S1970 Utility of Covered Metal Stents in Esophageal Penetrating Injuries

Abstract

INTRODUCTION: Management of esophageal perforations and leaks is traditionally managed via a surgical approach, however, here we show that self-expanding metal stents (SEMS) can be used to successfully treat esophageal injuries. CASE DESCRIPTION/METHODS: Case 1: A 27-yo man presented for GSW to the chest and went for surgical repair of the proximal esophagus. The esophageal defect was oversewn, but on day 7 an esophagram revealed an anterior leak. On EGD, there were 2 medium-sized perforations 30 cm from the incisors that were covered with a 12 cm × 20 mm fully covered stent under fluoroscopic guidance and anchored with two hemostatic clips. One week later the stent was exchanged because one perforation was still present. At two-weeks after the first EGD, the perforations had completely healed that was confirmed with esophagram. Case 2: A 21 year-old-woman presented for GSW to the neck who was found to have a T1 spinal cord injury with severe damage to the soft tissue. An esophageal perforation was found on a later esophagram and surgical repair failed to close the leak. EGD showed a perforation at 20 cm from the incisors that was treated with a 12 cm × 20 mm fully covered stent under fluoroscopic guidance and anchored with two hemostatic clips. She had a repeat EGD with stent exchange, but at week-two the tract had epithelialized that was further treated with APC and closure with 3 clips. DISCUSSION: Esophageal perforations are a life-threatening complication. If not corrected within the first 24 hours, morbidity and mortality increases significantly due to increased risk for fulminant mediastinitis and pleural contamination.1 Successful closure of benign esophageal perforations with stents is approximately 82%-100%.1 In a study of 15 patients, early (∼45 minutes) versus late (∼123 hours) esophageal stenting decreased hospital stay to 5 days compared to 44 days in the late group related to complications of sepsis and multiorgan failure.4 Serious complications from esophageal stenting are stent perforation, stent-related bleeding, and strictures which occurred at 2%, 0.8%, and 3.2%, respectively. In that same study, 73/340 experienced stent migration.5 A study of 44 patients comparing rates of esophageal migration with and without anchoring clips, migration occurred in 3/23 patients with hemostatic clips versus 12/21 without hemostatic clips.6 Here are two cases of esophageal perforation where fully covered esophageal SEMS were used without complication of stent migration due to anchoring clips.Figure 1.: Esophageal perforation.Figure 2.: SEMS covering perforation.Figure 3.: Healed perforation after SEMS.