Efficacy of endoscopic management of leak after foregut surgery with endoscopic Self-expanding covered metal stent

Amir H Aryaie, MD, Jordan Singer, BS, Mojtaba Fayezizadeh, MD, Jeffrey Marks, MD. University Hospitals Case Medical Center

Introduction: Anastomotic or staple line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents has been gaining popularity. In this study we aim to determine the effectiveness of self-expanding covered stents in management of leak after foregut surgery.

Methods: Consecutive patients who received a fully covered self expandable metal stent (FSEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution and complications were collected. Predictive factors for clinical success rate were also assessed.

Results: A total of 26 consecutive patients underwent placement of fully covered self expandable metal stents for anastomotic leak, following gastric sleeve (n=5), esophagectomy (n=5), gastric bypass (n=4), total gastrectomy (n=3), partial gastrectomy (n=3), and others (n=6). All the stents were removed successfully, and clinical resolution was achieved in 21 patients (81%) after a median of 2 (range 1-3) procedures, a median of 2 (range 1-4) stents, and a median of 42.5 (range 3-99) days. Complications presented in a total of 14 patients (54 %), including stent migration (n=11), tissue integration (n=2), bleeding (n=1), which in 1 cases required surgical intervention. One (4%) patient died due to a stent related cause. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate or time to resolution of leak.

Conclusion: Self-expanding covered stent is an effective tool for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Larger studies are needed to determine factors predictive of success.