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

OBJECTIVE. Gastroesophageal anastomotic leak after cancer resection has a mortality 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 intrathoracic anastomotic leakage. SUBJECTS AND METHODS. During a 52-month period, 14 patients had placement of stents for clinically significant postoperative leaks: 10 patients had an esophagogastrectomy and four patients had a total gastrectomy with esophagojejunal anastomosis. Thirteen of 14 patients had tumors that were histologically staged as T3 N1 MO or worse. Significant anastomotic leaks were revealed by a contrast-enhanced study at 3-28 days after surgery. Stents were inserted in patients in whom the leakage was debilitating or initial conservative treatment had failed. Stenting outcome in terms of clinical and radiologic healing, hospital stay, survival, and complications was assessed. RESULTS. No procedural morbidity or 30-day mortality occurred. Immediate postprocedural leak occlusion was obtained in all patients. Clinical healing of the leak occurred in 13 (92.8%) of 14 patients, with a median healing time of 6 days. Of the 13 patients, healing occurred within 10 days in 10 patients (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 method). Complications included five episodes of food blockages in three patients, which required endoscopic clearance, and one case of stent-related upper gastrointestinal hemorrhage. No patients developed anastomotic structure or occlusive epithelial hyperplasia. CONCLUSION. Covered esophageal stenting appears to reduce the mortality and morbidity of symptomatic anastomotic leakage after surgery for gastroesophageal cancer. Knitted nitinol stents may be best suited to this purpose.