Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents

Abstract

Objective: To evaluate the efficacy of a self-expanding plastic stent in the treatment of thoracic leaks after esophagectomy for cancer.

Summary background data: Anastomotic leaks are a major cause of morbidity and mortality after esophageal resection. Treatment options range from aggressive surgery to conservative management, but there remains much controversy on the best treatment.

Methods: Over a 6-year period (1998-2003), esophagogastric leaks were observed in 19 of 204 patients (9.3%) after esophagectomy. Between 1998 and 2000, anastomotic leaks were managed by reexploration (n = 7) or by conservative treatment (n = 3). Since 2001, insertion of self-expanding plastic stents was performed for all anastomotic leaks (n = 9). The short-term efficacy and long-term outcome of both treatments were analyzed.

Results: Self-expanding plastic stents were successfully placed in all patients without procedure-related morbidity. Immediate leak occlusion was obtained in 8 of 9 patients. The mean healing time (time to stent removal) was 29 days. Compared with the conventional treatment group, patients who were treated with stents had earlier oral intake (11 days versus 23 days), a less extensive intensive care course (25 days versus 47 days), and shorter hospital stay (35 days versus 57 days). In-hospital mortality was 0% (0 of 9 patients) in the stent group and 20% (2 of 10 patients) in the other group. After a mean follow-up of 12 months, none of the patients developed a stricture after stenting, but a stricture occurred in 1 patient after conservative treatment.

Conclusions: Self-expanding plastic stents can reduce leak-related morbidity and mortality after esophagectomy and may be considered a cost-effective treatment alternative.

FIGURE 1. Self-expanding plastic stent consisting of a polyester mesh and a silicone membrane.

FIGURE 2. A: Endoscopic view of a large mediastinal leak. B: Occlusion of the leak by a self-expanding plastic stent. C: Stent retrieval and almost complete healing after 4 weeks

FIGURE 3. A: A contrast study demonstrates a leak of the esophagogastrostomy. B: Occlusion of the leak by a self-expanding metal stent (↑). C: Complete healing after 4 weeks.

FIGURE 4. A: Endoscopic aspect of an anastomotic leak 6 days following esophagectomy. B: Change of the stent after 2 weeks reveals a residual leak. C: Retrieval of the stent and complete healing after 3 weeks.

FIGURE 5. CT in a patient with anastomotic leakage after esophagectomy. A: The abscess (⇑) is not sufficiently drained by the chest tube (↑). B: CT-guided insertion of a drainage (↑) after endoscopic stent placement. C: Complete regression of the abscess (⇑) after 4 weeks.