Symptomatic malignant gastroesophageal anastomotic leak: Management with covered metallic esophageal stents

OBJECTIVE. Gastroesophageal anastomotic leak after cancer resection has a m ortality rate of up to 60% and significant morbidity, whatever the mode of treatment. We assessed the efficacy of esophageal stenting as a therapeutic option to reduce the mortality and morbidity associated with symptomatic i ntrathoracic anastomotic leakage. SUBJECTS AND METHODS. During a 52-month period, 14 patients had placement o f stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophag ojejunal anastomosis. Thirteen of 14 patients had tumors that were histolog ically staged as T3 N1 MO or worse. Significant anastomotic leaks were reve aled by a contrast-enhanced study at 3-28 days after surgery. Stents were i nserted in patients in whom the leakage was debilitating or initial conserv ative treatment had failed. Stenting outcome in terms of clinical and radio logic healing, hospital stay, survival, and complications was assessed. RESULTS. No procedural morbidity or 30-day mortality occurred. Immediate po stprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing ti me of 6 days. Of the 13 patients, healing occurred within 10 days in 10 pat ients (76.9%). Eight of these 10 early closures received a knitted nitinol stent (p = 0.02). One patient (7%) died as a consequence of leakage at 135 days. Median survival for all 14 patients was Il months (Kaplan-Meier metho d). Complications included five episodes of food blockages in three patient s, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic structure o r occlusive epithelial hyperplasia. CONCLUSION. Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesoph ageal cancer. Knitted nitinol stents may be best suited to this purpose.