Self Expanding Metal Stents for Complications of Rygb: Do the Benefits Justify the Risks?

Introduction: Several recent reports suggest that self expanding endoluminal stents (SEES) may provide a less invasive and more effective method for managing foregut surgical complications. The objective of this study was to identify factors that might predispose to SEES migration and related complications.
Methods: We retrospectively reviewed the EMR of all patients undergoing SEES placement after foregut surgery between March 2002 and Sept 2009. Statistical comparison was made using Fisher’s exact test.
Results: 43 patients with mean age of 56 years underwent a total of 59 stent deployments. The indications for initial stenting post RY gastric bypass were GJ leak 9(20.9%), GJ stricture 4(9.3%), fistula 2(4.6%), and GJ marginal ulcer perforation 3(6.9%). Indications for initial post esophagectomy stenting were EG leak 7(16.2%) and EG stricture 4(9.3%). Esophageal stents were also placed for malignant primary stricture 8(18.6%), benign stricture 3 (6.9%) and esophageal perforation 3(6.9%). The average time to oral feeding for post RYGB SEES was 1.2 days for leaks, 1.6 days for perforated ulcers and 0 days forstricture and fistula. Time to oral feeds after esophageal stents was 1.71 days for post esophagectomy leak, 0.25 days for post esophagectomy stricture and 0 days for malignant stricture. SEES migration rate was 53 % (n=14) for post RYGB patients, 37 % (n=3) for post esophagectomy leak, 20% (n=1) for post esophagectomy stricture and 20 % (n=2) for malignant esophageal stricture. The SEES migration rate post RYGB surgery (53%)was significantlyhigher (p=0.02) than for esophageal stents (24%).Major complications were significantly more common (p= 0.04) due to stent migration after RYGB (n= 6) versus esopohageal stents (n= 0). In those patients post RYGB with stent migration and prior pelvic surgery, the incidence of major GI complications was 67 % which was significantly higher (p= 0.01) than in those patients with stent migration and no prior pelvic surgery. One patient had an acute free perforation of bowel related to stent erosion.

Comparison of stent placement post RYGB surgery vs. Esophageal stents

Indication No. of patients (n) No. of stents (n) Stent migration rate No. of restent procedures (n) Percentage of stents that needed replacement No of stent related procedures *No. (mean/stent) Migration leading to major complications (average per stent )
RYGB patients 18 26 53% (n=14) 8 30.7 40 (1.53) 6 (23%)
Esophageal stents 25 33 24 % (n=8) 8 24 58 (1.75) 0(0%)

* Includes procedures related to initial stent deployment and stent retrieval.

Conclusion: SEES facilitate early oral feeds in the management of complications after upper GI surgery. Esophageal stents migrate less and are more easily retrievable than stents placed at the GJ anastomosis. Careful consideration needs to be used when placing SEES for complications of RYGB, especially in patients with prior pelvic surgery where2/3 of patients with stent migration required surgical removal.

Session: Poster

Program Number: P259

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