Endoscopy 2018; 50(01): E23-E24
DOI: 10.1055/s-0043-120518
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Assessment of healing of esophageal fistulae following stent placement without complete stent removal

Claudia Zitron
A.C. Camargo Cancer Center, Endoscopy, Sao Paulo, Sao Paulo, Brazil
,
Adriane G. Pelosof
A.C. Camargo Cancer Center, Endoscopy, Sao Paulo, Sao Paulo, Brazil
,
Eloy Taglieri
A.C. Camargo Cancer Center, Endoscopy, Sao Paulo, Sao Paulo, Brazil
,
Gabriel R. Corbetta
A.C. Camargo Cancer Center, Endoscopy, Sao Paulo, Sao Paulo, Brazil
,
Otavio Micelli Neto
A.C. Camargo Cancer Center, Endoscopy, Sao Paulo, Sao Paulo, Brazil
,
Alvaro M. Seraphim
A.C. Camargo Cancer Center, Endoscopy, Sao Paulo, Sao Paulo, Brazil
› Author Affiliations
Further Information

Publication History

Publication Date:
03 November 2017 (online)

Anastomotic leaks and fistulae are among the major life-threatening post-esophagectomy complications, with incidence rates ranging from 3 % to 10 %, increasing post-surgical mortality to about 20 % [1].

The successful closure of post-surgical fistulae may be achieved by the use of fully covered, self-expandable, metal esophageal stents (SEMSs) [2]. When SEMSs are selected for treatment, stents need to be removed after 4 – 6 weeks. Endoscopy and contrast radiography examination may help to evaluate whether a fistula has been effectively closed [3]. If closure has not occurred, another stent should be placed at the site, followed by reassessment after another 3 – 4 weeks.

Whereas multiple stenting may be needed for the management of persistent fistulae, this significantly impacts the final treatment costs. Fully covered SEMSs (Hanarostent; M.I. Tech, Seoul, South Korea) have been our preferred choice for fistula management and, in order to minimize stent migration, Shim’s technique (external fixation) is performed to keep the stent properly positioned.

To evaluate the success in fistula closure, we opted not to remove the stent, but rather just to move it down, away from the fistula site. Such technique involves seizing the string at the distal flange of the stent with a biopsy forceps, and then repositioning the stent further down, towards the gastric antrum, dislodging the stent from the fistulous orifice ([Fig. 1], [Video 1]).

Zoom Image
Fig. 1 Repositioning of a fully covered, self-expandable, metal esophageal stent to assess fistula closure. From left to right: anastomotic fistula; stent in place; biopsy forceps seizing the string; dislodging the stent; the healed fistula. Source: Valéria Simões Lira

Video 1 Assessment of healing of esophageal fistula following stent placement without complete stent removal.


Quality:

This approach allows the fistula to be reassessed by endoscopic visualization and contrast radiography examination. If the fistula is not completely healed, the same stent may be easily repositioned, and another evaluation is performed within 2 – 4 weeks. As the stent is fully covered, this maneuver is easily handled with no complications. The stent is removed when a complete resolution of the fistula has been confirmed.

This technique of stent mobilization was successfully performed in five patients and it allows cost reduction, as no SEMS replacements are required per patient.

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  • References

  • 1 Sharma P, Kozarek R. Practice Parameters Committee of American College of Gastroenterology. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010; 105: 258-273
  • 2 Dasari BVM, Neely D, Kennedy A. The role of esophageal stents in the management of esophageal anastomotic leaks and benign esophageal perforations. Ann Surg 2014; 259: 852-860
  • 3 van Boeckel PG, Dua KS, Weusten BL. et al. Fully covered self-expandable metal stents (SEMS), partially covered SEMS and self-expandable plastic stents for the treatment of benign esophageal ruptures and anastomotic leaks. BMC Gastroenterol 2012; 12: 19