Treatment of esophageal anastomotic leakage with self-expanding metal stents: analysis of risk factors for treatment failure

Background and study aim: The endoscopic placement of self-expandable metallic esophageal stents (SEMS) has become the preferred primary treatment for esophageal anastomotic leakage in many institutions. The aim of this study was to investigate possible risk factors for failure of SEMS-based therapy in patients with esophageal anastomotic leakage.

Patients and methods: Beginning in 2003, all patients with an esophageal leak were initially approached and assessed for temporary closure with a SEMS. Until 2014, all patients at the Karolinska University Hospital with a leak from an esophagogastric or esophagojejunal anastomosis were identified. Data regarding the characteristics of the patients and leaks and the treatment outcomes were compiled. Failure of the SEMS treatment strategy was defined as death due to the leak or a major change in management strategy. The risk factors for treatment failure were analyzed with simple and multivariable logistic regression statistics.

Results: A total of 447 patients with an esophagogastric or esophagojejunal anastomosis were identified. Of these patients, 80 (18 %) had an anastomotic leak, of whom 46 (58 %) received a stent as first-line treatment. In 29 of these 46 patients, the leak healed without any major change in treatment strategy. Continuous leakage after the application of a stent, decreased physical performance preoperatively, and concomitant esophagotracheal fistula were identified as independent risk factors for failure with multivariable logistic regression analysis.

Conclusion: Stent treatment for esophageal anastomotic leakage is successful in the majority of cases. Continuous leakage after initial stent insertion, decreased physical performance preoperatively, and the development of an esophagotracheal fistula decrease the probability of successful treatment.

• References

• 1 Sauvanet A, Mariette C, Thomas P et al. Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: predictive factors. J Am Coll Surg 2005; 201: 253-262
• 2 Zilling T, Olseen P, Walther BS. Prediction of hospital stay after total gastrectomy. Anticancer Res 1997; 17: 1355-1359
• 3 Lang H, Piso P, Stukenborg C et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 2000; 26: 168-171
• 4 Sierzega M, Kolodziejczyk P, Kulig J et al. Impact of anastomotic leakage on long-term survival after total gastrectomy for carcinoma of the stomach. Br J Surg 2010; 97: 1035-1042
• 5 Meyer L, Meyer F, Dralle H et al. Insufficiency risk of esophagojejunal anastomosis after total abdominal gastrectomy for gastric carcinoma. Langenbecks Arch Surg 2005; 390: 510-516
• 6 Djarv T, Derogar M, Lagergren P. Influence of co-morbidity on long-term quality of life after oesophagectomy for cancer. Br J Surg 2014; 101: 495-501
• 7 Sarela AI, Tolan DJ, Harris K et al. Anastomotic leakage after esophagectomy for cancer: a mortality-free experience. J Am Coll Surg 2008; 206: 516-523
• 8 Turkyilmaz A, Eroglu A, Aydin Y et al. The management of esophagogastric anastomotic leak after esophagectomy for esophageal carcinoma. Dis Esophagus 2009; 22: 119-126
• 9 Urschel JD. Esophagogastrostomy anastomotic leaks complicating esophagectomy: a review. Am J Surg 1995; 169: 634-640
• 10 Whooley BP, Law S, Alexandrou A et al. Critical appraisal of the significance of intrathoracic anastomotic leakage after esophagectomy for cancer. Am J Surg 2001; 181: 198-203
• 11 Migita K, Takayama T, Matsumoto S et al. Risk factors for esophagojejunal anastomotic leakage after elective gastrectomy for gastric cancer. J Gastrointest Surg 2012; 16: 1659-1665
• 12 Schardey HM, Joosten U, Finke U et al. The prevention of anastomotic leakage after total gastrectomy with local decontamination. A prospective, randomized, double-blind, placebo-controlled multicenter trial. Ann Surg 1997; 225: 172-180
• 13 Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg 2004; 10: 71-75
• 14 Brangewitz M, Voigtlander T, Helfritz FA et al. Endoscopic closure of esophageal intrathoracic leaks: stent versus endoscopic vacuum-assisted closure, a retrospective analysis. Endoscopy 2013; 45: 433-438
• 15 Rodella L, Laterza E, De Manzoni G et al. Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy 1998; 30: 453-456
• 16 Bohm G, Mossdorf A, Klink C et al. Treatment algorithm for postoperative upper gastrointestinal fistulas and leaks using combined vicryl plug and fibrin glue. Endoscopy 2010; 42: 599-602
• 17 Choi HJ, Lee BI, Kim JJ et al. The temporary placement of covered self-expandable metal stents to seal various gastrointestinal leaks after surgery. Gut Liver 2013; 7: 112-115
• 18 Persson S, Elbe P, Rouvelas I et al. Predictors for failure of stent treatment for benign esophageal perforations – a single center 10-year experience. World J Gastroenterol 2014; 20: 10613-10619
• 19 Hoeppner J, Kulemann B, Seifert G et al. Covered self-expanding stent treatment for anastomotic leakage: outcomes in esophagogastric and esophagojejunal anastomoses. Surg Endosc 2014; 28: 1703-1711
• 20 Feith M, Gillen S, Schuster T et al. Healing occurs in most patients that receive endoscopic stents for anastomotic leakage; dislocation remains a problem. Clin Gastroenterol Hepatol 2011; 9: 202-210
• 21 Schweigert M, Solymosi N, Dubecz A et al. Endoscopic stent insertion for anastomotic leakage following oesophagectomy. Ann R Coll Surg Engl 2013; 95: 43-47
• 22 Elbe P, Lindblad M, Tsai J et al. Non-malignant respiratory tract fistula from the oesophagus. A lethal condition for which novel therapeutic options are emerging. Interact Cardiovasc Thorac 2013; 16: 257-262
• 23 Al-issa MA, Petersen TI, Taha AY et al. The role of esophageal stent placement in the management of postesophagectomy anastomotic leak. Saudi J Gastroenterol 2014; 20: 39-42
• 24 Feeney C, Hussey J, Carey M et al. Assessment of physical fitness for esophageal surgery, and targeting interventions to optimize outcomes. Dis Esophagus 2010; 23: 529-539
• 25 McCulloch P, Ward J, Tekkis PP. Mortality and morbidity in gastro-oesophageal cancer surgery: initial results of ASCOT multicentre prospective cohort study. BMJ 2003; 327: 1192-1197
• 26 Ferguson MK, Durkin AE. Preoperative prediction of the risk of pulmonary complications after esophagectomy for cancer. J Thorac Cardiovasc Surg 2002; 123: 661-669