Postsurgical Leaks Research Articles

An Endoscopic Strategy Combining Mega Stents and Over-The-Scope Clips for the Management of Post-Bariatric Surgery Leaks and Fistulas (with video)

Endoscopic stenting has proved effective in the management of post-surgical leaks but is strongly hampered by the high rate of stent migration. In this study, we evaluate our experience with a new approach involving the use of novel ultra-large expandable stents tailored for bariatric surgery leaks (Mega stents), combined with the use of the innovative over-the-scope clips (OTSC). Retrospective analysis of patients with post-bariatric surgery leaks managed at our institution by an approach combining Mega stents and over-the-scope clips. Twenty-two patients were treated for post-bariatric surgery leaks; 13 (59%) had a sleeve gastrectomy while nine (41%) had a RYGB. A total of 30 stents were inserted. Successful endoscopic insertion and removal were achieved in all patients. OTSC clips were applied in 12 patients (55%); five simultaneously with stents and seven after stent removal. Primary closure (after one endoscopic procedure) was achieved in 13 patients (59%) and in a total of 18 patients after multiple endoscopic procedures (82%). An average of 1.4 stents and 2.8 endoscopic procedures were required per patient. Stent migration occurred in four patients (18%), and all were retrievable endoscopically. Other complications included retrosternal pain and vomiting in 20 patients (91%) including one necessitating early removal, bleeding in two patients (9%), and perforation and esophageal stricture in one patient each (5%). Two mortalities were encountered, and one of them was stent-related (bleeding). Mega stents are effective in the management of post-bariatric surgery leaks. The combined use of Mega stents and OTSC clips is associated with a low incidence of migration and a low number of stents and procedures required per patient.

Clinical outcomes of self-expandable stent placement for benign esophageal diseases: A pooled analysis of the literature.

To analyze the outcomes of self-expandable stent placement for benign esophageal strictures and benign esophageal leaks in the literature. The PubMed, Embase and Cochrane databases were searched for relevant articles published between January 2000 and July 2014. Eight prospective studies were identified that analyzed the outcomes of stent placement for refractory benign esophageal strictures. The outcomes of stent placement for benign esophageal leaks, perforations and fistulae were extracted from 20 retrospective studies that were published after the inclusion period of a recent systematic review. Data were pooled and analyzed using descriptive statistics. Fully covered self-expandable metal stents (FC SEMS) (n = 85), biodegradable (BD) stents (n = 77) and self-expandable plastic stents (SEPS) (n = 70) were inserted in 232 patients with refractory benign esophageal strictures. The overall clinical success rate was 24.2% and according to stent type 14.1% for FC SEMS, 32.9% for BD stents and 27.1% for SEPS. Stent migration occurred in 24.6% of cases. The overall complication rate was 31.0%, including major (17.7%) and minor (13.4%) complications. A total of 643 patients were treated with self-expandable stents mainly for postsurgical leaks (64.5%), iatrogenic perforations (19.6%), Boerhaave's syndrome (7.8%) and fistulae (3.7%). FC SEMS and partially covered SEMS were used in the majority of patients. Successful closure of the defect was achieved in 76.8% of patients and according to etiology in 81.4% for postsurgical leaks, 86.0% for perforations and 64.7% for fistulae. The pooled stent migration rate was 16.5%. Stent-related complications occurred in 13.4% of patients, including major (7.8%) and minor (5.5%) complications. The outcomes of stent placement for refractory benign esophageal strictures were poor. However, randomized trials are needed to put this into perspective. The evidence on successful stent placement for benign esophageal leaks, perforations and fistulae is promising.

Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks

BackgroundAnastomotic leaks are a severe complication after colorectal surgery. We aimed to evaluate the long-term efficacy of endoscopic vacuum therapy for their treatment. MethodsRetrospective review of a series of post-surgical colorectal leaks treated with endoscopic vacuum therapy, with minimum follow-up of 1 year. Generalized peritonitis or haemodynamic instability was considered contraindication to endoscopic treatment. ResultsEndoscopic vacuum therapy was applied in 14 patients with colorectal leak, in 2 cases complicated by recto-vaginal fistula. Overall success rate was 79%, favoured by early beginning of treatment (90%) and presence of a stoma (100%) and no preoperative radiotherapy (86%). Median duration of treatment was 12.5 sessions (range 4–40). Median time for complete healing was 40.5 days (range 8–114), for a median cost of treatment of 3125 Euros. No complication related to endoscopic vacuum therapy was observed. Further surgery was required in 3 cases. ConclusionEndoscopic vacuum therapy is a safe treatment for post-surgical leaks, with high success rates.

Su1642 Predictors of Failure of Endoscopically Managed Post-Operative Bile Duct Leaks: a Large, Multi-Center Retrospective Study

Su1642 Predictors of Failure of Endoscopically Managed Post-Operative Bile Duct Leaks: a Large, Multi-Center Retrospective Study Anoop Prabhu*, Sunil Amin, Brian Rajca, Dennis Yang, Shailendra S. Chauhan, Peter V. Draganov, Farah Monzur, Laila Menon, Jonathan Buscaglia, Satish Nagula, Juan Carlos Bucobo, Lionel S. D, Petros C. Benias, David L. Carr-Locke, Nazia Hasan, ADAM J. Goodman, Amy Tyberg, Shireen a. Pais, Jawad Ahmad, Susana Gonzalez, Christopher J. Dimaio Gastroenterology, Mount Sinai School of Medicine, New York, NY; Gastroenterology and Hepatology, University of Florida, Gainesville, FL; Gastroenterology, Stony Brook University Medicine, Stony Brook, NY; Gastroenterology, Beth Israel Medical Center, New York, NY; Gastroenterology, NYU Langone Medical Center, New York, NY; Gastroenterology and Hepatobiliary DIseases, New York Medical College, Valhalla, NY Background: Post-operative biliary leaks are a common reason for referral for ERCP. Data is lacking regarding the variables that best predict persistence of these leaks after initial endoscopic therapy. Aims: Assess current practices in endoscopic management of bile leaks and identify predictors of failed resolution at follow-up ERCP. Methods: A multi-center retrospective review was performed of post-surgical biliary leaks referred to ERCP. Case-specific data was extracted on demographics, surgical details, cholangiogram findings, and endoscopic interventions, including use of stent and biliary sphincterotomy. Exclusion criteria were age!18, non-native biliary anatomy, and liver transplant. Data were stratified by persistence of leak at follow-up ERCP. Univariate analysis was performed using chi-squared test for categorical and student t-test for continuous variables. Variables whose univariate p-values were! 0.2 were used in a multivariate model. Results: A total of 219 cases of post-operative bile leaks were identified. The mean age was 55 17.6 years with 51.6% being female (Table 1). The mean time to leak identification was 12.8 28.1 days. The most common means of leak identification was bilious surgical drain output (43.4%). At index ERCP, the most frequent leak site was the cystic duct (43.8%). Patients underwent biliary sphincterotomy alone in 11 cases (5.0%), stenting alone in 50 cases (21.9%), both in 156 cases (71.2%), and neither in 2 cases. Of the 167 patients who underwent sphincterotomy, 26 (15.6%) had choledocholithiasis. Post-ERCP pancreatitis was the most common complication (1.83%). Follow-up ERCP data was available in 151 cases. Mean time between ERCPs was 49 28 days. Resolution of leak occurred in 125 (82.8%) cases. On univariate analysis, predictors of persistent leak were: non-cholecystectomy (p!.001), post-surgical drain placement (pZ.01), leak site (pZ.03), and fewer days between ERCPs (p!.001) (Table 2). On multivariate analysis, factors predictive of persistent leak were added days to leak identification (9.3 11.8 days in leak resolution vs 22.4 51.1 days in leak persistence group; OR 1.04, 95% CI 1.00-1.08) and fewer days between ERCPs (52 25.8 days in leak resolution vs 31.5 24.3 days in leak persistence group; OR 0.85, 95% CI 0.730.99). Age, gender, surgery indication/type, drain placement, leak site, sphincterotomy, or stent choice/location were not predictive of leak persistence on multivariate analysis. Conclusions: The majority of post-surgical bile leaks were treated with combination stent placement and biliary sphincterotomy. Though most leaks resolve with endoscopic management, failure of leak resolution is associated with increased time to leak identification and decreasing time between index and followup ERCP. Neither stent choice nor sphincterotomy predict persistence of leak at follow-up ERCP.

Endoscopic Removal of an Esophageal Stent After Diffuse Hyperplastic Tissue Ingrowth

Endoscopic placement of esophageal Self-Expandable Metal Stents (SEMS) is a therapeutic option for post-surgical esophageal leaks. Partially covered SEMS are mainly designed for malignant esophageal strictures, but are used off-label to close post-surgical leaks due to their lower migration rate than fully covered SEMS, and better adherence to the esophageal wall. Partially covered esophageal SEMS can achieve post-surgical fistula healing, but their removal is difficult due to tissue ingrowth through the uncovered part. A challenging case of a difficult removal of a partially covered esophageal SEMS (remove the indefinite article) is (below) presented.

Over-The-Scope Clips in Luminal Leaks: A Quick Fix or the Real Deal?

Purpose: The Over-The-Scope Clip (OTSC®) has recently been used to successfully treat gastrointestinal perforations, leaks, and fistulas; many of which were previously managed surgically. While results have been promising, clinical data remains limited. The goal of this study was to retrospectively review the efficacy of OTSC® at our hospital. Methods: We performed a retrospective clinical case series of OTSC® cases at our hospital, which included patients treated between March 2012 and January 2013. Charts were reviewed for indications for use, patient demographics (age, sex), outcomes, and complications. Outcomes included resolution of defect confirmed by fluoroscopy at the time of endoscopy and defect recurrence during follow-up. Results: Four patients (all female, mean age 48 years, range 40-65 years) with five post-surgical leaks were treated with OTSC. Initial surgical therapy included laparoscopic paraesophageal hernia repair and fundoplication (n=1), laparoscopic sleeve gastrectomy (n=1), partial gastrectomy for revision of roux-en-y anastomosis with marginal ulcer (n=1) and Ivor-Lewis esophagectomy for esophageal perforation (n=1). Patients had previously failed luminal stenting (n=2), hemoclip closure (n=1) or had a leak location not amenable to endoscopic stenting (n=1). The defects occurred in the stomach (n=4) and esophagus (n=1) as one patient had both an esophageal and gastric leak after esophagectomy. A total of seven OTSC clips (sizes: 12/6gc n=3, 11/6t n=3, 12/6t n=1) were placed with one patient undergoing OTSC clip placement four times at two different leak sites. OTSCs were initially successful in all cases as verified by fluoroscopy at time of endoscopy. Two patients remain clinically well without further leak and two had recurrence of the defect. The patient with two leaks had resolution of one leak post-OTSC and recurrence of one leak. Clinical follow-up of successful OTSC was 202 and 286 days. Time to failure for OTSC was 34 and 74 days. There were no complications of OTSCs at time of endoscopy or during follow-up. Conclusion: This case series suggests that OTSC is safe and initially successful for post-surgical leaks. However long-term clinical effectiveness varied. Further investigation is warranted to determine factors predictive of long-term OTSC success.

Treatment of Lower-GI Post-Surgical Fistulas With the Over-the-Scope Clip

Post-surgical colorectal leaks and fistulas are severe complications that dramatically increase morbidity and mortality. Over-the-scope clip (OTSC) application, introduced in clinical practice in 2007, represents an innovative technique to seal the visceral wall for acute and chronic colorectal post-surgical leaks and fistula management. Endoscopic closure of colorectal post-surgical leaks and fistulas with OTSC is a safe technique that accomplishes a high success rate in both acute and chronic cases, including rectovaginal, rectovesical, and colocutaneous fistulas. Overall success rate is higher than 80%, as reported in the literature, in both acute and chronic situations. No OTSC-related complications have been described in the lower gastrointestinal tract so far. This article is part of an expert video encyclopedia.

Removable and repositionable covered metal self-expandable stents for leaks after upper gastrointestinal surgery: experiences in a tertiary referral hospital

Anastomotic leakages are severe complications of upper gastrointestinal surgery with serious morbidity and mortality. Until recently, only abscess drainage was possible. Since 2007, removable and repositionable covered metal self-expandable stents (RReCoMSeS) have been used in our hospital to cover leaks. Patients with postsurgical gastrointestinal leaks treated with RReCoMSeS between January 2007 and March 2010 were retrospectively evaluated and described. Twenty-six patients were treated with RReCoMSeS (totally covered Choo/Hanaro and partially covered Endoflex stents). Included patients had anastomotic leaks after esophagectomy (15) and bariatric surgery (11). Overall successful sealing of the leak occurred in 81 % (including multiple procedures). In total 33 RReCoMSeS were used (mean 1.3 stents and 1.7 procedures per patient). Twenty-one of 33 RReCoMSeS succeeded in sealing the leak (64 %). Migration occurred in 24 % RReCoMSeS, and 9 % disintegrated. One stent (3 %) caused a perforation. RReCoMSeS are a safe alternative for treating postsurgical leaks in the upper gastrointestinal tract. In 81 % of patients and with 64 % of the inserted stents, leaks were sealed successfully, with few complications. Fewer stents per patient were needed thanks to their repositionability. Stent migration is a major problem.

A few thoughts on “Interventional radiology in the management of benign biliary stenoses, biliary leaks and fistulas: a pictorial review”

Dear Editor, We read with great interest the article by Krokidis and colleagues [1] recently published in Insights into Imaging. In this well-presented pictorial review, the authors point out the crucial role of interventional radiology as a minimally invasive approach to treat benign strictures, to divert the bile away from the site of the fistula, and to seal the leaking tract. Balloon dilation was reported as the strategy of choice in the percutaneous treatment of benign biliary strictures (although burdened by 29–58 % re-stenosis), while the role of stent placement was reported to still be controversial. A different approach can be the use of novel bioabsorbable biliary stents [2], which may limit the number of balloon dilations in bilioplasty, also overcoming the problem of stent withdrawal. Regarding bile leaks, the authors discuss—inter alia—the role of percutaneous drainage of biliary collections, of coil/gelfoam embolisation of bilio-vascular fistulas, and of covered stents. However, we underline that the most commonly used technique for treating postsurgical biliary leak is percutaneous transhepatic biliary drainage, which allow for bile diversion from the site of the fistula [3]. Moreover, an occlusion balloon placed above the site of the fistula has been demonstrated to allow for complete external drainage of the bile, thus representing a valuable option to treat post-surgical biliary leaks [3, 4]. In case of direct communication between a collection and the biliary system, it may happen that percutaneous drainage is not enough to allow for full healing and surgery may be required, as the authors show in Figure 3 [1]. We note that, in this particular setting, percutaneous cyanoacrilyc glue embolisation has been reported as a feasible technique, which may lead to fistula sealing, avoiding the morbidity related to surgical re-intervention [5].

Use of the EvolutionTM Fully Covered Self-Expandable Metal Stent for the Endoscopic Therapy of Esophageal Leaks

Purpose: Fully covered self-expandable metal stents (FCSEMS) have been utilized increasingly in the endoscopic therapy of benign esophageal conditions, thereby obviating the need for surgery. We present our experience with the use of the Cook Medical EvolutionTM FCSEMS for esophageal leaks, highlighting its efficacy and safety. Methods: We undertook a retrospective case review of patients with esophageal leaks in whom the EvolutionTM FCSEMS was utilized, analyzing for technical success with stent placement and removal, stent migration, treatment success and complications. Results: Twenty-one FCSEMS were placed in 8 patients from April 2011 to March 2012. Causes for esophageal leaks include 6 post-surgical leaks, 1 traumatic injury, and 1 tracheoesophageal fistula in a patient who received radiation for NSCLC. Surgery included esophageal adenocarcinoma (n=3, two of whom received neo-adjuvant chemo-radiotherapy), esophageal diverticulum (n=1), achalasia (n=1), and hiatal hernia repair (n=1). Six (75%) were male with the median age 62 (range 47-70) years. The median time from surgery to stent placement was 43 days (range 1-169). Median size of defect as assessed endoscopically was 23 mm (range 5-70 mm). Immediate closure of the leak was achieved in 9/21 (43%) endoscopies, confirmed by radiologic studies. However, of the 12/21 (57%) unsuccessful closures, 6 occurred in 1 patient who had a 70 mm defect. Median time from stent deployment to re-positioning or removal was 20 days (range 3-47). We report a 100% successful uncomplicated removal rate. 9/21 (43%) stents migrated, causing a clinically significant leak requiring re-positioning or repeat stenting. Eventual closure of esophageal leak was reported in 3/8 (38%) patients, after 9, 28 and 87 days of stenting, with initial 5 mm, 10 mm, and 60 mm defects respectively. A total of 10 endoscopies and 7 FCSEMs were required to achieve this result. Of the patients with persistent leak, 1 patient with a 10 mm defect had considerable reduction in the amount of leak post FCSEMS removal at day 203 of follow up. Three patients with 10 mm, 20 mm, and 70 mm defects are still undergoing continued endoscopic management with esophageal stents in situ, at day 149, 197, and 121 of follow up respectively. The patient with a 5 mm defect from TE fistula currently has a stent in place with plans for removal in 20 days. Conclusion: The EvolutionTM fully covered esophageal stent has moderate clinical efficacy in the treatment of esophageal leaks. Though it may obviate further surgery, multiple endoscopies and numerous stents may be needed for a successful long-term outcome. This is due in part to stent migration and the size of the initial defect. They are however, reliable to deploy and safely removable with ease.

Endoscopic closure of gastrointestinal defects with an over-the-scope clip device. A case series and review of the literature

The over-the-scope clip (OTSC) is a novel endoscopic tool used in the non surgical treatment of gastrointestinal perforations, fistula, and anastomotic leaks. The aim of the present study was to evaluate the therapeutic efficacy of this new endoscopic device on anastomotic postsurgical leak and fistulas or GI perforation in a tertiary referral center. The study group consisted of nine patients (three female, six male, age: 22-65 years). The indications were anastomotic leak in five patients, fistula in three patients, and perforation in one patient. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used. All of the patients were treated with only one OTSC. None of the patients underwent additional endoscopic treatments. The median size of the defects were 15 mm (range 5-20 mm). OTSC was favourable in five of nine patients (three with leak, and one with fistula and perforation, each). OTSC could not be deployed or partially closed the defect in the remaining four patients because of fibrosis at the edges of the defect. Excluding the case with perforation, the median time elapsed between the diagnosis and the placement of OTSC was 35 days (range: 20-80) in the successful group and 70 days (range: 38-94) in the unsuccessful group. There were no complications due to the OTSC application or the applicator cap. OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy is lower in cases with fistulas mainly due to associated fibrosis at the borders.

Efficacy of the over-the-scope clip (OTSC) for treatment of colorectal postsurgical leaks and fistulas

Colorectal postsurgical leaks and fistulas are severe complications that dramatically increase morbidity and mortality. The aim of this study was to evaluate the clinical impact of over-the-scope clip (OTSC) closure to seal the visceral wall in the management of acute and chronic colorectal postsurgical leaks and fistulas. We reviewed our prospective series of acute and chronic colorectal postsurgical leaks and fistulas observed between April 2008 and September 2011 and treated by OTSC. Indications were all cases with an orifice <15 mm in maximum diameter with no extraluminal abscess and luminal stenosis. Endoscopic OTSC closure was performed in 14 consecutive patients (mean defect = 9.1 mm in diameter) by means of 10.5- or 12-mm clips, depending on the wall defect diameter. In eight cases, the indication was an acute leak and in six cases a chronic leak, mainly after anterior rectal resection; two cases were complicated by a rectovaginal fistula and in two other cases by a colocutaneous fistula. OTSC treatment was used to complete endoscopic vacuum-assisted closure of a large defect in three cases. The overall success rate was 86 % (12/14): 87 % (7/8) in acute and 83 % (5/6) in chronic cases. No OTSC-related complications occurred. Further surgery was required in one case. Endoscopic OTSC closure of colorectal postsurgical leaks and fistulas is a safe technique, with a high success rate in both acute and chronic cases, including rectovaginal and colocutaneous fistulas.

683m: Multimodal Endoscopic Approach to Postsurgical Gastro-Esophageal Anastomotic Leaks

683m: Multimodal Endoscopic Approach to Postsurgical Gastro-Esophageal Anastomotic Leaks

Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system

Endoscopic treatment options for postsurgical intrathoracic leaks include injection of fibrin glue, clip application, and stent placement. Endoscopic vacuum-assisted closure (E-VAC) may be an effective treatment option. To demonstrate that E-VAC is an effective endoscopic treatment option for closure of major intrathoracic postsurgical leaks. A prospective, single-center study at an academic medical center. Eight consecutive patients with major intrathoracic postsurgical leaks. Endoscopic placement of transnasal draining tubes, armed with a size-adjusted sponge at their distal end, in the necrotic anastomotic cavities, followed by continuous suction. Sponge and drainage were changed twice weekly. Patients were followed-up for 193 +/- 137 days. Successful leak closure. Successful closure of leaks was achieved in 7 of 8 patients (88%) after a mean of 23 +/- 8 days. A median of 7 endoscopic interventions was necessary. No major treatment-associated short-term or long-term (follow-up, 193 +/- 137 days) complications were noted. Small sample size, single-center study, and lack of randomization. E-VAC is an effective endoscopic treatment modality for major postsurgical intrathoracic leaks. (This study is registered at Clinicaltrials.gov, identifier NCT00876551.).

A Comparison of Three Endoscopic Suturing Devices for Natural Orifice Translumenal Endoscopic Surgery Gastrotomy Closure

Background: With the heightened concern for post-surgical leak, the standard practice of repairing hollow viscous injuries with suture should be mimicked in natural orifice translumenal endoscopic surgery (NOTES) closure. This study aimed to compare 3 endoscopic suturing devices in a survival porcine model. Methods: Three groups of 10 pigs each were assigned a NOTES gastrotomy closure by either a tissue plicating device (TPD), tissue anchoring (t-tag) device (TAD), or flexible suturing device (FSD). The TPD requires an individual intubation for each plication applied (2-4 per closure). The TAD and FSD require pre-gastrotomy suture placement to facilitate their tissue closure. A uniform gastrotomy was created, and a brief peritoneoscopy was performed prior to closure. Procedure times were recorded. TAD and FSD times were adjusted for overall comparison secondary to pre- and post-gastrotomy steps required. An upper GI fluoroscopy was administered to assess for gastric leak on post-operative days 0, 2, and 7. Animals were survived to 14 days when a necropsy and gastric burst pressure test was performed. Results: The recorded closure times (min: sec) were 45:00 ± 16: 42 (mean±SD), 25: 27 ± 9: 31, and 35: 35 ± 21: 46 for TPD, TAD, and FSD, respectively. Though not statistically significant, pre-gastrotomy suture placement in the latter groups provided improved gastric insufflation and endoscopic visualization resulting in shorter closure times. Only one fluoroscopic leak was revealed in the TAD group resulting in abdominal sepsis and death on day 7. One other early death also occurred in the TAD group on day 4 from a pulmonary complication unrelated to surgery. Abscesses developed in 10 animals: TPD (n=1), TAD (n=5) and FSD (n=4). Of them, half were large (>2 cm) or diffuse collections: TAD (n=3) and FSD (n=2). Two adjacent organ injuries were also identified: TPD (n=1) and TAD (n=1). Mean bursting pressures were 85 ± 16, 93 ± 33, and 81 ± 22 mmHg for TPD, TAD, and FSD, respectively (p=NS). Conclusion: The 3 endoscopic suturing devices offer feasible closure options by providing a reproducible surgical closure. Though procedure times were statistically similar, placement of a pre-gastrotomy suture provided a technical advantage to the TAD and FSD and trended toward a more efficient closure. Continued experience and engineering improvements of these devices will likely improve results. The prevalence of abscess formation without evidence of leak, however, requires close attention in the ongoing development of closure tools for human NOTES trials.

Surgical Repair Versus a Removable Esophageal Plastic Stent for Treatment of Post-Surgical Esophageal Leaks

Surgical Repair Versus a Removable Esophageal Plastic Stent for Treatment of Post-Surgical Esophageal Leaks

Successful Treatment of Postcraniectomy Orthostatic Headache with Lumbar Epidural Blood Patches

Postcraniectomy orthostatic headache is a rare, but disabling, condition which can often interfere with patient rehabilitation. Previously, postsurgical CSF leaks have generally been managed with surgical repair. We present the case of a 32-year-old man with postcraniectomy orthostatic headache which was successively managed with repeated lumbar epidural blood patches.

Successful Sealing of Benign Esophageal Leaks after Temporary Placement of a Self-Expanding Plastic Stent without Fluoroscopic Guidance

We report on our experience with the temporary use of a self-expanding plastic stent (SEPS) in the treatment of non-malignant esophageal leaks. Between November 2001 and May 2005 ten patients with iatrogenic esophageal perforations (n = 4), post-surgical leaks (n = 5) and esophago-mediastinal fistulas after caustic injury (n = 1) were treated by temporary SEPS placement. In eight out of ten patients SEPS placement was done without fluoroscopy due to the emergency setting. Stent removal was performed with a rat-toothed forceps. Leaks were located in the proximal (n = 1), middle (n = 6) and distal (n = 3) parts of the esophagus. The mean leakage size was 2 cm. Stent placement without fluoroscopy was always successful. The median duration of stent therapy was 55.5 days (range 15,438). In 7/10 cases the SEPS was readily removed, showing complete healing of the former leak. Four patients died during the follow-up. However, their deaths were not related to the stent therapy. The temporary use of the SEPS represents a safe method for sealing benign esophageal leaks. In the emergency-setting SEPS placement without fluoroscopy is feasible and the stent can be easily removed. In contained perforations without severe mediastinitis of the mid esophagus the SEPS should be discussed as a gentle first-line therapy.

Another Scintigraphic Pattern of a Postsurgical Bile Leak

Another Scintigraphic Pattern of a Postsurgical Bile Leak

Trans-sphenoidal treatment of postsurgical cerebrospinal fluid fistula: CT-guided closure.

Cerebrospinal fluid (CSF) leakage after trans-sphenoidal surgery is a troublesome complication with a risk of meningitis and pneumocephalus. We suggest CT-guided intrasphenoidal injection of fibrin sealant through a 12-gauge needle as a simple alternative to surgical management of CSF fistulae. We treated eight patients, operated via the trans-sphenoidal route (five pituitary adenomas, three craniopharyngiomas), for a postoperative CSF leak by CT-guided intrasphenoidal injection of fibrin sealant alone in three cases and fibrin sealant and autologous blood in 5. CT was obtained 10 days after the procedure in all cases. In four patients, the CSF leak was closed successfully at the first attempt. The procedure was repeated on the four remaining patients because only a reduction in leakage was obtained at the first attempt. This procedure preserves olfaction and avoids the risk of frontal lobe damage. It could therefore represent the treatment of choice in many cases of anterior cranial fossa postsurgical CSF leaks.