To Stent Or Not to Stent: Outcomes of Self-expanding Intraluminal Stents in Foregut Surgery

Hrishikesh Nerkar, MD, Anna Ibele, MD, Jon Gabrielsen, MD, William Strodel, MD, Anthony T Petrick, MD. Geisinger Medical Center, Dept of MIS and Bariatric Surgery.

Background: Self-expanding stents (SES) have been used with increasing frequency to treat the complications of foregut surgery. The safety and effectiveness of SES for these indications has been difficult to determine due to lack of comparative controls. The aim of our study was to compare the complications and effectiveness of SES placed for esophageal complications (eSES) against those placed for bariatric complications (gSES).

Methods: We reviewed EMR data from our patients, aged 18 years or older, who underwent bariatric and/or foregut surgery between January 2002 and June 2013 and in whom SES were utilized post-operatively. Demographic data was collected as well as perioperative and outcomes data. Data between the eSES and gSES groups was then compared using the Wilcoxon rank-sum test and Cochran-Armitage test.

Results: A total of 102 patients had 132 SES placed over the study period. Eleven patients with SES placed to treat non-operative problems were excluded. Indications for SES included leaks (n=59), strictures (n=18), prophylactic anastomotic (n=11), masses with obstruction (n=9) or perforation (n=2), fistula (n=2), and idiopathic perforation (n=1). Eighteen stents were secured with sutures. Mean follow was 17 months (range 1-84) for eSES and 27 months (range 2-161) for gSES patients.

41 patients had 58 eSESs placed (21 for leaks), while 50 patients had 63 gSESs placed (38 for leaks). eSES patients underwent 159 endoscopies (median=3/patient), whereas the gSES group required only 136 endoscopies (median=2/patient; p=N.S.).

There was no significant difference in rates of dysphagia (53% eSES vs 52% gSES) or the need for premature stent removal (2% eSES vs 2% gSES). More patients with eSES required stent replacement (41% vs 28%) but this was not significant (p=0.18).

Persistent leaks occurred similarly for each group (19% eSES vs16% gSES), as did stent migration (17% eSES vs 16% gSES). Stents were sutured in 1 eSES patient and 17 gSES patients. The overall migration rate for all SES was higher for non-sutured stents (19% vs 5%) but not significant (p=0.12). 12% (n=5) required IR intervention in both groups and there was no significant difference in re-operative rates (34% eSES and 40% gSES). Stents caused no anastomotic disruptions.

The eSES group took longer to return to full liquid diet (mean 11.6; median 3 days) when compared to the gSES patients (mean 7.7; median 2 days) and had longer LOS (mean 12.3: median 8 vs mean 10.1; median 5 days) but neither was significant.

Conclusion: Current SES models were designed for esophageal placement. Our study demonstrates that the patient tolerance, safety and effectiveness are similar for both esophageal and bariatric surgical complications. Migration is common but suturing may lower the frequency. We need to develop randomized trials to determine if SES are cost effective or clinically superior to more conventional management strategies.

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