Stent-in-stent Technique for Esophageal Anastomotic Leak Closure

Abstract

Purpose: A 65-year-old man with gastric adenocarcinoma with extension into the distal esophagus underwent partial esophagogastrectomy with gastric pull-up and stapled anastomosis. Postoperatively, the patient developed an anastomotic leak. Primary closure of the leak was performed with a pleural patch, but failed. The patient was a poor candidate for further surgical intervention, thus endoscopic closure was pursued. A 12 x 2.2 cm partially covered self-expanding metal stent (PCSEMS; Wallflex, Boston Scientific, Natick, MA) was placed across the 1-cm defect. A PCSEMS was chosen in order to decrease risk of stent migration. Post-placement contrast study showed no extravasation; the patient was able to tolerate a soft diet. Six weeks after PCSEMS placement, EGD showed the stent embedded across the anastomosis with hyperplastic tissue at the ends of the stent. A stent-in-stent technique was then used to remove the PCSEMS. A 12 x 2.2cm fully covered selfexpanding metal stent (FCSEMS; Wallflex, Boston Scientific, Natick, MA) was deployed within the PCSEMS (Figure 1). After 4 weeks of dual stenting, both stents were removed without significant resistance by grasping the stent drawstrings (Figure 1). Contrast study confirmed leak closure. The patient continues to tolerate a solid diet. In benign esophageal conditions such as leaks and fistulas, PCSEMS have the advantage of mucosal anchoring, with a more secure placement and likely improved seal of defects. This benefit is also their main drawback, leading to difficult removal with higher risk of complications such as severe bleeding or perforation. The stent-in-stent technique results in pressure necrosis by the inner FCSEMS onto the hyperplastic mucosa. This causes the tissue to recede, allowing for removal of the PCSEMS. Esophageal leaks and fistulas are associated with high surgical morbidity and mortality. Endoscopic closure with the stent-in-stent technique could be a safe, effective and less invasive alternative.Figure: Partially-covered metal stent in the distal esophagus (A). Six weeks after placement (B). Fully-covered metal stent placed within the partially-covered metal stent (C). Endoscopic appearance after stents removed. Residual surgical suture, arrow (D).