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  Table of Contents  
LETTER TO THE EDITOR
Year : 2015  |  Volume : 52  |  Issue : 3  |  Page : 307-308
 

Esophageal stent placement for acute intra-thoracic anastomotic leak after esophagectomy


1 Department of Surgical Oncology, Rockland Hospital, Qutab Institutional Area, New Delhi, India
2 Department of Gasteroentrology, Rockland Hospital, Qutab Institutional Area, New Delhi, India

Date of Web Publication18-Feb-2016

Correspondence Address:
A K Giri
Department of Surgical Oncology, Rockland Hospital, Qutab Institutional Area, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.176706

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How to cite this article:
Giri A K, Bassi K K, Gupta VK, Singh B P, Abraham S W, Pandey K K. Esophageal stent placement for acute intra-thoracic anastomotic leak after esophagectomy. Indian J Cancer 2015;52:307-8

How to cite this URL:
Giri A K, Bassi K K, Gupta VK, Singh B P, Abraham S W, Pandey K K. Esophageal stent placement for acute intra-thoracic anastomotic leak after esophagectomy. Indian J Cancer [serial online] 2015 [cited 2019 Jun 26];52:307-8. Available from: http://www.indianjcancer.com/text.asp?2015/52/3/307/176706


Sir,

Post-esophagectomy intrathoracic anastomotic leak is a dreaded complication mandating re-exploration of the thoracic cavity which carries high morbidity and mortality in nutritionally depleted patients. We have successfully managed a patient with post-operative intra-thoracic anastomotic leak by placement of self-expanding stent.

A 64-year-male patient of carcinoma esophagus underwent Ivor-Lewis esophagectomy with stapled supra-azygous gastro-esophageal anastomosis in February 2011. On post-operative eighth day gastrograffin study showed leak at the anastomotic site [Figure 1]a which was confirmed by computerized axial tomography (CT) scan of chest [Figure 1]b. Patient was hemodynamically unstable. Endoscopy showed partial circumferential disruption (less than 1/3rd) [Figure 1]c; there was no necrosis of gastric conduit. Self-expanding covered metallic stent (120 × 23 mm) was placed across the anastomosis under fluoroscopic guidance. Check endoscopy was done to confirm the position of stent [Figure 2]a. The stent was not snuggly fitting due to disparity in esophageal and gastric tube lumen. Subsequently the patient was managed conservatively and started on oral feeds after four days. Chest X- ray showed containment and resolution of leak. [Figure 2]b He was discharged from the hospital with Intra-luminal stent in place. On follow up he developed collection in the right pleural cavity. [Figure 3] The collection was likely due to disparity in the gastric tube lumen and diameter of the stent. Collection was drained under CT guidance. There was recollection of the pus after first aspiration; subsequently intercostal catheter drainage was done. He was doing well at three month of follow up. The stent could not be retrieved later due to in-growth of granulation tissue in the uncovered portions of the stent.
Figure 1: (a) Gastrografin dye study on post operative day 8 showing leak. (b) CT scan of chest showing anastomotic leak in thoracic cavity. (c) Endoscopic view of anastomotic leak

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Figure 2: (a) Endoscopic placement of expandable stent across the anastomosis. (b) Containment of leak after placDement of intraluminal esophageal stent

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Figure 3: Chest X-ray on follow up showing development intrathoracic collection

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Intra-thoracic esophageal anastomotic leak is one of worst complications and fare worse than cervical esophageal leaks.[1] There is high mortality associated with thoracic leak to the tune of 40%.[2] Clinically stable patients with small leaks can be managed conservatively, but most patients require surgical management in the form of open drainage, debridement of mediastinum or possible repair.

Many authors have reported use of esophageal stents and endoscopic hemoclips for managing intra-thoracic leaks with successful outcome.[3],[4] Dai et al. Evaluated the efficacy of self-expanding plastic stents for the treatment of esophageal anastomotic leaks, perforations, and fistulae in a series of 41 patients. Complete healing of anastomotic leaks was observed in 90% of the patients.[5] Freeman et al. Used endoluminal esophageal stent placement as initial therapy in a series of 17 patients with anastomotic leak after esophagectomy for benign or malignant disease. Fourteen patients were able to initiate oral nutrition within 72 hrs of stent placement. Stent migration occurred in three patients, requiring repositioning in two and replacement in one.[6] Recently biodegradable stents has been tried with success rate of 80% to contain the esophageal leaks or perforations.[7] Thoracic anastomotic leaks can be managed with esophageal stents sparing the patient the morbidity of open surgical intervention. It is important to place stents with appropriate diameter which fit snuggly at upper and lower end while placing it across the leaking anastomosis in order to decrease risk of intrathoracic collection.

 
  References Top

1.
Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004;10:71-5.  Back to cited text no. 1
    
2.
Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg 1998;85:1446-9.  Back to cited text no. 2
    
3.
Schweigert M, Dubecz A, Stadlhuber RJ, Muschweck H, Stein HJ. Treatment of intrathoracic esophageal anastomotic leaks by means of endoscopic stent implantation. Interact Cardiovasc Thorac Surg 2011;12:147-51.  Back to cited text no. 3
    
4.
Tekinbas C, Erol MM, Akdogan R, Turkyilmaz S, Aslan M. Treatment of anastomotic leaks after esophagectomy with endoscopic hemoclips. J Thorac Cardiovasc Surg 2009;137:766-7.  Back to cited text no. 4
    
5.
Dai Y, Chopra SS, Kneif S, Hünerbein M. Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents. J Thorac Cardiovasc Surg 2011;141:1213-7.  Back to cited text no. 5
    
6.
Freeman RK, Vyverberg A, Ascioti AJ. Esophageal stent placement for the treatment of acute intrathoracic anastomotic leak after esophagectomy. Ann Thorac Surg 2011;92:204-8.  Back to cited text no. 6
    
7.
Cerná M, Köcher M, Válek V, Aujesky´ R, Neoral C, Andrasšina T, et al. Covered biodegradable stent: New therapeutic option for the management of esophageal perforation or anastomotic leak. Cardiovasc Intervent Radiol 2011;34:1267-71.  Back to cited text no. 7
    


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