The Endoscopic Stent Management of Anastomotic Leaks Following Upper Gastrointestinal Surgery

Cici Zhang, MD, Kevin Hutchingson, Lucy Martinek, MD, Julio Teixiera, MD. Lenox Hill Hospital

Introduction: Endoscopically placed, self-expandable stents have become an increasingly accepted technique for the management of anastamotic complications. The objective of our study was to determine the success of endoscopically stents in patients with anastomotic, staple line leaks, fistulas and strictures.

Methods: A retrospective review of patients who had undergone endoscopic stent placement for the management of complications after various foregut procedures was conducted. All stents were anchored endoscopically with 4-0 Prolene and evaluated with upper GI studies. Twenty patients were included in the study and none were excluded. The data was analyzed using SPSS software.

Results: From September 2005 to August 2014, twenty-one patients (14 were female, mean age of 44) developed anastomotic complication after foregut surgery (leak =14, fistula=4, stricture=4). One patient had a stricture and a fistula. Fourteen patients were referred from other surgeons and eighteen were bariatric patients. Leaks were diagnosed by CT scan and confirmed on endoscopic visualization. Symptomatic improvements were found in 19 patients (90%), 16 (76%) had resumption of oral diet in 48 hours, and 10 (50%) patients had stent related morbidity. There were seven stents migrations that required stent exchange. Two patients died due to unrelated causes. Chi-square analysis demonstrated significant benefit in stent management of leaks compared to strictures and fistulas (p = 0.010) and increased morbidity of using stents in patients with fistulas (p = 0.011).

Conclusion: Gastrointestinal leaks after foregut surgery remain a primary cause of serious morbidity and mortality in both bariatric population as well as the general surgical patients. The advent of endoscopic stent has revolutionalized the management of anastomotic complications following foregut surgery, in particular, bariatric surgery. In 2013, an estimated over 13,000 stents were sold from one company alone for the management of foregut complications. In our experience, stents have shown be safe and viable method to expedite enteral nutrition, facilitate healing and improve symptomatic outcome in patients with leaks and strictures.

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