Self-expanding covered metallic stent treatment of

ª Springer Science+Business Media, LLC 2012

Abdominal Imaging

Abdom Imaging (2012) DOI: 10.1007/s00261-012-9895-1

Self-expanding covered metallic stent treatment of esophagojejunostomy fistulas Fahrettin Kucukay,1 Rıza S. Okten,1 Erkan Parlak,2 Selcuk Disibeyaz,2 Yusuf Ozogul,3 E. Birol Bostanci,3 Tulay Olcer1 1

Department of Radiology, Turkiye Yuksek Ihtisas Hospital, Kizilay sokak No 4, Sihhiye, 06100 Ankara, Turkey Department of Gastroenterology, Turkiye Yuksek Ihtisas Hospital, Sihhiye, 06100 Ankara, Turkey 3 Department of Gastroenterologic Surgery, Turkiye Yuksek Ihtisas Hospital, Sihhiye, 06100 Ankara, Turkey 2

Abstract Purpose: The purpose of this study is to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks that seen after total gastrectomy–esophagojejunostomy (EJ) operations. Materials and methods: Contrast radiography and endoscopy revealed EJ fistulas in 14 patients. SECMSs were implanted both fluoroscopically and endoscopically to seal fistulas. Postoperative fistula diagnosis times, postoperative covered stent implantation times, primary success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, procedure-related mortality– morbidity, and mortality related with factors other than the procedure were noted. Results: Technical success rate was 100 %. Clinical success rate was 79 %. Reduction of the fluid from surgical drains was observed in all patients. There were no procedure-related mortality. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. In one patient (7 %), stent dislocation was observed at the 10th day after the intervention. Non procedure-related mortality was 21 %. No anastomotic stricture, no in-stent stenosis was observed during the follow up period(11.09 ± 3.21 months). Conclusion: From the above results we concluded that SECMS treatment for EJ fistulas is a safe, effective and technically easy procedure. Key words: Esophagus—Endoscopy—Gastric—Small intestine—Surgery

Correspondence to: Fahrettin Kucukay; email: [email protected]

Anastomotic dehiscence of esophagojejunostomy (EJ) following total gastrectomy for malignant tumors of the stomach is one of the most feared and fatal complication [1]. Use of covered stents in thoracic esophageal anastomotic leaks and in the anastomotic complications following bariatric surgery is well defined in the previous studies [2–5]. However, there are few reports concerning endoluminal therapy of the leaks that seen after total gastrectomy-EJ operations, which are limited in the number of the cases [6–12]. The purpose of this study was to analyze the outcomes of the self-expanding covered metallic stent (SECMS) therapy in the management of the postoperative anastomotic leaks, with major dehiscences,that seen after total gastrectomy–EJ operations.

Materials and methods Fourteen patients who had total gastrectomy and EJ operations for malignant gastric tumor (gastric adenocarcinoma) were referred to our clinic for determination and management of anastomotic fistulas within a 2-year period. The study was continued 2.5 years and ended after the fourteenth patient was accepted. Institutional approval and written informed consents, from the patients for both the procedure and the study, were obtained. The patients had a mean age of 47.42 ± 7.29 para-anastomoticyears (between 35 and 65 years). The stage of the gastric carcinomas were stage 1 in 1 patient (1 of 14, 7 %), stage 2 in 3 patients (3 of 14, 21 %), and stage 3 in 10 patients(10 of 14, 72 %). All patients were in sepsis and all had surgical drains at the region. The patients were evaluated with contrast radiography and endoscopy. Endoscopically, degree of dehiscences were determined visually as minor (below 50 % of the anastomotic circumferences) or major (above 50 % of the anastomotic circumferences). The patients with

F. Kucukay et al.: Treatment of esophagojejunostomy fistulas

improvement in the status of the patients, oral intake after the procedure, lack of migration within 15 days, and reduction of the drainage from the surgical drains. A patient had to satisfy all of these criteria to be deemed a clinical success. Mortality and morbidity related with the procedure were recorded. Postoperative fistula diagnosis times, postoperative covered stent implantation times, technical success rates, clinical success rates, postinterventional oral feeding beginning times, reduction of the drainage from the surgical drains, and mortality related with factors other than the procedure were noted. The patients were followed up with abdominal radiographies with oral barium and clinically, unless a problem was encountered. Oral barium studies were scheduled at third, sixth and 12 months after the intervention.

Results Fig. 1. Photograph and schematic drawings of the covered stents that used to seal fistulas. Lower left part shows uncovered barrel-shaped ends and lower right part and upper part show fully covered stent.

major dehiscences were included into the study, while the patients with minor dehiscences were excluded. The patients with minor dehiscences were treated either conservatively or with endoscopically endoclips application. Meglumine amidotrizoate (Gastrografin, Schering, West Sussex, UK) was used for contrast radiography. Contrast radiography and endoscopy revealed EJ fistulas (dehiscence ranging between 50 % and 85 % of the anastomotic circumference) in all patients. Endoscopy and flouroscopy guided, guidewire (Back-up Meier 0.35’’, j tip, 300 cm, Boston Scientific Inc., Miami, FL) insertions to the efferent loops of the anastomosis which were performed. Fistula localizations were determined. SECMSs (Microtech Co. Ltd., Nanjing, China) ranging between 100 and 120 mm in length and 20–22 mm in width were introduced over the guidewire. These stents were used off-label to repair the fistulas. All stents were barrel-shaped in both proximal and distal ends. Two stents had uncovered barrel-shaped ends and the rest of the stents were fully covered including both proximal and distal barrel-shaped ends (Fig. 1). These two stents with uncovered barrel-shaped ends were used instead of fully covered stents because there were only these stents at the time of intervention in two patients. A total of 16 stents in 14 patients were released (Fig. 2). After implantation of the covered stents, contrast radiography and endoscopy examinations were performed to exclude fistula and dislocation of the stents. Technical success (successful insertion) criterion was determined as successful excluding of the fistula with fully covered SECMS, without stent dislocation in the early postinterventional period (within 15 days). Clinical success criteria were clinical

Mean diagnosis time of fistula at postoperative period was 5.4 ± 1.8 days (between 3 and 8 days). Mean SECMS implantation time at postoperative period was 6.3 ± 2.2 days (between 3 and 9 days). Technical success rate was 100 %. Mean oral feeding beginning time at postinterventional period was 1.7 ± 0.9 days (between 1 and 3 days). Clinical success rate was 79 % (11 of 14 patients). Clinical deterioration was observed in 21 % (3 of 14 patients) of the patients. These patients were critically ill and two of them (14 %) had multidrug-resistant septicemia and one of them (7 %) had acute heart failure. Reduction of the fluid from surgical drains was observed in all patients (100 %). Procedure-related mortality was 0 %. Procedure-related morbidity (Table 1) was observed in 21 % (3 of 14 patients) of the patients. Recurrent fistula was observed in two patients (14 %) at the third and fifth day after the intervention. SECMSs with uncovered barrel-shaped proximal and distal ends were used in these patients. On control radiographies of these patients, leakage from uncovered barrel-shaped proximal end to the lateral wall of the covered shaft was seen. Inadequate expansion in the shaft of the SECMS comparing to uncovered barrel-shaped proximal end caused a gap between the parts of the SECMS and resulted with unsealing of the fistula. We performed ballooning of the narrow segment, but procedures failed to seal the fistulas. These stents were removed with grasping forceps endoscopically and replaced with fully covered SECMSs. There were complete sealing of the fistulas after replacement with fully covered SECMS. In one patient (7 %) in which anastomotic dehisce was 50 % of the circumference, stent dislocation was observed at the 10th day after the intervention (Fig. 3). Fistula was closed at the contrast radiography examination, but the stent was removed with surgical laparotomy to prevent possible obstruction.


Fig. 2. A–C. 46-Year-old man with EJ fistula. A Contrast radiography showing anastomotic fistula (white asterisks); B Endoscopic image of fistula (black arrow); and C Control contrast radiography image after the covered stent implantation.

Non-procedure-related mortality was 21 % (3 of 14 patients). These were the same patients in whom clinical deterioration were observed. Two patients (14 %) died because of septicemia and 1 patient (7 %) died because of acute heart failure at the first month.

Mean follow up period of the patients was 11.09 ± 3.21 months (between 4 and 15 months). No stent migration other than previously described, no anastomotic stricture, no in-stent stenosis, no stent fracture, and no perforation was observed during the follow up period.


Table 1. Patient characteristics including age, used stents, procedure-related morbidity, and current patient status Patient age 35 65 44 52 50 42 40 41 44 49 52 52 50 48 a b

Used stents 22 22 20 20 22 22 22 20 22 20 20 20 22 22 22 20

9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9

120 120 100 120 100 100 100 100 120 120 120 100 100 120 120 100

Follow up (months) a

mm mma mma mma mma mmb mma mma mma mmb mma mma mma mma mma mma

1 4 14 10 1 15 8 9 11 12 13 14 1 12

Procedure-related morbidity

Current patient status

None None None None None Recurrent fistula that required use of fully covered stent None None Recurrent fistula that required use of fully covered stent None None None None Stent dislocation

Ex, septicemia Alive Alive Alive Ex, septicemia Alive Alive Alive Alive Alive Alive Alive Ex, heart failure Alive

Fully covered stent Partially covered stent with uncovered barrel-shaped ends

Fig. 3. 48-Year-old man with treated EJ fistula. Contrast radiography image of migrated stent (black arrow).

Discussion Esophagojejenostomy following total gastrectomy for malignant diseases has considerable morbidity and mortality although recent advances in the surgical techniques have been reported. One of the most encountered and the only complication with some influence on patients quality of life in the first few postoperative

months is the proximal anastomotic fistula which had been reported between 6 % and 12.8 % in different series [6, 13–15]. Type of reconstruction or surgical radicality did not change the frequency of anastomotic leakage significantly [6, 13, 14]. Secondary surgical intervention is a treatment option in these cases, but reoperation with resuturing of the anastomoses and surgical drainage was found to have high mortality rate (64 %) in the study of Lang et al. [13]. They suggested that reoperation should only have been considered when conservative management fails. Conservative management includes antibotic therapy, percutaneous drainage of abscess, and nasojejunal tube placement. Nasojejunal tube placement after total gastrectomy and EJ was thought to prevent possible severe morbidity or mortality, traditionally. However, Doglietto et al. [6] demonstrated that routine placement of a nasojejunal tube after roux-en-Y EJ was unnecessary in elective total gastrectomy for gastric cancer. When they compared routine versus no placement of a nasojejunal tube they had found similar findings regarding postoperative complications but a slightly higher incidence of pulmonary complications in nasojejunal tube group. Endoscopic endoclips application, with/without heater or argon plasma coagulation, for limited perforation or fistula formation was reported in previous studies [7, 16]. But, in these cases wound separation was restricted. The placement of self-expanding plastic stent for esophageal anastomotic leaks was found highly effective treatment by Langer et al. [17]. Absence of mucosal proliferation and epithelial bleeding were found as advantageous sides of this application as well as low cost. Owing to very smooth surface shaping and little radial force, these stents are prone to migration especially in the absence of a stricture or stenosis. Migration rates are higher in the plastic stents than the metallic ones (6 %–


18 % vs. 6 %). Another complication that observed in that study was persistance of the leakage after plastic stenting. All these raised reintervention rates in plastic self-expanding stent placement. Also in that study, leaks smaller than one third of the esophageal circumference were stented. In a study of Gelbmann CM et al. [18], stent migration rate was 30 % with use use of selfexpandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Repositioning of the migrated stents which necessiated a secondary intervention was possible in all cases. SECMSs have been used for palliation of the EJ fistulas following total gastrectomy and were found to reduce mortality and morbidity of symptomatic EJ leakage [8–12]. Expected side effects of metallic stenting are migration, mucosal proliferation, and epithelial hyperplasia. In the study of Choudhury et al. [8], they observed no significant epithelial hyperplasia or symptomatic anastomotic stricture. Food blockage,necessiated endoscopic clearence in three patients at five episodes in that study. The median survival of the entire patient group was found as 11 months (range, 4–18 months). In our series, no anastomotic stricture or no in-stent stenosis was observed. Self-expanding covered metallic stenting is a technically easy procedure concerning our technical success rate. But, 79 % clinical success rate indicates that close follow up these critically ill patients is required. Stent migration which was 7 % in our series is another main problem in this treatment. Another issue that must be taken into consideration is not to use SEMS with uncovered barrel-shaped ends to seal the fistulas. This forms a gap between the parts of the stent, which results with inadequate sealing of the fistula and free passage of fluid through the non-covered portion of stent. We observed this situation in 14 % (2 of 14 patients) of the patients which required removal of the first stent. This study has some limitations. We did not use retrievable SECMS for the intervention or we did not remove the SECMS after the healing of fistula. This was because dehiscences were major (ranging between 50 % and 85 % of the anastomotic circumferences), limited survival expectancy in these patients especially in advanced stages and the anastomotic strictures following the removal of the SECMS. In conclusion, SECMS treatment for EJ fistulas is safe, effective, and technically easy procedure. Conflicts of interest. Drs. Fahrettin Kucukay M.D.,Rıza S. Okten M.D., Erkan Parlak M.D., Selcuk Disibeyaz M.D., Yusuf Ozogul

M.D., E Birol Bostanci M.D., and Olcer M.D. have no conflicts of interest or financial ties to disclose.

References 1. Csendes A, Dı´ az JC, Burdiles P, et al. (1990) Classification and treatment of anastomotic leakage after extended total gastrectomy in gastric carcinoma. Hepatogastroenterology 37:174–177 2. Schubert D, Scheidbach H, Kuhn R, et al. (2005) Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents. Gastrointest Endosc 61:891–896 3. Tuebergen D, Rijcken E, Mennigen R, et al. (2008) Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations. J Gastrointest Surg 12:1168–1176 4. Eubanks S, Edwards CA, Fearing NM, et al. (2008) Use of endoscopic stents to treat anastomotic complications after bariatric surgery. J Am Coll Surg 206:935–938 (discussion 938–939) 5. Blackmon SH, Santora R, Schwarz P, Barroso A, Dunkin BJ (2010) Utility of removable esophageal covered self-expanding metal stents for leak and fistula management. Ann Thorac Surg 89:931–936 (discussion 936–937) 6. Doglietto GB, Papa V, Tortorelli AP, et al. (2004) Nasojejunal tube placement after total gastrectomy: a multicenter prospective randomized trial. Arch Surg 139:1309–1313 7. Rodella L, Laterza E, De Manzoni G, et al. (1998) Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy 30:453–456 8. Roy-Choudhury SH, Nicholson AA, Wedgwood KR, et al. (2001) Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. AJR Am J Roentgenol 176:161–165 9. Nowakowski P, Ziaja K, Ludyga T, et al. (2007) Self-expandable metallic stents in the treatment of post-esophagogastrostomy/ postesophagoenterostomy fistula. Dis Esophagus 20:358–360 10. Sampaio JA, Waechter FL, Pereira-Lima J, et al. (2003) Successful treatment of esophagojejunal disconnection after total gastrectomy by insertion of a covered self-expandable esophageal metallic stent. Gastrointest Endosc 58:453–456 11. Cho YP, Lee DH, Jang HJ, et al. (2003) Leakage of jejunal end of roux limb after total gastrectomy: management with a placement of a covered metallic stent: case report. J Korean Med Sci 18:437–440 12. Curcio G, Mocciaro F, Tarantino I, et al. (2010) Self-expandable metal stent for closure of a large leak after total gastrectomy. Case Rep Gastroenterol 4:293–297 13. Lang H, Piso P, Stukenborg C, Raab R, Ja¨hne J (2000) Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma. Eur J Surg Oncol 26:168– 171 14. Bracale U, Marzano E, Nastro P, et al. (2010) Side-to-side esophagojejunostomy during totally laparoscopic total gastrectomy for malignant disease: a multicenter study. Surg Endosc 24:2475–2479 15. Scurtu R, Groza N, Otel O, Goia A, Funariu G (2005) Quality of life in patients with esophagojejunal anastomosis after total gastrectomy for cancer. Rom J Gastroenterol 14:367–372 16. Qadeer MA, Dumot JA, Vargo JJ, Lopez AR, Rice TW (2007) Endoscopic clips for closing esophageal perforations: case report and pooled analysis. Gastrointest Endosc 66:605–611 17. Langer FB, Wenzl E, Prager G, et al. (2005) Management of postoperative esophageal leaks with the polyflex self-expanding covered plastic stent. Ann Thorac Surg 79:398–403 18. Gelbmann CM, Ratiu NL, Rath HC, et al. (2004) Use of selfexpandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy 36:695–699