Kaplı stent ile başarı ile tedavi edilen uzamış servikal ösefago-gastrik anastomoz kaçağı olgusu (Doç.Dr.Mehmet Özdoğan)

60 yaşında erkek hasta yutma güçlüğü ve kilo kaybı nedeni ile 3 ay önce gastroenteroloji kliniğine başvurmuş. Yapılan üst endoskopide ön kesicilerden 25. cm’de lümeni tama yakın tıkayan kitle saptanmış. Alınan biyopsi sonucu skuamöz hücreli kanser gelmiş. Toraks BT’de karina hizasında ösefagus duvarında kalınlaşma ve periösefageal dokuda infiltrasyonla uyumlu görünüm saptanan hastaya 2 kür kemoterapi ve radyoterapi içeren neoadjuvan tedavi uygulanmış. Neoadjuvan tedavinin sonlanmasından 2 hafta sonra hasta ösefajektomi amacı ile kliniğimize yatırıldı. Yapılan kontrol BT’de tümörün parsiyel cevap verdiği ve duvar kalınlaşmasının anlamlı şekilde gerilediği gözlendi.

Preoperatif hazırlıkların tamamlanmasından sonra, hasta transhiatal ösefajektomi yapılması planlanarak ameliyata alındı. Transhiatal diseksiyon sırasında karina komşuluğunda sert yapışıklıklar olduğu görüldü ve diseksiyonun güvenle yapılamayacağına karar verilerek sağ torakotomi yapıldı. Tümör keskin diseksiyonla ayrıldı ve el ile iki tabaka servikal ösefago-gastrik anastomoz gerçekleştirildi. Beslenme jejunostomisi yerleştirilerek ameliyat sonlandırıldı.

Erken postoperatif dönemde sorunsuz seyreden hastanın sol servikal insizyonundan postoperatif 9. gün seropürülan drenaj olması üzerine dikişleri alındı. Tükürük fistülü gerçekleştiği gözlendi. Lokal pansuman ve yaraya packing yapılarak tedavisi sağlana hasta postoperatif dönemde jejunostomi ile enteral yoldan beslendi. Postoperatif 20. gün halen drenajın yüksek miktarda devam etmesi üzerine baryumlu pasaj garfisi çekildi. Grafilerde Ösefago-gastrik anastomozun sol tarafından kaçak olduğu ve baryum kaçağının mediastende oluşan kaviteyi doldurduğu görüldü (Resim 1 ve 2). Hastaya üst endoskopi yapıldığında anastomozun sol anterolateralinde fistül ağzı görüntülendi (Resim 3).
Esofago-gastrik anastomoz bölgesine, fistül ağzını kapatacak şekilde 8 cm’lik kaplı stent yerleştirildi (Resim 4 ve 5). Stent yerleştirildikten sonraya hastaya oral yoldan sıvı gıda başlandı. İşlem sonrası 10. gün stent çıkartıldı. Bu sırada fistül ağzının kapanmış olduğu gözlendi. İşlem sonrası 12. gün çekilen kontrol baryumlu grafide kaçak saptanmadı. Hasta katı gıda alır halde taburcu edildi.

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Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations.

Department of General Surgery, Unit of Surgical Endoscopy, University of Muenster, Muenster, Germany.

BACKGROUND: Intra-thoracic esophageal leakage after esophageal resection or esophageal perforation is a life-threatening event. The objective of this non-randomized observational study was to evaluate the effects of endoluminal stent treatment in patients with esophageal anastomotic leakages or perforations in a single tertiary care center. METHODS: Thirty-two consecutive patients with an intrathoracic esophageal leak, caused by esophagectomy (n = 19), transhiatal gastrectomy (n = 3), laparoscopic fundoplication (n = 2), and iatrogenic or spontaneous perforation (n = 8), undergoing endoscopic stent treatment were evaluated. Hospital stay, mortality and morbidity, sealing rate, extraction rates, complications, and long-term effects were measured. RESULTS: Median time interval between diagnosis and stent treatment was 3 and 5 days, respectively. Eighteen patients had futile surgical closure of the defect before stenting, while in 14 patients, stent placement was the primary treatment for leakage. Stent placement was technically correct in all patients. Functional sealing was achieved in 78%. Mortality was 15.6%. Stent extraction rate was 70%. Overall method-related complications occurred in nine patients (28%). CONCLUSIONS: Implantation of self-expanding stents after esophageal resection or perforation is a feasible and safe procedure with an acceptable morbidity even if used as last-choice treatment.

PMID: 18317849 [PubMed - indexed for MEDLINE]

 

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Zentralbl Chir. 2006 Oct;131(5):369-75. Links

[Endoscopic treatment of mediastinal anastomotic leaks]

[Article in German]

Schubert D, Pross M, Nestler G, Ptok H, Scheidbach H, Fahlke J, Lippert H.

Klinik für Allgemein-Viszeral-und Gefässchirurgie, Otto von Guericke-Universität Magdeburg. schubertdr@hotmail.com

BACKGROUND: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic anastomotic leaks are often associated with poor results and carry a high morbidity and mortality. This report describes our results with the endoscopic treatment of intrathoracic anastomotic leakages. PATIENTS: 27 consecutive patients presenting with clinically apparent intrathoracic anastomotic leak, caused by resection of an epiphrenic diverticulum (n=1), esophagectomy for esophageal cancer (n=19), limited resection for carcinoma of the gastroesophageal junction (n=1) or gastrectomy for gastric cancer (n=6) were endoscopically treated. The extent of the dehiscences ranged from about 10-70%. After endoscopic lavage and debridement of the leakage (mean duration: 16,8 days) the leaks were closed with fibrin clue (n=9) or endoclips (n=2) in cases of smaller leaks or by stent placement (n=11), stent placement after unsuccessful fibrin clue injections (n=3) or stent placement and endoclipping (n=1) in patients with a large leakage. Simultaneously the periesophageal mediastinum was drained by chest drains. RESULTS: 25 of 27 patients were successfully treated endoscopically. Under endoscopic treatment one patient died due to septic multiorgan failure. Another patient developed a refractory, persistent leak. Procedure related complications (stent migration, anastomotic stenosis) were obtained in 6 patients. CONCLUSION: An endoscopic approach is successful and safe to treat symptomatic intrathoracic anastomotic leaks smaller than 70% of the circumference. An endoscopic lavage and debridement of the leak, prior to leak closure, seems to be helpful to reduce mediastinal and pleural inflammation. In patients with smaller leaks (<30%) fibrin clue injections and endoclipping is recommended. Patients with a dehiscence from 30-70% of the circumference profit from stent placement.

PMID: 17089284 [PubMed - indexed for MEDLINE]

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Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents.

Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, Lippert H, Pross M.

Department of General, Visceral and Vascular Surgery, Faculty of Medicine, Otto von Guericke University Magdeburg, Magdeburg, Germany.

BACKGROUND: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic esophageal anastomotic leaks often is associated with poor results and carries a high morbidity and mortality. The successful treatment of esophageal anastomotic insufficiencies and perforations when using covered, self-expanding metallic stents is described. METHODS: The feasibility and the outcome of endoscopic treatment of intrathoracic anastomotic leakages when using silicone-covered self-expanding polyester stents were investigated. Twelve consecutive patients presented with clinically apparent intrathoracic esophageal anastomotic leak caused by resection of an epiphrenic diverticulum (n = 1), esophagectomy for esophageal cancer (n = 9), or gastrectomy for gastric cancer (n = 2), were endoscopically treated in our department. The extent of the dehiscences ranged from about 20% to 70% of the anastomotic circumference. After endoscopic lavage and debridement of the leakage at 2-day intervals (mean duration, 8.6 days), a large-diameter polyester stent (Polyflex; proximal/distal diameters 25/21 mm) was placed to seal the leakage. Simultaneously, the periesophageal mediastinum was drained by chest drains. OBSERVATIONS: All 12 patients were successfully treated endoscopically without the need for reoperation. A complete closure of the leakage was obtained in 11 of 12 patients after stent removal (median time to stent retrieval, 4 weeks, range 2-8 weeks). In one patient, a persistent leak was sealed endoscopically after stent removal by using 3 clips. Distal stent migration was obtained in two patients. CONCLUSIONS: The placement of silicone-covered self-expanding polyester stents seems to be a successful minimally invasive treatment option for clinically apparent intrathoracic esophageal anastomotic leaks.