Esophageal perforation due to removal of partially covered self-expanding metal stents placed for benign perforation or leak

Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands.
Endoscopy (Impact Factor: 5.05). 02/2011; 43(2):156-9. DOI: 10.1055/s-0030-1255849
Source: PubMed


Benign esophageal perforations and anastomotic leaks can be effectively managed by stent placement. However, when partially covered self-expanding metal stents (SEMS) are used, safe removal may be complicated. In this case series, we evaluated the complicated removal of SEMS placed for a benign esophageal perforation or leak in four patients. In all patients a partially covered SEMS was placed. After a median stent time of 29 days (range 21 - 30), the SEMS were found to have become embedded in the esophageal wall. Endoscopic removal resulted in perforation in all patients. All patients recovered uneventfully, although one patient underwent esophagectomy. If uncovered SEMS ends become embedded, removal of the stent may cause major damage to the esophageal wall. It is therefore recommended to remove embedded partially covered SEMS only after first placing a fully covered SEMS or self-expanding plastic stent inside this stent to necrotize the ingrown tissue at the uncovered stent ends.

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    • "Some investigators prefer a longer period before removal, with periods of 3 weeks to 3 months reported [9 –11]. We chose a shorter stent time to facilitate stent removal and reduce the risk of damage to the gut wall, which has been described with stent removal [12]. The use of a dedicated instrument for stent removal might further reduce the risk of bowel damage during stent removal. "
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    ABSTRACT: BACKGROUND: Gastric bypass is one of the most common operations for morbid obesity. One of the most feared complications is a leak, most commonly encountered in the gastrojejunal anastomosis (GJA), leading to significant morbidity and increased costs. Our objective was to evaluate the effectiveness of stenting leaks in the GJA. The setting was a university hospital in Stockholm, Sweden. METHODS: We performed a retrospective analysis of all gastric bypasses from January 2001 to August 2011, with special reference to the treatment of leaks in the GJA. RESULTS: A postoperative leak in the GJA occurred in 69 of 2214 patients. The risk was greater with open surgery and revisional surgery. The risk was also greater with age >50 years but not with a body mass index >50 kg/m(2). There was no mortality. In the later part of the series, stents were used, with a stent time of 2 weeks. The migration rate was 23%, and need for restenting was 20%. CONCLUSION: It is safe and advantageous to use stents in the treatment of leaks at the GJA. Patients can be on oral nutrition and oral medication, reducing the need for in-hospital care.
    Full-text · Article · Mar 2012 · Surgery for Obesity and Related Diseases
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    • "Particularly, reactive nonmalignant tissue in- or overgrowth and embedding of the stent in the esophageal wall may be a problem, especially when partially covered stents are left in place for a longer duration. Endoscopic stent removal in case of severe stent embedding may cause esophageal perforation [20]. On the other hand, migration rates are higher when fully covered stents, either SEMS or SEPS, are used [21-23]. "
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    ABSTRACT: Benign esophageal ruptures and anastomotic leaks are life-threatening conditions that are often treated surgically. Recently, placement of partially and fully covered metal or plastic stents has emerged as a minimally invasive treatment option. We aimed to determine the clinical effectiveness of covered stent placement for the treatment of esophageal ruptures and anastomotic leaks with special emphasis on different stent designs. Consecutive patients who underwent placement of a fully covered self-expandable metal stent (FSEMS), a partially covered SEMS (PSEMS) or a self-expanding plastic stent (SEPS) for a benign esophageal rupture or anastomotic leak after upper gastrointestinal surgery in the period 2007-2010 were included. Data on patient demographics, type of lesion, stent placement and removal, clinical success and complications were collected A total of 52 patients received 83 esophageal stents (61 PSEMS, 15 FSEMS, 7 SEPS) for an anastomotic leak (n=32), iatrogenic rupture (n=13), Boerhaave's syndrome (n=4) or other cause (n=3). Endoscopic stent removal was successful in all but eight patients treated with a PSEMS due to tissue ingrowth. Clinical success was achieved in 34 (76%, intention-to-treat: 65%) patients (PSEMS: 73%, FSEMS: 83%, SEPS: 83%) after a median of 1 (range 1-5) stent and a median stenting time of 39 (range 7-120) days. In total, 33 complications in 24 (46%) patients occurred (tissue in- or overgrowth (n=8), stent migration (n=10), ruptured stent cover (all Ultraflex; n=6), food obstruction (n=3), severe pain (n=2), esophageal rupture (n=2), hemorrhage (n=2)). One (2%) patient died of a stent-related cause. Covered stents placed for a period of 5-6 weeks may well be an alternative to surgery for treating benign esophageal ruptures or anastomotic leaks. As efficacy between PSEMS, FSEMS and SEPS is not different, stent choice should depend on expected risks of stent migration (SEPS and FSEMS) and tissue in- or overgrowth (PSEMS).
    Full-text · Article · Feb 2012 · BMC Gastroenterology

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