Fully covered esophageal stents: Endoscopic salvage from a surgical perspective

Ryan P Kelly, BMSc, MD, Caolan Walsh, MD, James Ellsmere, BSc, MSc, MD. Dalhousie University

BACKGROUND: Perforation, fistulization and leak are rare but significant complications of foregut surgery. These complications carry considerable morbidity and mortality and can be challenging to manage from a surgical perspective. Endoscopic salvage treatment with fully covered self-expanding metallic stents (cSEMS) is an evolving area of interest. To date, data regarding cSEMS has been limited to small observational series. Our aim is to report our institutional experience with salvage endoscopy for complicated esophageal disease.

METHODS: Patients that received cSEMS between July 1, 2014 and September 15, 2015 were included. Patients with duodenal stents were excluded. Primary outcome was in-hospital mortality. Secondary outcomes were rate of stent migration, bleeding, and re-intervention.

RESULTS: A total of 27 self-expanding stents were placed over the study period. The mean age was 66. Of these patients, 8 required cSEMS with proximal deployment in the esophagus. The total number of stent deployments including repositioning and stent changes was 16. There were no severe adverse events and no in-hospital mortalities. The overall adverse event rate was 50% (8/16). These were limited to stent migrations (4/16) and bleeding (4/16). Overall, 12 re-interventions were required for 4/8 patients. One patient required 6 repeat endoscopic interventions. All re-interventions were limited to endoscopic stent repositioning. Overall survival at 1 year was 87.5% (7/8) with the only death related to diffuse metastatic disease after successful placement of 23cm stent from esophagus to duodenum to exclude a gastric perforation secondary to diffuse large B cell lymphoma.

CONCLUSIONS: Endoscopic salvage and prophylactic treatment of benign and malignant conditions with esophageal cSEMS is an evolving domain of surgical endoscopy. Here we have reported our institutional outcomes with salvage esophageal cSEMS. Overall survival after treatment with esophageal cSEMS is excellent for benign disease with all of our patients alive at follow-up. Adverse events are limited to stent migration, which often manifest as bleeding. Having a high index of suspicion and a low threshold for repeat endoscopy can manage the majority of these adverse events. Furthermore, endoscopic directed proximal fixation can be utilized to reduce stent migration.