Treatment Of Esophageal Leaks Research Articles

Preemptive endoluminal vacuum therapy with the VACStent-A pilot study to reduce anastomotic leakage after Ivor Lewis hybrid esophagectomy.

Endoscopic treatment by vacuum therapy (EVT) or covered stents has emerged as an improved treatment option for upper gastrointestinal wall defects and is regarded as an improved treatment option for anastomotic leakage (AL) after esophagectomy. However, endoluminal EVT devices may lead to obstruction of the GI tract; and a high rate of migration and missing functional drainage has been shown for covered stents. The recently developed VACStent, a combination of a fully covered stent within a polyurethane sponge cylinder may overcome these issues allowing EVT while stent passage is still open. Initial clinical applications have demonstrated efficacy, practicability and safety in the treatment of esophageal leaks (AL). In this pilot study, 9 patients with high-risk anastomosis after neoadjuvant therapy undergoing hybrid esophagectomy received the VACStent in a preemptive setting for the assessment of the reduction of the AL rate, postoperative morbidity and mortality. Technical success of the application of the VACStent® was achieved in all interventions. One patient experienced anastomotic leakage 10 days after esophagectomy and was successfully treated with two consecutive VACStents and a VAC Sponge. In summary, mortality in-hospital was 0% and anastomotic healing was uneventful without septic episodes. No severe device-related adverse events (SADE) nor significant local bleeding or erosion could be observed. Oral intake of liquids or food was documented in all patients. The device handling was regarded uncomplicated. The preemptive application of the VACStent offers a promising new option for improved clinical treatment avoiding of critical situations in hybrid esophagectomy, which should be validated in a large clinical study.

Endoluminal wound vac: an evolving role in treatment of esophageal perforation

: The treatment of esophageal leaks and perforations has evolved over time with the advancement of technology. Compared to traditional surgical intervention, newer less invasive options such as stents can be effective with less morbidity. The latest addition to the surgeon’s armamentarium, endoluminal wound vac therapy (EVT), uses the principle of negative pressure wound therapy to heal leaks and perforations.

Endoscopic vacuum therapy versus stenting for postoperative esophago-enteric anastomotic leakage: systematic review and meta-analysis.

Esophageal anastomotic leakage still represents a challenging complication after esophageal surgery. Endoscopically placed self-expandable metal stents (SEMS) are the treatment of choice, but since the introduction of endoscopic vacuum therapy (EVT) for esophageal leakage 10 years ago, increasing evidence has demonstrated that EVT might be a superior alternative. Therefore, we performed a systematic review and meta-analysis to compare the effectiveness and related morbidity of SEMS and EVT in the treatment of esophageal leak. We systematically searched for studies comparing SEMS and EVT to treat anastomotic leakage after esophageal surgery. Predefined end points including outcome, treatment success, endoscopy, treatment duration, hospitalization time, morbidity, and mortality were assessed and included in the meta-analysis. Five retrospective studies including 274 patients matched the inclusion criteria. Compared with stenting, EVT was significantly associated with a higher rate of leak closure (odds ratio [OR] 3.14, 95 % confidence interval [CI] 1.23 to 7.98), more endoscopic device changes (pooled median difference of 3.09; 95 %CI 1.54 to 4.64]), a shorter duration of treatment (pooled median difference -11.90 days; 95 %CI -18.59 to -5.21 days), and a lower mortality rate (OR 0.39, 95 %CI 0.18 to 0.83). There were no significant differences in short-term and major complications. Owing to the retrospective quality of the studies with potential biases, the results of the meta-analysis must be interpreted with caution. However, the analysis indicates the potential benefit of EVT, which should be further investigated with standardized and prospectively collected data.

Self-expanding plastic stent for esophageal leaks and fistulae.

Self-expanding plastic stents (SEPS) have emerged as a good alternative to surgery in esophageal leaks and fistulae. There is scarce published literature regarding its efficacy in these conditions. We present our experience with SEPS in treatment of esophageal leaks and fistulae. Consecutive patients admitted in a tertiary referral center who underwent SEPS placement for esophageal leak or fistula between February 2012 and February 2015 were retrospectively evaluated. Patients underwent prior assessment with upper gastrointestinal endoscopic and thoracic contrast-enhanced computed tomography assessment. SEPS (25-mm flares, 21-mm diameter) were placed under fluoroscopic guidance. A silk thread tied to upper end was routed through nostril and fixed to prevent stent migration. Nasojejunal tube was inserted in all patients. Intercostal drain was inserted in the case of hydro/pyopneumothorax. Twelve patients [eight male, median age 45.3years (19 to 65years)] were included. Etiologies were spontaneous leaks due to Boerhaave syndrome (n=2), corrosive fistulae (n=2), tubercular fistulae (n=4), invasive Candida esophagitis-induced fistula (n=1), iatrogenic leaks (n=2; one achalasia dilatation, one obesity surgery), and pancreaticoesophageal fistula due to ruptured pancreatic pseudocyst (n=1). Stent placement was successful in all patients with no immediate postprocedure complications. Successful healing was seen in nine patients (75%). Stents were removed after a median time of 83.5days (13-190days). Stent migration was seen in four patients (33.3%), and in two of them, it was retrieved and redeployed; none had early migration (<72h). Reasons for SEPS failure in our cohort were failure of effective sepsis control in two patients and poor wound healing seen in one patient having multiple tubercular fistulae. SEPS is a safe, well-tolerated treatment with good success rate (75%) in treatment of esophageal leaks and fistulae.

Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes

Factors associated with successful endoscopic therapy with temporary stents for esophageal leaks, fistulae, and perforations (L/F/P) are not well known. To evaluate the safety, efficacy, and outcomes of esophageal stenting in these patients and identify factors associated with successful closure. Retrospective. Academic tertiary referral center. All patients with attempted stent placement for esophageal L/F/P between January 2003 and May 2012. Esophageal stent placement and removal. Factors predictive of therapeutic success defined as complete closure after index stent removal (primary closure) or after further endoscopic stenting (secondary closure). Sixty-seven patients with 132 attempted stents for esophageal L/F/P were considered; 13 patients were excluded. Among the remaining 54 patients, 117 stents were placed for leaks (29 patients; 64 stents), fistulae (15 patients; 36 stents), and perforations (10 patients; 17 stents). Procedural technical success was achieved in all patients (100%). Primary closure was successful in 40 patients (74%) and secondary closure in an additional 5 (83% overall). On short-term (<3 months) follow-up, 27 patients (50%) were asymptomatic, whereas 22 (41%) had technical adverse events, including stent migration in 15 patients (28%). Factors associated with successful primary closure include a shorter time between diagnosis of esophageal L/F/P and initial stent insertion (9.03 vs 22.54 days; P = .003), and a smaller luminal opening size (P = .002). Retrospective, single-center study. Temporary stents are safe and effective in treating esophageal L/F/P. Defect opening size and time from diagnosis to stent placement appear to be candidate predictors for successful closure.

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.

Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents

Esophageal anastomotic leaks, perforations, and fistulae are associated with considerable morbidity and mortality. The aim of the present study was to assess the efficacy of self-expanding plastic stents in the treatment of esophageal leaks. From 2001 to 2009, 41 patients with postoperative anastomotic leaks (n = 30), esophageal perforations (n = 6), or fistulae (n = 5) were treated by endoscopic insertion of self-expanding plastic stents. The clinical outcome of the patients was analyzed, including leak healing, morbidity, and mortality. Self-expanding plastic stents were successfully inserted in all 41 patients without procedure-related complications. Non-ventilated patients received oral feeding an average of 3.9 days after stent placement. Complete leak healing was obtained in 27 of 30 patients (90%) with anastomotic leaks and 5 patients (83%) with perforation. Sealing of fistulae by the stents was achieved in all 5 patients, and closure of the fistula was observed in 2 patients (40%). The mean healing time was 30 days for anastomotic leaks, 15 days for esophageal perforations, and 16 days for fistulae. Stent migration occurred in 14 cases, but endoscopic reintervention and new stent placement were successful in all cases. In-hospital mortality after treatment of esophageal leaks with stents was 10%. In combination with effective interventional or surgical drainage, stenting is a viable option for the treatment of esophageal anastomotic leaks and perforations, but the success in tracheoesophageal fistula is limited.

Endoscopic Treatment with the Use of Silicone Covered Self Expanding Polyester Stents in Esophageal Leaks, Strictures, and Fistulae

Background: In this retrospective review, we describe our experience with the use of self-expanding plastic stents (SEPS) in the treatment of esophageal leaks, strictures, and fistulae in our institution. Methods: Nine patients were treated with the insertion of a SEPS by endoscopic and radiological guidance. One patient had esophageal perforation due to foreign body and had persistent esophageal leak after surgical repair with prior self-expandable metal stent placement. A plastic stent was placed to close the persistent esophageal leak.

Unifying concepts in treatment of esophageal leaks

The Journal of Trauma: Injury, Infection, and Critical Care: June 1985 - Volume 25 - Issue 6 - p 568

Unifying concepts in treatment of esophageal leaks

We treated 75 patients with esophageal trauma, perforation, or anastomotic leak. Several factors were shown to be associated with an increased mortality, including delayed treatment, presence of severe underlying esophageal disease, total parenteral nutrition catheter infection, the necessity for major extirpative procedures to treat the perforation, and the use of exclusion and diversion in the continuity procedure. The use of local muscle flaps to buttress suture line closure has led to excellent results in the 19 patients so treated. Delayed treatment of perforation or an anastomotic leak is a major problem, but the treatment protocol described herein has led to the survival of 12 of 16 patients treated. The use of primary muscle flap closure for extensive esophageal defects or delayed treatment of nonhealing leaks was evaluated in five patients. All five had healing of the defect, with one resultant esophageal stricture.