Curcio G, Mocciaro F, Tarantino I, Barresi L, Pagano D, Spada M, Traina M
Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center, Palermo, Italy.
Case Rep Gastroenterol. 2010 Aug 23;4(2):293-297. doi: 10.1159/000318860.
In recent years, self-expandable metallic stents (SEMSs) have emerged as a promising treatment alternative for the bridging and sealing of esophageal perforations and extensive anastomotic leaks after esophageal resection or total gastrectomy. A 56-year-old woman underwent a total gastrectomy with Roux-en-Y end-to-side esophagojejunostomy for a gastric signet ring cell carcinoma. Ten days later, esophagogastroduodenoscopy showed a 2 cm fistula in the distal end of the Roux limb of the anastomosis. This was confirmed by gastrografin esophagography. The patient was started on total parenteral nutrition. Having deemed clipping treatment for this fistula unfeasible, we decided to insert a partially silicone-coated SEMS (Evolution Controlled Release Esophageal Stent System, Cook Medical, Winston-Salem, N.C., USA). The stent was removed after ten days. Gastrografin esophagography showed no further contrast extravasation, and esophagogastroduodenoscopy showed closure of the fistula. No clinical complications were observed, and the patient was able to start normal per os nutrition. In conclusion, the treatment of symptomatic leaks in patients who have undergone esophagojejunostomy is challenging, and leakage from the jejunal stump can be a potentially serious complication. In the treatment of leakage after total gastrectomy, plastic stents (which are either too light or exercise too little radial force) and totally covered metallic stents may not adhere sufficiently to the esophagojeujunal walls and, as a result, migrate beyond the anastomosis. The promising results of this report suggest that early stenting, using a partially silicone-coated SEMS, is a feasible alternative to surgical treatment in this category of patients.
近年来，自膨式金属支架（SEMSs）已成为食管穿孔桥接和封闭以及食管切除或全胃切除术后广泛吻合口漏的一种有前景的治疗选择。一名56岁女性因胃印戒细胞癌接受了全胃切除术及Roux-en-Y食管空肠端侧吻合术。术后10天，食管胃十二指肠镜检查显示吻合口Roux袢远端有一个2厘米的瘘口。泛影葡胺食管造影证实了这一点。患者开始接受全胃肠外营养。鉴于对此瘘口进行夹闭治疗不可行，我们决定插入一个部分涂有硅胶的SEMS（Evolution可控释放食管支架系统，美国北卡罗来纳州温斯顿 - 塞勒姆市库克医疗公司）。10天后取出支架。泛影葡胺食管造影显示无进一步造影剂外渗，食管胃十二指肠镜检查显示瘘口闭合。未观察到临床并发症，患者能够开始正常经口营养。总之，食管空肠吻合术后有症状漏的治疗具有挑战性，空肠残端漏可能是一种潜在的严重并发症。在全胃切除术后漏的治疗中，塑料支架（要么过轻，要么径向力过小）和完全覆盖的金属支架可能无法充分附着于食管空肠壁，结果会迁移至吻合口之外。本报告的良好结果表明，对于此类患者，早期使用部分涂有硅胶的SEMS进行支架置入是一种可行的手术治疗替代方法。
