Salvage endoscopy utilizing covered Self Expanding Metal Stents (cSEMS) in complicated duodenal leaks

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

Duodenal injuries and subsequent leaks are associated with significant morbidity and mortality. They are very difficult to manage due to the high volumes of gastric secretions, bile, and pancreatic enzymes passing through the duodenum. This reducing the rate of spontaneous closure and subsequent development of chronic abscesses, fistulas, sepsis and death. Surgical management is also challenging due to the duodenums fixed retroperitoneal location and intimate anatomic relationship with the biliary and pancreatic ducts. Covered self expanding metal stents (cSEMS) originally designed for esophageal and colorectal applications have now been employed in the duodenum. They convey the theoretical advantage of reducing enteric content through the defect, thus reducing sepsis and promoting healing. There is scarce literature in regards to applicability and overall feasibility of cSEMS in patients with complicated duodenal leaks. A total of thirteen duodenal SEMS where inserted in our institution between January 1, 2014 and September 15, 2015. Eight of these were used for palliation of malignancies causing gastric outlet obstruction and two for the treatment of benign duodenal strictures.

We observed three cases of duodenal leaks treated with cSEMS. The first patient leaked after a transduodenal resection of a Gastrointestinal Stromal Tumour (GIST). This patient required multiple laparotomies, washouts, and drain placements. The patient was left hostile abdomen and a chronic duodenocutaneous fistula. After placement of a cSEMS the patient was discharged home after only 5 days. The second patient developed duodenal injury and leak after multiple retroperitoneal necrosectomies for necrotizing pancreatitis. The cSEMS remained in good position for 4 weeks before stent erosion and upper gastrointestinal bleed requiring its removal. Subsequent CT scan did confirmed resolution of the leak. The third patient developed a duodenal leak after a partial duodenal resection as part of en “en bloc” colon, liver, and duodenal resection for metastatic locally advanced colon cancer. A cSEMS was inserted post operative day two and bilious drain output dropped to scant after only 48 hours. Unfortunately, the patient died shortly thereafter secondary to liver failure.  Although erosion occurred in the second patient, it remained it adequate position long enough to heal the leak. Salvage endoscopy with cSEMS should be strongly considered in patients with complicated duodenal leaks as part of traditional the surgical management.

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