated through the pulled-up gastric tube into the trachea. We performed immediate re-thoracotomy with resection of the gastric tube and closure of the tracheal fistula using a muscle flap. The most frequent complication of stent therapy was stent dislocation and occurred in 61 of 115 patients (53%), including 41 of 84 patients (49%) with esophagogastrostomy, 17 of 28 patients (61%) with esophagojejunostomy, and all 3 patients (100%) with esophagocolonostomy. Although 60 of 109 patients (55%) who primarily were stented with a Choo stent had a stent dislocation, the rate of stent dislocation for the Niti-S stent was 1 of 6 patients (17%). Early, intermediate, and late stent dislocations were encountered in 24, 28, and 17 of 115 patients (21%, 24%, and 15%), respectively. Early and intermediate stent dislocation with persistent leakage led to repeated stent placements in 43 patients. Overall, 72 patients (63%) received 1 stent, 23 patients (20%) received 2 stents, 9 patients (8%) received 3 stents, and 11 patients (10%) received more than 3 stents (range, 4 10 stents). Patients with late stent dislocation presented in 3 different ways. First, in 6 of 115 patients (5%), the stent dislocated completely, migrated asymptomatically through the entire intestinum, and was harvested from the patient s excretion by chance. Second, the stent was not in place at routine endoscopy 4 to 6 weeks after stent placement and was not detectable by other means such as radiographs in 7 of 115 patients (6%). Thus, unrecognized complete intestinal passage must have been assumed as well. Third, surgical interventions were necessary in 4 of 115 patients (3%), all owing to late stent dislocations. In 3 of these patients, all stented for leaking esophagojejunostomy, the stent also was not detectable at routine endoscopy 4 to 6 weeks after stent placement, but was found on abdominal radiographs in the small intestine not reachable by endoscopy. Because all 3 patients were completely asymptomatic, we made no further effort to remove the stent at that time and waited for completion of the intestinal passage. However, all 3 patients presented with acute abdomen 3 months, 2 months, and 1 week later (Figure 4) and underwent emergency laparotomy. The stents were stuck at the Roux-en-Y anastomosis in 2 patients and at the ileocecal valve in 1 patient, causing intestinal perforations at these sites. We performed resection of the affected part of the intestine in all 3 patients (Figure 5). In the remaining patient undergoing surgical intervention, we performed prophylactic open gastrotomy to remove a dislocated stent before the onset of symptoms because this stent had asymptomatically migrated into the stomach but could not be removed endoscopically because of a stricture of the esophagogastrostomy. Endoscopic Follow-Up Evaluation Of the 95 surviving patients who were stented and did not undergo reoperation, 93 patients (98%) were followed up in our department for at least 3 months after initial surgery with a mean follow-up period of 17 months (range, 3 73 mo). Endoscopic stent removal was performed in 74 of 93 patients (80%) after a median of 54 days (range, d) after initial stent placement. In 5 of these patients (5%), the retrieval lasso could not be grasped as a result of tissue ingrowth. In these cases, the proximal end of the stent itself was mobilized endoscopically and directly grasped with a forceps to remove the stent. In 2 more patients (2%), the stent was not removable at all because of hyperplastic tissue overgrowth. The whereabouts of the stents in the remaining 17 patients already have been exemplified earlier with surgical removal in Figure 5. Resection specimen of a dislocated stent that got stuck and caused intestinal perforation at the ileocecal valve.

7 208 FEITH ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 3 4 patients (4%) and asymptomatic complete intestinal passage in 13 patients (14%). Eleven patients (12%) developed symptomatic anastomotic strictures and all were treated endoscopically by bougie dilations. Endoscopy revealed anastomotic stricture in another 24 patients (26%) who, however, were clinically asymptomatic. In these patients, we performed prophylactic bougie dilations. Literature Review Quantitative analysis of our literature review with all available studies on stent therapy that comprised 10 or more patients with esophageal anastomotic leakage after esophagectomy or gastrectomy for cancer is shown in Table 1. Discussion The concept of additional stent placement in the conservative management of esophageal anastomotic leakage after esophagectomy or gastrectomy provides the advantage of immediate leak occlusion, which allows early oral feeding, avoids further contamination of the mediastinum, and, finally, results in shorter hospital stays However, stent placement also forces the need for adequate perianastomotic drainage because stents not only stop further intestinal leakage to the extraintestinal perianastomotic region but also prevent internal drainage of any fluid collection in the mediastinum or pleural cavities. These issues have been emphasized repeatedly in several reports, however, without finally rendering endoscopic stent therapy the treatment of choice for anastomotic esophageal leakage This is mainly owing to fundamental deficits of the available studies, among them small case loads (all 32 patients), different underlying diseases (malignant and benign), 14,15,17 heterogeneous causes of esophageal leaks (anastomotic leakages and esophageal perforations), 13 15,17,18 and varying therapeutic regimens with different time intervals between diagnosis and treatment (stent therapy as first treatment option, after ineffective other therapeutic means, or even as last-choice procedure). 15,17 In the present study, we only included patients with esophageal anastomotic leakages after esophagectomy or gastrectomy for cancer that primarily were managed with stent placement right after diagnosis of the leakage. Our series of 115 patients is a large cohort. However, similar to all other studies, ours also was not randomized and therefore lacked a control group. Thus, comparison of stent therapy with other treatment regimens can be made only by looking into published figures. For surgical revision and for conservative treatment without a stent, in-hospital mortality rates are reported at 35% to 64% 1 4 and 19% to 46%, 4,6 8,21,22 respectively. Compared with these numbers, the in-hospital mortality in our series (9%) and in other reports on stent therapy (0% 29%) is substantially lower. With respect to healing of the esophageal leakage, numbers are given at 59% 22 and 58% 21 for conservative treatment without a stent but at 70% to 95% with stent therapy It must be mentioned, however, that comparisons of stent therapy with other treatment regimen for esophageal leakages are limited by the heterogeneous nature of the patient cohorts. Because there is common agreement in the literature that extensive ischemia of the conduit is not an indication for stent therapy but necessitates immediate reoperation, these assumingly most severe cases consistently are excluded from the stent group and find themselves unexceptionally in the surgical revision group. Apart from that, the criteria qualifying for stent therapy, if at all clearly defined, differ considerably between studies. Although we stented all adequately perfused anastomotic leakages irrespective of size, some investigators restrict stent therapy to leakages affecting less than one third, 15 less than two thirds, 17 or less than 70% of the circumference, 14 and some also set a minimum size of the leakage for stent therapy ,16 We believe that the state of perfusion of the anastomotic region is the paramount determinant for healing, and that therefore endoscopy is the decisive diagnostic tool and that all adequately perfused esophageal anastomotic leakages qualify for stent therapy. Nevertheless, the size of the leakage, the time from appearance of leakage to diagnosis and treatment, and the degree of mediastinal or pleural infection are important parameters that influence the outcome of stent therapy. With these parameters in mind, it appears highly plausible that the most favorable outcomes of stent therapies have been reported for iatrogenic esophageal perforation. 5,23 To mimic this ideal situation in the postoperative course, we strongly recommend immediate endoscopy on the slightest clinical suspicion of anastomotic leakage and stent placement without the least delay to keep extraesophageal infection as minimal as possible. The outcome of stent therapy presented in this study and published elsewhere is convincing because the mainly technical concerns on temporary stent placement appear unwarranted. The available data show that stent placement was technically feasible in virtually all patients without procedure-related morbidity or mortality and led to instant primary sealing of the leakage in 74% of our patients and in 88% (range, 78% 100%) of the patients in other studies Moreover, elective stent removal proved to be endoscopically feasible in the vast majority of patients and most investigators, including us, explicitly recommend elective stent removal to avoid possible complications of permanent stenting such as penetration, dislocation, stenosis, and reflux with aspiration. 13,14,16 19 Finally, all anastomotic strictures after stent removal in our series and most other reports could be handled endoscopically. 13,15 Nevertheless, there can be no denying that a couple of stent-specific problems may occur. The rate of patients with stent dislocation was remarkably high at 53% in our series. Interestingly, we saw stent dislocation in all patients with esophagocolonostomies. The numbers for esophagojejunostomies and esophagogastrostomies in our series were 61% and 49%, respectively. Langer et al 15 had similar results for esophagocolonostomies (100%) and esophagogastrostomies (44%) but encountered stent dislocation in only 1 of 5 patients with esophagojejunostomies (20%). It is important to mention that stent dislocation is observed more frequently in the therapy of anastomotic leakage than in the palliative treatment of malignant stenosis in which rigid tumor stenosis provides an outer force on the stent for a tight fit and reduced risk of dislocation. 24 In this context, our observation of less stent dislocations with the Niti-S stent also could be attributed to its larger diameter, possibly resulting in a tighter fit to the esophageal wall. However, numbers are too small to draw conclusions on stent sizes from our study. In parallel, the different rates of stent dislocation encountered

8 March 2011 STENT THERAPY FOR ESOPHAGEAL ANASTOMOTIC LEAK 209 for the different types of anastomoses also might be caused by differences in the anatomic texture and motility of the anastomosed colon, stomach, and small intestine. Although all early and intermediate stent dislocations could be managed endoscopically, both complete intestinal passage and surgical stent removals were seen only in late stent dislocations. This most likely is owing to early diagnosis in patients with early or intermediate stent dislocation because they become symptomatic for persisting leakage before the stent vanishes out of endoscopic range. In these patients, even repeated endoscopic interventions appear worthwhile, 15 albeit the rate of healing decreased with the number of stents applied in our series. Stent dislocation with intestinal obstruction and subsequent intestinal perforation, however, is a major complication requiring surgery. However, cases of bowel perforation caused by stent migration rarely are reported in the literature but appear to be associated mostly with small-bowel obstruction We assume that the rate of patients requiring surgical intervention for removal of dislocated stents is still underestimated in the literature because most reports on stent dislocations are from nonsurgical patients. It appears plausible that the risk for stents to get stuck somewhere in the intestine is higher in patients who underwent extended abdominal surgeries with altered intraabdominal anatomy and, most likely, adhesions than in nonoperated patients with a high chance of asymptomatic complete intestinal passage. Surgical revision clearly is required in patients with intestinal perforation. However, based on our experience, we also suggest early surgical intervention in the case of endoscopically unreachable stent dislocation in patients undergoing surgery for upper gastrointestinal carcinomas. In summary, the available data clearly show the feasibility of temporary stent placement and removal with low procedure-related morbidity and mortality and, because of the favorable outcome of stent therapy compared with other treatment regimens, suggest stent therapy as the treatment of choice in the management of adequately perfused esophageal anastomotic leakage. However, because stent dislocation remains a common problem in these postoperative patients, the optimal type of stent, the best time for stent removal, and useful additional endoscopic means for stent fixation have yet to be defined in these patients. 25,26 On this basis, it can be concluded that an experienced interventional endoscopist is indispensable for any surgical unit performing esophageal surgery. References 1. Griffin SM, Lamb PJ, Dresner SM, et al. Diagnosis and management of mediastinal leak following radical oesophagectomy. Br J Surg 2001;88: Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995;169: Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10: 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: DeMeester TR. Perforation of the esophagus. Ann Thorac Surg 1986;42: Sauvanet A, Baltar J, Le Mee J, et al. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg 1998;85: Viste A, Eide GE, Søreide O. Stomach cancer: a prospective study of anastomotic failure following total gastrectomy. Acta Chir Scand 1987;153: Griffin S, Desai J, Charlton M, et al. Factors influencing mortality and morbidity following oesophageal resection. Eur J Cardiothorac Surg 1989;3: Utidehaag MJ, Hooft JE, Veschuur EM, et al. A fully-covered stent (Alimaxx-E) for the palliation of malignant dysphagia: a prospective follow-up study. Gastrointest Endosc 2009;70: Brown TH, Nicholson DA, Irving MH, et al. Use of a self-expanding metal stent for oesophagogastric fistulation. Br J Surg 1995;82: Hünerbein M, Stroszczynski C, Moesta KT, et al. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents. Ann Surg 2003;240: Roy-Choudhury SH, Nicholson AA, Wedgwood KR, et al. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. AJR Am J Roentgenol 2001;176: Doniec JM, Schniewind B, Kahlke V, et al. Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy. Endoscopy 2003;35: 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: Langer FB, Wenzl E, Prager G, et al. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg 2005;79: Kauer WKH, Stein HJ, Dittler HJ, et al. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagectomy. Surg Endosc 2007;22: 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 2008;12: Leers JM, Vivaldi C, Schäfer H, et al. Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent. Surg Endosc 2009;23: Dai YY, Gretschel S, Dudeck O, et al. Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents. Br J Surg 2009;96: Eloubeidi MA, Lope TL. Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of removal, and tissue response in humans. Am J Gastroenterol 2009;104: Fan ST, Lau WY, Yip WC, et al. Healing of esophageal fistulas after surgical treatment for carcinoma of the esophagus and the upper part of the stomach. Surg Gynecol Obstet 1988;166: Tersløv-Jørgensen S, Pedersen H, Larsen V. Conservative treatment with total parenteral nutrition in patients with gastroesophageal anastomotic leaks (anastomotic leaks conservatively treated). Acta Chir Scand 1979;145: Brinster CJ, Singhal S, Lee L, et al. Evolving options in the management of esophageal perforation. Ann Thorac Surg 2004; 77: Verschuur EM, Steyerberg EW, Kuipers EJ, et al. Effect of stent size on complications and recurrent dysphagia in patients with esophageal or gastric cardia cancer. Gastrointest Endosc 2007; 66: Lowe AS, Beckett CG, Jowett S, et al. Self-expandable metal

9 210 FEITH ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 9, No. 3 stent placement for palliation of malignant gastroduodenal obstruction: experience in a large, single, UK centre. Clin Radiol 2007;62: Diller R, Senninger N, Kautz G, et al. Stent migration necessitating surgical intervention. Surg Endosc 2003;17: Stawowy M, Kruse A, Mortensen FV, et al. Endoscopic stenting for malignant gastric outlet obstruction. Surg Laparosc Endosc Percutan Tech 2007;17:5 9. Reprint requests Address requests for reprints to: Prof. Marcus Feith, MD, Chirurgische Klinik und Poliklinik, Klinikum Rechts der Isar, Technische Universität München, Ismaningerstr 22, Munich, Germany. feith@chir.med.tu-muenchen.de; fax: Conflicts of interest The authors disclose no conflicts.