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Extended Stent Usage for Persistent Esophageal Leak: Should There Be Limits?

2010; Elsevier BV; Volume: 90; Issue: 5 Linguagem: Inglês

10.1016/j.athoracsur.2010.02.104

1552-6259

John A. Odell, Kenneth R. DeVault,

Esophageal Cancer Research and Treatment

A patient with a spontaneous esophageal perforation was unsuccessfully managed elsewhere by repeated stent placement. Because of inability to remove the stents and persistent empyema, staged procedures of esophagectomy and later restoration of gastrointestinal continuity were necessary. A patient with a spontaneous esophageal perforation was unsuccessfully managed elsewhere by repeated stent placement. Because of inability to remove the stents and persistent empyema, staged procedures of esophagectomy and later restoration of gastrointestinal continuity were necessary. Stents are increasingly being used in clinical practice to cover leaks or keep strictures open. When the usual indications for a procedure are broadened and used indiscriminately, without an exit strategy (in this instance the ability to remove the stent), the likelihood of complications will increase. An example of such a situation is presented.A 64-year-old man was referred for management of a chronic empyema and persistent leak from the esophagus. In May 2008, the patient was admitted to another hospital 48 hours after an acute onset of chest pain, which occurred after eating a toasted bagel. A diagnosis of Boerhaave's syndrome was made. Thereafter a decision was made to initially manage the patient conservatively. Chest drains were inserted and esophageal stents were placed. Initially an uncovered stent was placed followed later by a covered stent. Because of persistence of his leak, a thoracotomy was performed 13 days after the initial onset of symptoms, with an attempted closure of the esophagus. This failed, and the patient continued to drain pus through the chest drains. Ventilation and a tracheostomy were required for ongoing sepsis and respiratory failure. Two further stents were placed at roughly 2-week intervals, but the esophagus continued to leak.Three and a half months after admission, a jejunostomy was placed and the patient was discharged. He had regular barium swallows, but the leak persisted. One further attempt at closure with a stent (no. 5) at a different institution was performed in January 2009, without success. Attempts at removal of this stent 2 weeks later were unsuccessful. Barium swallows at monthly intervals continued to demonstrate the leak. Pus (approximately 30 mL/day) was drained through the chest tube.The patient was seen in our institution 13 months after his initial presentation. His nutrition appeared good. On examination he had a well-healed thoracotomy and tracheostomy scar. A large chest drain emptied into a colostomy bag. A jejunostomy tube was in place.A barium swallow, computed tomographic scan, and chest roentgenogram (Fig 1) confirmed a continued esophageal leak with a pocket of food and debris surrounding the stents within the lower esophagus (the endoleak) with further drainage through the chest drain. These stents extended from the thoracic inlet to the gastroesophageal junction. An endoscopy revealed the first stent visible at 20 cm, from just below the cricopharyngeus, and thereafter multiple stents extending to the gastroesophageal junction were seen.Because of the multiple stents, the inability to remove the stents endoscopically, and the chronic empyema, it was believed that the only recourse was an esophagectomy.The first stage was undertaken in August 2009, 15 months after the initial perforation. A redo right thoracotomy was difficult because of extensive adhesions. The intermediate bronchus was adherent to the esophagus and during mobilization it was entered and it required repair. A cavity communicating with the esophagus and the site of the leak was entered. This contained foul smelling pus and food debris. The esophagus was dilated and it was difficult to encircle. The esophagus was opened lengthways and the foul-smelling tube of interconnected stents was removed (Figs 2A,2B). The esophagus was divided at the hiatus and was oversewn. The lung was decorticated. The proximal portion of the esophagus was brought out as a spit fistula on the left anterior chest. Numerous organisms were cultured, including Proteus mirabilus, methicillin- resistant Staphylococcus aureus, a Streptococcus, a Lactobacillus, and a Klebsiella species, Mycobacteria chelonae, Mycobacteria abscessus, and two resistant Candida species for which he received appropriate antibiotics.Fig 2(A, B) The removed “tube of stents.”View Large Image Figure ViewerDownload (PPT)The patient was discharged on postoperative day 7.Three months later, intestinal continuity was re-established. The mobilized stomach was brought retrosternally and was anastamozed to the esophagus. This operation was uneventful.CommentStents (primarily those for palliation of esophageal cancer [1Hegarty M.M. Angorn I.B. Bryer J.V. Henderson B.J. Le Roux B.T. Logan A. Pulsion intubation for palliation of carcinoma of the oesophagus.Br J Surg. 1977; 64: 160-165Crossref PubMed Scopus (34) Google Scholar]) have been used in the esophagus for decades. More recently (ie, during the last decade) covered self-expanding stents have additionally been used for management of spontaneous perforations [2Freeman R.K. Van Woerkom J.M. Ascioti A.J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.Ann Thorac Surg. 2007; 83: 2003-2007Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 3Amrani L. Menard C. Berdah S. et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization.”.Gastrointest Endosc. 2009; 69: 1282-1287Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4McLoughlin M.T. Byrne M.F. Endoscopic stenting: where are we now and where can we go?.World J Gastroenterol. 2008; 14: 3798-3803Crossref PubMed Scopus (32) Google Scholar], iatrogenic perforations [3Amrani L. Menard C. Berdah S. et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization.”.Gastrointest Endosc. 2009; 69: 1282-1287Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 5Salminen P. Gullichsen R. Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks.Surg Endosc. 2009; 23: 1526-1530Crossref PubMed Scopus (110) Google Scholar], and anastomotic leaks [6Al-Haddad M. Craig C.A. Odell J. Pajaro O. Wallace M.B. The use of self-expandable plastic stents for non-malignant esophago-pleural fistulas.Dis Esophagus. 2007; 20: 538-541Crossref PubMed Scopus (9) Google Scholar].It is uncertain how often stents are used in the management of spontaneous esophageal perforations; based on publications, it is becoming a common method of management. The reason for this perceived increased usage is not difficult to imagine, as gastroenterologists can now perform the procedure with sedation rather than general anesthesia, and a major operation can often be avoided. However, enthusiasm for use of stents must be tempered by knowledge of potential complications and recognition that the stent should be able to be removed once it has served its purpose of allowing healing of the esophagus and reduction of pleural spillage. Uncovered stents are difficult to remove and use of this stent, as the first procedure in this patient, set the stage for an irrecoverable situation. The new silicone-coated polyester stents do not seem to be altered by acid or bile, and these stents are more easily removed.The exact role of stents for management of perforations needs to be defined. Patients in Freeman's large series were treated as part of an approved protocol of the institutional review board, with informed consent having been obtained prior to the study and the procedure [2Freeman R.K. Van Woerkom J.M. Ascioti A.J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.Ann Thorac Surg. 2007; 83: 2003-2007Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar]. In this patient, multiple stents continued to be inserted, until the whole length of the esophagus was an immobile plastic tube, without peristalsis, extending from just below the cricopharnygeous to the gastroesophageal junction. As a leak associated with multiple foreign bodies remained, there was no likelihood that the empyema would heal.The patient related the following: “Every time I went for an endoscopy, I found when I awoke, that another stent had been placed.” Stents are increasingly being used in clinical practice to cover leaks or keep strictures open. When the usual indications for a procedure are broadened and used indiscriminately, without an exit strategy (in this instance the ability to remove the stent), the likelihood of complications will increase. An example of such a situation is presented. A 64-year-old man was referred for management of a chronic empyema and persistent leak from the esophagus. In May 2008, the patient was admitted to another hospital 48 hours after an acute onset of chest pain, which occurred after eating a toasted bagel. A diagnosis of Boerhaave's syndrome was made. Thereafter a decision was made to initially manage the patient conservatively. Chest drains were inserted and esophageal stents were placed. Initially an uncovered stent was placed followed later by a covered stent. Because of persistence of his leak, a thoracotomy was performed 13 days after the initial onset of symptoms, with an attempted closure of the esophagus. This failed, and the patient continued to drain pus through the chest drains. Ventilation and a tracheostomy were required for ongoing sepsis and respiratory failure. Two further stents were placed at roughly 2-week intervals, but the esophagus continued to leak. Three and a half months after admission, a jejunostomy was placed and the patient was discharged. He had regular barium swallows, but the leak persisted. One further attempt at closure with a stent (no. 5) at a different institution was performed in January 2009, without success. Attempts at removal of this stent 2 weeks later were unsuccessful. Barium swallows at monthly intervals continued to demonstrate the leak. Pus (approximately 30 mL/day) was drained through the chest tube. The patient was seen in our institution 13 months after his initial presentation. His nutrition appeared good. On examination he had a well-healed thoracotomy and tracheostomy scar. A large chest drain emptied into a colostomy bag. A jejunostomy tube was in place. A barium swallow, computed tomographic scan, and chest roentgenogram (Fig 1) confirmed a continued esophageal leak with a pocket of food and debris surrounding the stents within the lower esophagus (the endoleak) with further drainage through the chest drain. These stents extended from the thoracic inlet to the gastroesophageal junction. An endoscopy revealed the first stent visible at 20 cm, from just below the cricopharyngeus, and thereafter multiple stents extending to the gastroesophageal junction were seen. Because of the multiple stents, the inability to remove the stents endoscopically, and the chronic empyema, it was believed that the only recourse was an esophagectomy. The first stage was undertaken in August 2009, 15 months after the initial perforation. A redo right thoracotomy was difficult because of extensive adhesions. The intermediate bronchus was adherent to the esophagus and during mobilization it was entered and it required repair. A cavity communicating with the esophagus and the site of the leak was entered. This contained foul smelling pus and food debris. The esophagus was dilated and it was difficult to encircle. The esophagus was opened lengthways and the foul-smelling tube of interconnected stents was removed (Figs 2A,2B). The esophagus was divided at the hiatus and was oversewn. The lung was decorticated. The proximal portion of the esophagus was brought out as a spit fistula on the left anterior chest. Numerous organisms were cultured, including Proteus mirabilus, methicillin- resistant Staphylococcus aureus, a Streptococcus, a Lactobacillus, and a Klebsiella species, Mycobacteria chelonae, Mycobacteria abscessus, and two resistant Candida species for which he received appropriate antibiotics. The patient was discharged on postoperative day 7. Three months later, intestinal continuity was re-established. The mobilized stomach was brought retrosternally and was anastamozed to the esophagus. This operation was uneventful. CommentStents (primarily those for palliation of esophageal cancer [1Hegarty M.M. Angorn I.B. Bryer J.V. Henderson B.J. Le Roux B.T. Logan A. Pulsion intubation for palliation of carcinoma of the oesophagus.Br J Surg. 1977; 64: 160-165Crossref PubMed Scopus (34) Google Scholar]) have been used in the esophagus for decades. More recently (ie, during the last decade) covered self-expanding stents have additionally been used for management of spontaneous perforations [2Freeman R.K. Van Woerkom J.M. Ascioti A.J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.Ann Thorac Surg. 2007; 83: 2003-2007Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 3Amrani L. Menard C. Berdah S. et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization.”.Gastrointest Endosc. 2009; 69: 1282-1287Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4McLoughlin M.T. Byrne M.F. Endoscopic stenting: where are we now and where can we go?.World J Gastroenterol. 2008; 14: 3798-3803Crossref PubMed Scopus (32) Google Scholar], iatrogenic perforations [3Amrani L. Menard C. Berdah S. et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization.”.Gastrointest Endosc. 2009; 69: 1282-1287Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 5Salminen P. Gullichsen R. Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks.Surg Endosc. 2009; 23: 1526-1530Crossref PubMed Scopus (110) Google Scholar], and anastomotic leaks [6Al-Haddad M. Craig C.A. Odell J. Pajaro O. Wallace M.B. The use of self-expandable plastic stents for non-malignant esophago-pleural fistulas.Dis Esophagus. 2007; 20: 538-541Crossref PubMed Scopus (9) Google Scholar].It is uncertain how often stents are used in the management of spontaneous esophageal perforations; based on publications, it is becoming a common method of management. The reason for this perceived increased usage is not difficult to imagine, as gastroenterologists can now perform the procedure with sedation rather than general anesthesia, and a major operation can often be avoided. However, enthusiasm for use of stents must be tempered by knowledge of potential complications and recognition that the stent should be able to be removed once it has served its purpose of allowing healing of the esophagus and reduction of pleural spillage. Uncovered stents are difficult to remove and use of this stent, as the first procedure in this patient, set the stage for an irrecoverable situation. The new silicone-coated polyester stents do not seem to be altered by acid or bile, and these stents are more easily removed.The exact role of stents for management of perforations needs to be defined. Patients in Freeman's large series were treated as part of an approved protocol of the institutional review board, with informed consent having been obtained prior to the study and the procedure [2Freeman R.K. Van Woerkom J.M. Ascioti A.J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.Ann Thorac Surg. 2007; 83: 2003-2007Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar]. In this patient, multiple stents continued to be inserted, until the whole length of the esophagus was an immobile plastic tube, without peristalsis, extending from just below the cricopharnygeous to the gastroesophageal junction. As a leak associated with multiple foreign bodies remained, there was no likelihood that the empyema would heal.The patient related the following: “Every time I went for an endoscopy, I found when I awoke, that another stent had been placed.” Stents (primarily those for palliation of esophageal cancer [1Hegarty M.M. Angorn I.B. Bryer J.V. Henderson B.J. Le Roux B.T. Logan A. Pulsion intubation for palliation of carcinoma of the oesophagus.Br J Surg. 1977; 64: 160-165Crossref PubMed Scopus (34) Google Scholar]) have been used in the esophagus for decades. More recently (ie, during the last decade) covered self-expanding stents have additionally been used for management of spontaneous perforations [2Freeman R.K. Van Woerkom J.M. Ascioti A.J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.Ann Thorac Surg. 2007; 83: 2003-2007Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 3Amrani L. Menard C. Berdah S. et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization.”.Gastrointest Endosc. 2009; 69: 1282-1287Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 4McLoughlin M.T. Byrne M.F. Endoscopic stenting: where are we now and where can we go?.World J Gastroenterol. 2008; 14: 3798-3803Crossref PubMed Scopus (32) Google Scholar], iatrogenic perforations [3Amrani L. Menard C. Berdah S. et al.From iatrogenic digestive perforation to complete anastomotic disunion: endoscopic stenting as a new concept of “stent-guided regeneration and re-epithelialization.”.Gastrointest Endosc. 2009; 69: 1282-1287Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar, 5Salminen P. Gullichsen R. Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks.Surg Endosc. 2009; 23: 1526-1530Crossref PubMed Scopus (110) Google Scholar], and anastomotic leaks [6Al-Haddad M. Craig C.A. Odell J. Pajaro O. Wallace M.B. The use of self-expandable plastic stents for non-malignant esophago-pleural fistulas.Dis Esophagus. 2007; 20: 538-541Crossref PubMed Scopus (9) Google Scholar]. It is uncertain how often stents are used in the management of spontaneous esophageal perforations; based on publications, it is becoming a common method of management. The reason for this perceived increased usage is not difficult to imagine, as gastroenterologists can now perform the procedure with sedation rather than general anesthesia, and a major operation can often be avoided. However, enthusiasm for use of stents must be tempered by knowledge of potential complications and recognition that the stent should be able to be removed once it has served its purpose of allowing healing of the esophagus and reduction of pleural spillage. Uncovered stents are difficult to remove and use of this stent, as the first procedure in this patient, set the stage for an irrecoverable situation. The new silicone-coated polyester stents do not seem to be altered by acid or bile, and these stents are more easily removed. The exact role of stents for management of perforations needs to be defined. Patients in Freeman's large series were treated as part of an approved protocol of the institutional review board, with informed consent having been obtained prior to the study and the procedure [2Freeman R.K. Van Woerkom J.M. Ascioti A.J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.Ann Thorac Surg. 2007; 83: 2003-2007Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar]. In this patient, multiple stents continued to be inserted, until the whole length of the esophagus was an immobile plastic tube, without peristalsis, extending from just below the cricopharnygeous to the gastroesophageal junction. As a leak associated with multiple foreign bodies remained, there was no likelihood that the empyema would heal. The patient related the following: “Every time I went for an endoscopy, I found when I awoke, that another stent had been placed.”