Esophageal Stent Placement for Perforation, Fistula...
Transcript of Esophageal Stent Placement for Perforation, Fistula...
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Esophageal Stent Placement for
Perforation, Fistula and
Anastomotic Leak
Richard K. Freeman, MD, MBA
Vice Chair for Cardiothoracic Surgery
Medical Director for Cancer Services
St Vincent Hospital and Health System
Indianapolis, Indiana
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No disclosures but…
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Q54. Esophageal stent placement for an acute esophageal perforation:
a. Is an appropriate initial therapy for all patients
b. Is effective treatment as an isolated procedure in the majority of patients
c. Is associated with a relative high rate of success and low rate of mortality in select patients
d. Has not been found to be beneficial unless an initial operative repair has failed.
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Goals of Therapy for Esophageal
Perforation
Resuscitation/supportive care
Directed antimicrobial therapy
Occlusion of the perforation
Elimination of infection in the mediastinum, pleural spaces,
neck and/or abdomen
Preservation of foregut continuity
Delivery of nutrition (enteral preferred)
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Traditional Therapy
Perforation
Non-operative therapy
Narrow inclusion criteria
Operative repair
“Failure” rate 39%*
*Force et al; Ann Thorac Surg, 2010
May increase if repair is > 24 hrs
Esophageal diversion
50% never undergo reconstruction
Morbidity ~70%
Mortality ~20%
Esophagectomy
Mortality 4-13%
Anastomotic Leak
Non-operative therapy
30% eventually require surgery*
*Crestanello et al; JTCVS, 2005
Reoperative therapy
“Failure” rate ~ 25%
Esophageal diversion
50% never undergo reconstruction
Morbidity ~70%
Mortality ~20%
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Intraoperative Esophageal Perforation
14 year old male
“Uneventful” laparoscopic Nissen fundoplication
Postoperative esophageal leak delayed diagnosis
Two attempted repairs Primary repair beneath
fundoplication
Presented at the Society of Thoracic Surgeons’ 42nd Annual Meeting, 2006
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Clinical Course
Transferred to our facility with multi-system organ failure Pulmonary
Renal
Gastrointestinal
Bacteremia
Continued esophageal fistula
Intra-abdominal compartment syndrome
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Operative Course
Endoluminal esophageal stent
VATS decortication
Abdominal “silo” for compartment syndrome
Renal Failure resolved
Weaned from ventilator
Tolerated enteral feeding
Esophagram→resolved leak
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Follow-up
Stent removed endoscopically on day 20
Transferred to pediatric rehabilitation tolerating a regular diet
Has required no subsequent surgery
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Esophageal Stenting - Historic
Esophageal intubation for malignant obstruction
Symonds (1887) – ivory & silver prostheses
Celestin (1959) – pull through tubes/laparotomy
Atkinson and Ferguson (1977) – placed with endoscopy
Self –expanding metallic stents (1990’s)
Gianturco
Ultraflex
Wallstent
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Current Esophageal Stents
Ultraflex
Polyflex
Alimax
Wallflex
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Minimally Invasive and Robotic Surgery
Michael J. Mack, MD
JAMA. 2001;285:568-572.
Future research will focus on delivery of diagnostic
and therapeutic modalities through natural orifices…
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Hybrid Operative and Endoscopic Treatment Strategy
Ideal treatment for an esophageal perforation or fistula: Fulfill traditional goals of operative therapy
Closure of the perforation Drainage of the mediastinum and pleural space(s) Establish enteral nutrition Maintain foregut continuity
Avoid thoracotomy/celiotomy and primary repair
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Confirm and localize the perforation or fistula by esophagram
CT scan of chest/abdomen
Identify need for other procedures
Esophageal Stent Placement
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Esophageal Stent Placement
Performed in the operating room
General anesthesia
Associated procedures
Flouroscopy
Endoscopy, stent placement and any associated procedures performed by a thoracic surgeon
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Esophageal stent placement
Using the esophagram as a guide, identify the target area at esophagoscopy
Asses the possibility of using a stent
Place a PEG before attempting stent placement
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Polyflex Esophageal Stent
Silicone coated polyester
Non-permeable
Can be repositioned
Substantial radial force / lower frequency of migration
Does not “fracture”
Easily removed
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Endoscopic stent placement
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Endoscopy After Stent Placement
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Post-Stent Treatment
Care for the patient as if they had required operative repair
ICU environment
Volume resuscitation
Directed antibiotic therapy
Respiratory support if needed
NPO
PPI’s
Gastric drainage
Nutrition (preferably enteral)
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Post-Stent Treatment
Esophagram 48 hrs after placement (or when the patient can
participate) to confirm occlusion
Oral intake initiated (“soft mechanical” diet)
Discharge when drain(s) are removed
Remove stent at 2-4 weeks
OR/general anesthesia
EGD
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Tracheo-Esophageal Fistula
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Esophageal Fistulae
N 21
Age 58 + 20 (range 14-93)
Attempted repairs (at least one) 1.4 + 1 (range 1-4)
Associated procedures 20 (95%) (excluding PEG)
Occlusion 20 (95%)
Length of Stay 12 + 14 (median 8)*
Migration 5 (24%)
Mortality 1 (5%)
Postoperative Esophageal Leak Management with the Polyflex Esophageal Stent
Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana
Richard K. Freeman, MD,*, Anthony J. Ascioti, MD, Thomas C. Wozniak, MD
J Thorac Cardiovasc Surg 2007;133:333-338
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Iatrogenic Esophageal Perforation
N 17
Age (mean yrs) 54 + 20 (range 17-91)
Perforation to stent (mean hrs) 39 + 39 (range 3-121)
Associated procedures 8 (47%) (excluding PEG)
Leak occlusion 16 (94%)
Length of stay 8 + 9 (median 5)
Stent Migration 3 (17%)
Mortality 0
Esophageal Stent Placement for the Treatment of Iatrogenic Intrathoracic Esophageal Perforation
Richard K. Freeman, MD, Jaclyn M. Van Woerkom, RN, BSN, and Anthony J. Ascioti, MD
Department of Thoracic and Cardiovascular Surgery, St. Vincent Hospital, Indianapolis, Indiana
Ann Thorac Surg 2007;83:2003-2008
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Spontaneous Esophageal Perforations
N 19
Age 48 + 18 (range 26-67)
Perforation to stent 22 + 33 (range 6-78)
Associated procedures 9 (47%) (excluding PEG)
Leak occlusion 17 (89%)
Length of stay 9 + 12
Migration 4 (21%)
Mortality 0
Esophageal Stent Placement for the Treatment of Spontaneous Esophageal Perforations
Richard K Freeman MD, Jaclyn M. Van Woerkom RN, BSN, Amy Vyverberg RN BSN, Anthony J. Ascioti MD
Department of Thoracic and Cardiovascular Surgery, St Vincent Hospital, Indianapolis, Indiana
Ann Thorac Surg 2009; 88: 194-8.
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Spontaneous Esophageal Perforations
Associated alcohol ingestion 9 (46%)
Obesity (BMI > 30) 7 (37%)
Mediastinitis at diagnosis 13 (68%)
Sepsis at diagnosis 3 (16%)
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Stent Placement for Intrathoracic Leak After Esophagectomy
N 17
Age 62 + 13 (range 46-68)
Neoadjuvant Chemo/radiation 16
Associated procedures 7 (41%)
Leak occlusion 16 (94%)
Oral nutrition within 72 hrs 14 (82%)
Migration 3 (18%)
Mortality 0
Freeman RK, Van Woerkom JM, Vyverberg A, Ascioti AJ: Esophageal Stent Placement for the Treatment of Acute Intrathoracic
Anastomotic Leak Following Esophagectomy. Ann Thorac Surg: 2011;92:204-208.
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N
Patients receiving a stent 187
Successful 172
Anastomotic leak 31
Chronic fistula 38
Perforation 103
Spontaneous 42
Iatrogenic 61
Associated malignancy 14
Failed 15 (8%)
Anastomotic leak 2
Chronic fistula 3
Perforation 9
Spontaneous 4
Iatrogenic 6
Freeman RK, Ascioti, AJ, Giannini T, Mahiidhara RJ. An Analysis of Unsuccessful Esophageal Stent Placements for Esophageal
Perforation, Fistula or Anastomotic Leak. Ann Thorac Surg 2012;94:959-965.
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Case Presentation
86 year old female presents to the ED with four hours of chest pain after an EGD
FEV1 0.8 liters (38%)
EGDMass in the mid esophagus – “likely malignant”
Severe kyphosis
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Case Presentation
Polyflex stent placed
Repeat esophagram 40 hours later
Clear liquids initiated
Home on hospital day 5
Underwent chemo/radiation as definitive therapy
Stent removed 79 days after placement
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Following Chemo/Radiation Therapy
Before After
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Conclusions
Esophageal perforation or fistula can be effectively treated in the majority of patients using an occlusive esophageal stent as part of a hybrid operative approach Rapid sealing of leak
Early oral nutrition & hydration
Alternative to reoperative repair / esophageal diversion / esophagectomy
Appears to reduce hospital length of stay
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Conclusions
Esophageal stent placement for a postoperative intra-thoracic leak following esophagogastrostomy
Safe and effective
Avoids reoperation in the majority of patients
Possible with most types of anastomoses
Results in earlier oral nutrition
May decrease hospital stay
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